Category Archives: Cutting Edge PEM

Learn what is hot in the realm of pediatric emergency medicine. What is the latest research say and how might that help you optimize your patient management? What are the latest patient care products? This column will help you and your patients.

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

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

Management of Aggression in Emergency Departments is more than just PRNs

Anik Jhonsa, MD

In recent years pediatric emergency departments have seen a dramatic rise in the number of children and families presenting seeking mental health treatment.  As a child and adolescent psychiatrist primarily working in the emergency room, I’m often asked by my Emergency Medicine colleagues to develop an “agitation plan” for patients who are deemed at risk of acting out in an aggressive manner.  Most often these requests tend to focus on the PRN medication plan should a child become aggressive or upset.  However, most successful agitation plans begin well before any medication needs to be administered. read more

A Case for Ketofol in the Pediatric ED

Imagine it’s a warm day in June when an 18-month old male with a complicated facial laceration involving the oral mucosa from a dog bite presents to your emergency department (ED). His parents are requesting that his lacerations be repaired by a plastic surgeon.   You recognize their concern and are happy to oblige. You want to ensure the best outcome so you decide to do procedural sedation for the repair. You reach for your handy dandy procedural sedation hammer Ketamine. However, while your patient has obviously achieved a dissociative state, he seems to be periodically moving and tongue thrusting. Your consultant is not very pleased at that thought of attempting a delicate repair on a moving child. What can be done? read more

Toxicology Notes: Considerations for Cyanide Treatment in the Emergency Department

While working the overnight shift a child is brought in to your emergency department from a house fire. His burns are minor, but he was found in the house and likely had a significant smoke inhalation. The paramedics have started oxygen therapy, and as an astute emergency physician you add a blood gas with cooximetry, lactate and cyanide level to your initial orders. You are preparing to administer the CYANOKIT (hydroxocobalamin) but you pause for a moment to ask, “Should I be sending additional labs before I give this medications? Will this affect management in the next 24 hours? Are there other options?” read more