Procedural sedation is often required in the pediatric emergency department for a variety of chief complaints, including abscess incision and drainage, fracture reduction, laceration repair and burn management. While there have been numerous advances in the field of procedural sedation as well as updates to practice guidelines, there are often no guidelines for indications for sedation or medications for particular patient types.
Miller et al describes patient care variability in the setting of procedural sedation in the pediatric emergency department. The objective of this study was to describe sedation trends over time as well as to quantify the variation in procedural sedation in terms of rate of use, patient characteristics, indications and choice of agents. A retrospective, cross-sectional study was performed. Data were obtained using the Pediatric Health Information System (PHIS) database. This database contains emergency department, inpatient, ambulatory surgery and observation encounter-level data from 45 tertiary care hospitals in the Unites States. Inclusion criteria consisted of children who presented to a participating emergency department between January 1, 2009 and December 31, 2014 and were younger than 19 years of age. The authors identified patients who would potentially receive procedural sedation based on the following diagnostic categories: fractures, lacerations, abscesses, dislocations, and other (burns, amputations, etc.). Patients with chronic comorbid conditions, patients who received paralytics (these were likely used for intubation) and patients receiving sedation medications in the operating room were excluded. Administration of the following medications were considered to constitute procedural sedation: propofol, ketamine, ketamine and propofol, midazolam and fentanyl, dexmedetomidine, etomidate, chloral hydrate, pentobarbital, methohexital, meperidine, promethazine, and chlorpromazine. Single agent use of an opiate or benzodiazepine was not considered procedural sedation.read more
Assistant Professor of Pediatric Emergency Medicine, Emory University
Two years ago one of my colleagues sent a reminder that June 21st is ASK day and that we clinicians should support this day as Pediatric Emergency Medicine Physicians. ASK (Asking Saves Kids) is a day that the American Academy of Pediatrics and the Brady Center to Prevent Gun Violence have promoted to encourage parents to ask about the presence of unlocked guns in the homes where their children play. ASK day is held annually on the first day of summer, a season where children spend a lot of time in the homes of others. As a PEM Physician I am very cognizant of safety. I ensure that my children are always buckled into car seats with whomever drives them, I ask about swimming pools and pets when they visit others homes and ensure that grandparents medicines are put up when we visit. But I had never asked about the presence of unlocked guns in the homes my children visited. I embarked with trepidation and asked the parent of my son’s best friend. After I completed this uncomfortable conversation I began to reflect if this was a difficult conversation for me a pediatric emergency medicine physician who has seen multiple children harmed by firearms imagine the difficulty for other parents without a similar perspective.read more
The road to success isn’t always straight. Some of the greatest minds and talents in recent history had their share of struggles. Albert Einstein was slow to speak and difficulties in school; Michael Jordan was cut from his Varsity basketball team; Steve Jobs was fired from his own company. Medic al trainees may also struggle to meet various standards of performance across one or more clinical competencies. Identifying the problem resident/fellow and formulating an organized approach to remediation can be a struggle.read more
Even if you have turned off all news sources over the past two years, it would be hard to escape the urgent alarms regarding opioid misuse in the US. The statistics are remarkable.
Since 1999, overdose deaths involving opioids quadrupled.1
2000-2015: greater than half a million people died from drug overdoses.
91 Americans die every day from an opioid overdose.
1999 to 2010: number of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled. 2,3
This is compelling evidence that we have a problem—perhaps some more than others. Opioid addiction is a frequent challenge for those caring for adults in the Emergency Department with some centers (e.g., rural) seeing more of this than others. Those who care for injured and ill children are left with two important questions: (1) What is the evidence regarding opioid addiction in children? (2) To what extent is the management of acute pain in the Emergency Department contributing to an increase in opioid related morbidity and mortality?read more
6-day-old term Haitian male presented to the Emergency Department (ED) for abdominal distension. Per mother, the patient was born at home and delivery was uncomplicated. History revealed the patient was able to pass stool and urinate in the first day of life. He tolerated frequent breastfeeding until day of life 3 when he developed increased fussiness, feeding intolerance, and constipation without emesis. Abdominal distension developed and increasingly worsened over the next 48 hours. Although there were no prenatal medical visits, mother stated that there were no fevers or known infections during pregnancy.read more