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.

Firecracker and Blast Injuries

Jonathan Eisenberg, MD

As a child, my father told me a story about his neighbor who had a mishap with a firecracker and blew off the second through fourth digits.  He would then hold out his thumb and pinky and wave to me.  This scared me to such an extent that I still have never lit a firecracker, even during my less frontal lobe-oriented teen years.  I now think that this story was a fabrication—but it is not that far off from its realistic basis.

Fireworks are most popular during the month surrounding July 4th in the US.  These colorful combustibles have been around in the US since July 4th, 1777, and we spend more than $700 million dollars per year on them.  There are many varieties and categories from novelty and daytime fireworks (both generally have smaller explosions) to the larger aerial fireworks and a host of nuanced state laws which allow for an all, some, or none approach to sales. read more

Severe Acute Respiratory Syndrome Coronavirus-2 and Multi-system Inflammatory Syndrome in Children: Preliminary Reports

By Nicholas Pokrajac, MD, Co-editor

What is the Multi-system Inflammatory Syndrome in Children (MIS-C)?

Most children infected with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) have a mild course of illness.1 However, there have been recent reports of a number of children developing a condition with similarities to Kawasaki disease (KD) and toxic shock syndrome (TSS) within epicenters of the SARS-CoV-2 outbreak, including over 200 children in New York, Italy, and the United Kingdom. This condition has been named the Multisystem Inflammatory Syndrome in Children (MIS-C). As of May 14, 2020, the Centers for Disease Control and Prevention (CDC) recommends reporting of suspected cases to their local or state health departments. This article is a brief summary of preliminary reports on MIS-C to serve as a primer for emergency clinicians. read more

Update on COVID-19 and Pediatric Patients for Emergency Department Physicians

Written by the Pediatric Emergency Medicine Committee of the ACEP Florida Chapter

The COVID-19 pandemic is rapidly evolving and the healthcare challenges are continuing to increase and evolve. Despite the widespread global incidence and increasing number of cases, the epidemiology and clinical presentation of COVID-19 in pediatric patients is not well understood. The majority of children seen for emergency medical problems in the United States are seen in general emergency departments, not pediatric-specific institutions, and this will likely continue with the current pandemic.  The information below is based on current evidence, and is meant to assist in the evaluation and management of pediatric patients with suspected or confirmed COVID-19. However, it must be noted that new information is available on a daily basis, and the understanding of COVID-19 including the epidemiology, clinical presentation, testing recommendations, and clinical management is subject to change. Additionally, the information below does not pertain nor apply to neonates. read more

Is it time to rethink fasting times in the emergency department?

Chumpitazi, CE, Camp, EA, Bhamidipati, DR, et al. “Shortened Preprocedural Fasting in the Pediatric Emergency Department.” The American Journal of Emergency Medicine, vol. 36, no. 9, 2018, pp. 1577–1580.

Carmen D. Sulton, MD

The relationship between pre-procedural fasting times and aspiration and/or pulmonary complications are often a topic in anesthesia and sedation literature. In particular, fasting or nil per os (NPO) guidelines for urgent procedures outside of the operating room continue to be vague.  Prolonged fasting times can often be difficult for both emergency providers and families to manage. The American Society of Anesthesiologists (ASA) guidelines focus on 2 hours of fasting for clear liquids and up to 8 hours for full fatty meals. The American College of Emergency Physicians (ACEP) states that procedures in the emergency department (ED) setting should not be delayed based on fasting times alone. Many studies looking specifically at fasting times and adverse events often are under-powered, or may not focus specifically on patients in the ED setting.  read more

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.

The structure of their study is elegant in that they completed a large, randomized study in which there was a 2-by-2 factorial design, allowing for the assessment of both fluid type (0.9% sodium chloride or 0.45% sodium chloride) and rate of administration (10% of body weight replaced in a 36 hour regimen or 5% body weight replaced in a 48 hour regimen).  This design allowed for an assessment of both sodium chloride concentration and fast replacement with a higher volume versus slow replacement with a lower volume.

And drum roll please…  there was no significant difference in proportion of patients with a drop in Glasgow Coma Score or neurocognitive assessment after recovery between all four treatment groups.  Interestingly, there was a trend to a higher incidence of clinically apparent brain injury in the slow hydration groups, but this was not statistically significant.   Now there were a few differences between non-neurologic adverse events, mainly higher rates of hyperchloremic acidosis in the 0.9% sodium chloride group and/or rapid administration group, and higher rates of hypocalcemia and hypophosphatemia in the 0.9% sodium chloride groups.  However, the take home point from this study is that isotonic versus hypotonic intravenous hydration and slow versus fast hydration does not affect the incidence of neurologic compromise in diabetic ketoacidosis.  We can hydrate these patients when they are in extremis without having that nagging thought in the back of our minds that we are increasing the risk of cerebral edema.

It is time to rethink our protocols and open discussion with our endocrinology and critical care colleagues about fluids in DKA.

 

Reference:

Kuppermann N, Ghetti S, Schunk JE, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378(24):2275-2287. doi:10.1056/NEJMoa1716816.