First rotations: Peds EM

Discussion in 'Emergency Medicine' started by AmoryBlaine, Jun 17, 2008.

  1. AmoryBlaine

    AmoryBlaine the last tycoon
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    There was some good stuff going on the MICU thread so I thought I'd try to mine the collective brain of the forum.

    I'm starting on Peds EM, have only done a few shifts on my aways (neither of which was particularly strong on Peds) and haven't done any Peds otherwise in over a year.

    Just hoping for some pearls, words of wisdom etc -- I have yet to see a really medically sick kid.
     
  2. EM_Rebuilder

    EM_Rebuilder Member
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    ...and I doubt you will see many in the Peds ED. The Peds ED, more than any ED, seems to be MUCH more like a 'clinic'. It is constant URIs, feeding question/concerns, very minor trauma/bumps/bruises. Sure, there will be an occasional sick child or bad trauma, but all in all, you will be ok.

    One of the biggest thing is to review abx for OM, strep, etc etc. Get good at looking in ears and making good interactions with children.... also getting down Rxs in per kg amounts. The Harriat Lane book is good for drugs and the common peds things you see....

    I think someone good to remeber in Peds is that common things are common and rashes usually dont mean anything...
     
  3. anonymousEM

    anonymousEM Senior Member
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    can go down fast. DO NOT SIT ON A KID WHO LOOKS SICK, get your senior, attending, etc early.
     
  4. KidDr

    KidDr Senior Member
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    peds EM is great! (but I'm completely biased...)

    Some very general guidelines:

    --Get used to calculating all meds/IVF based on weight. Harriet Lane and Uptodate are good places to look.

    --If getting blood gasses, VBGs or CBGs are the norm, not ABGs.

    --Acute gastro with dehydration: NS 20 mL/kg, repeat (either 10 mL/kg or 20 mL/kg) as needed. Many will also give Zofran 0.1 mg/kg IV. If trying rehydration w/o an IV, can give Zofran 0.1 mg/kg SL.

    --Fever (38 or higher) in infants <4 weeks: full sepsis workup (blood/urine/CSF and cultures), antibiotics (Amp/Gent or Amp/Cefotaxime), and admission; do CXR if respiratory symptoms and consider if WBC is high (>15-20). Add Acyclovir (20 mg/kg/dose) and send CSF HSV PCR if there is any maternal HSV history or the kid doesn't look good or has neurological stuff going on (esp. seizures) or has CSF pleocytosis with a negative gram stain.

    --Fever (38 or higher) in infants 1-3 months: If ill-appearing or high fever (>38.5-39)--blood/urine/CSF and cultures, CXR if any respiratory symptoms, empiric antibiotics (Ceftriaxone or Cefotaxime, 50 mg/kg IV/IM), and admission.
    If well-appearing: UA/UC, CBC, blood culture. CXR if any respiratory symptoms (especially tachypnea). +/- LP (some LP all of these kids, some don't; but most will argue that if you're going to give empiric Ceftriaxone, you better get an LP before you do it). Admission and empiric antibiotics if UA/CSF abnormal or if WBC >15. If labs normal and WBC <15, +/- Ceftriaxone and f/u in 24 hours.

    --Fever (39 or higher) without a source in children 3-36 months (assuming they're fully immunized with 3 doses each of HIV and PCV-7 and essentially well-appearing): For 3-6 months, do CBC, blood culture (if WBC>15), UA/UC and strongly consider Ceftriaxone for kids with WBC >15. Do CXR if there's respiratory symptoms and also consider CXR if WBC >20. For 6-36 months, obtain UA/UC in any uncircumcised boys <12 months or any girl <24 months. Many will also do CBC/blood cultures in children 6-36 months...but studies would say they're not necessary. If cultures are taken or antibiotics given, f/u with PMD or ED in 24 hours. If UA positive treat with 3rd generation Cephalosporin until cultures return (Ceftriaxone 50 mg/kg IM if sending home, Ceftriaxone or Cefotaxime 50 mg/kg IV if admitting).

    --Bronchiolitis (you'll still see it in the summer, though not due to RSV): Supportive care is the norm; can try a neb (either Albuterol or Epi) to see if there's any clinical response. Criteria for admission includes young infants (<4-6 weeks of age due to risk of apnea), hypoxia requiring supplemental O2, inability to eat/drink/stay hydrated, significant vomiting, or medically complex kids with co-morbidities.

    --Croup: For kids with stridor at rest or difficulty breathing: Epi neb + Dexamethasone (0.6 mg/kg either PO or IM), then observation for 1-2 hours in the ED. If stridor returns they get a 2nd Epi neb and usually admission (hopefully your hospital has a SSU---cause that's all these kids usually need---just a few more hours of observation).

    --Asthma: If increased work of breathing, give 2-3 nebs back to back (Albuterol/Atrovent) and steroids asap (Oral: 2 mg/kg Prednisone or Prednisolone; IV: 2 mg/kg Methylpred). Consider baseline VBG if severe.

    --Acute otitis media (AOM): For kids >2 years of age with "nonsevere" infections, "watch and wait" (counseling on the use of analgesics and providing an antibiotic Rx but asking the family not to fill it unless symptoms continue past 48 hours) is an option. High-dose Amox (80-90 mg/kg/day divided TID) is 1st line, Augmentin (use the ES-600 formulation and dose the Amox at 80-90 mg/kg/day divided BID) and 3rd generation Cephalosporins (usually Cefdinir at 12 mg/kg/day divided QD-BID) are 2nd line treatment.

    --Pneumonia: Empiric treatment for presumed bacterial pneumonia:
    -Outpatient: same as AOM above; or for older children, give Azithromycin 10 mg/kg on day 1, then 5 mg/kg on days 2-5
    -Inpatient: 2nd or 3rd generation Cephalosporin (Cefuroxime or Ceftriaxone or Cefotaxime)

    That's what I can think of off the top of my head, I hope it's helpful!

    BTW, UpToDate has great reviews of all the above topics specific to pediatrics. I use UpToDate daily at work to look up various things.
     
    #4 KidDr, Jun 20, 2008
    Last edited: Jun 21, 2008
  5. roja

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    From a training standpoint:

    Peds EM is one of the easiest to quickly minimize stuff. That's because 90% of it is BS. However, at this stage in the game, you should take at least 90% of your patients and be asking yourself: what else could this be? what would I NOT want to miss?

    Get in the habit of this. (Its good thinking in the adult ED as well).

    Most important pearl for peds is: Give good discharge instructions.
     
  6. dmunorse

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    Question from a soon to be EM intern...I saw an article reviewing a study looking at using a few drops of an aqueous anesthetic (I want to say it was aq. Lido, but it mentioned some practitioners using another that escapes me) in the infected ear as a quick fix to get fast relief of pain and as a bridge to when the oral analgesics take their effect. The study had found lower pain scores at time intervals (I think 30 and 60 minutes) for the pts. with the anesthetic vs. control.

    Anybody around here do that? Why/why not?
     
    #6 dmunorse, Jun 21, 2008
    Last edited: Jun 21, 2008
  7. AmoryBlaine

    AmoryBlaine the last tycoon
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    That seems like pretty solid advice that I will take to heart -- a good framework for learning.

    And KidDr thanks for the long post.
     
  8. roja

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    I think they are talking about Auralgan, which is fantastic. Put a few drops in the ear and give them some po motrin and you have much happier children
     
  9. Seaglass

    Seaglass Quantum Member
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    RE: Pediatric fever in age <36 mo - there is a large variation in practice. For example where I trained and worked we pretty much never did blood cx or CBC.

    Search on ACEP for their clinical guideline on pediatric fever. It's very well researched and will give you the plusses and minuses of the different parts of the workup.

    Also good things to know are:

    Workup of febrile seizure

    Workup of first simple seizure

    Basic laceration repair

    Basic abscess I&D

    Any book on negotiation - most of working in the Peds ED is manipulating the parents to get the child taken care of.

    Oh - and DKA mgmt. I had a peds intern last month who didn't know this in MAY!
     
  10. KidDr

    KidDr Senior Member
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    Very true--I should have emphasized this more in my post.
    Like you, I've seen large variation across different hospital sites.
    I think (I hope) the trend is moving toward doing fewer labs, when appropriate.
    A recent article in BMJ about this topic re-emphasized that the main bacterial infection causing fever in this group (febrile children 6-36 months w/o a source) is UTIs----and that the majority of blood cultures done in this age group that turn up positive are false-positives.

    BMJ reference: http://adc.bmj.com/cgi/content/abstract/adc.2007.130583v1
     
  11. roja

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    Kiddr- thanks! you just found my first article for Journal club!
     
  12. KidDr

    KidDr Senior Member
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    you're welcome! hope it goes great.
     

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