Category Archives: Ped EM Section Columns

Time to rethink fluids in DKA?

A comment on “Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis” by Kuppermann et al. (2018)

Jessica Wall, MD, MPH

In medical school and residency we are taught to be vigilant for mental status changes and cerebral edema in our pediatric patients with diabetic ketoacidosis (DKA).  It is medical dogma that we must rehydrate them gently and slowly to prevent such a devastating complication, but the little evidence that we have for this teaching is observational and/or decades old.  Recently, “Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis” was published in The New England Journal of Medicine, with which Nate Kuppermann and the PECARN DKA FLUID Study Group have taken a major first step in changing how we think about fluid administration in DKA. read more

What is Your Blindspot: Managing Cognitive Bias

Taryn R Taylor MD, MEd

I can vividly remember my first day as a REAL doctor. I started on the pediatric pulmonology service, and recall spending what felt like an hour, deliberating whether I could order Tylenol for my patient. Would it interact with the Pulmozyme treatment? Fortunately, I had very patient senior resident who calmed my nerves and was empathetic to my intern anxiety.  July is an exciting, terrifying, rewarding and sometimes frustrating month, as we celebrate a new “medical year.” Whether or not you subscribe to the controversial premise of the July effect, there is no doubt that during this time you can leave a pivotal educational footprint in the life and career of a young doctor. read more

Variation in Pediatric Procedural Sedations Across Children’s Hospital Emergency Departments: Research Write-Up

Carmen D. Sulton, MD

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

If you could ASK one question to save your child’s life? Firearm Injury Prevention

Kiesha Fraser Doh, MD

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 Remediation

Jenny Sanders, MD

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