Pediatric Emerg Med 4.docx - road.uww.edu | Web Storage Docs ...

Date: Tue, 4 Aug 1998 21:43:44 -0500Reply-To: jay pershad <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jay pershad <[email protected]>Subject: Re: Antibiotics for neonatal fever

If you read Feigin & Cherry's text book of infectious disease or Oski's

textbook, late onset LISTERIA (usually meningitis) can occur upto 3 months

of age. Hence if you will remember, the usual treatment of infants prior to

the early 90's, was, inpatient management of all infants under 3 months

with a diagnosis of FWS, with AMP+Gent.

Subsequently, the studies by Baskin, O Rourke, Fleisher & then by Bonadio

in 1992-1993, that prospectively looked at selective outpatient management

of infants 28-90 days changed this practice. With the arrival of

Ceftriaxone and then the controversial "fever" guidelines, outpatient

management of the 4-12 week old became quite common, especially if they

met "low risk" criteria.

Listeria as the offending organism, has never been discussed in the above

literature, as the age group for outpatient Mx was lowered. None of these

studies reported Listeria as a big offender in the 28-90 days age group

presenting as sepsis or as r/o sepsis/OB. My personal ancecdotal experience

shares this view.

I have dropped Ampicillin in the routine treatment of r/o sepsis after the

neonatal age group (>28 days) UNLESS they have meningitis. Listeria is very

mailto:[email protected]


much like late onset GBS disease and other bacterial causes of neonatal

meningitis. You have to cover for the neonatal bugs until 3 months of age

if they present with MENINGITIS.

BTW, germaine to all this discussion is the fact that Ampicillin is the

only penicillin that covers Listeria and is also synergistic with the

aminoglycosides in GBS dis or listeriosis.

Hope that helps.

Jay Pershad

"We care for wee folks"

----------

> From: Isaacman, Daniel M.D. <[email protected]>

> One of our former chief residents just asked me a question that I'd like

to

> throw out for the group. He was trained (not by me) to treat all

neonates

> with amp and cefotaximine (or ceftriaxone or gent) until 8 weeks of age.

> The question is when can the amp be dropped. Various practitioners seem

to

> differ between 4 and 8 weeks of age. Does anyone have a cutpoint that

they

> use and a reference that substantiates that particular choice? Thanks.

>

> Daniel J. Isaacman, M.D.

>

For more information, send mail to [email protected] with the message: info PED-EM-L

The URL for the PED-EM-L Web Page is:

http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

Date: Thu, 6 Aug 1998 07:51:07 -0400Reply-To: Shane Curran <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Shane Curran <[email protected]>Subject: Paediatric burnsX-To: [email protected]

Our local fire crews have offered to give us some money to purchase a new

piece of equipment instead of giving it to the tertiary burns unit 500 km

away.

They have asked that we nominate a piece of equipment that is useful in

managemnet of childrens burns.

the only thing that i could come up with was a cooximeter seeing as we

presently have no means of measuring carboxyhemoglobin at this hospital (or

met or sulf haemoglobins either)

We have all of the other usual ED acute management tools

Can anyone think of anything that would fit the criteria taht a department

that sees 30000/year wouldn't or should have?

Failing that anyone got any recomendations obn brands of cooximeters and

likely prices?








Date: Sun, 9 Aug 1998 01:48:41 +0200Reply-To: João Luis Barreira <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: João Luis Barreira <[email protected]>Subject: Re: MethemoglobinemiaX-To: javier benito <[email protected]>

In a recent personal review about methemoglobinemia at my Pediatric

Emergency Department at Oporto's Hospital de S. Jo=E3o I found that all o=

f our

twelve cases since 1989 were related to percutanous exposure to anyline d=

yes

used to paint the shoes the children were using. Interestingly in a

compehensive review I've done about this topic I couldn't found any serie=

s

like ours. Does anyone have some experience like this.

Is someone using some kind of protocol to investigate and treat children

with methemoglobinemia ? I think the idea of searching urinary nitrites i=

s

worthwhile...





I would apreciate any feedback about this topic.

Thanxs...

Jo=E3o Lu=EDs Barreira, MD

Oporto, PORTUGAL

[email protected]

-----Original Message-----

From: javier benito <[email protected]>

To: Multiple recipients of list PED-EM-L <[email protected]>

Date: sexta-feira, 7 de agosto de 1998 16:43

Subject: Methemoglobinemia

The most frequent oxidative agent which produce acquired

methemoglobinemia in my practice is the enhance contents of nitrates in

vegetables from unsuitable manure soil. This kind of methemoglobinemia

usually causes minimal clinical problems (range < 30%). In most cases,

is not necesary to determinate the level of nitrates in blood or

vegetables to confirm the presumptive diagnosis. However it's very easy

to colect a urine specimen and performed a dipstick test for nitrites.

In the last three cases of methemoglobinemia presumptively caused for

vegetables that we attended in our emergency room, the disptick test for

nitrites was positive. Although this fact don=B4t change the treatment I


think it helps to eliminate another causes of methemoglobinemia.

I'd like to know other opinions. Thaks for your help. Javier Benito.

Hospital Cruces. Bilbao. Spain.

For more information, send mail to [email protected] with the

message: info PED-EM-L






Date: Wed, 12 Aug 1998 17:04:52 -0600Reply-To: "Charles J. Graham" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Charles J. Graham" <[email protected]>Subject: Re: COBRA Question

HCFA has just released new guidelines for their carriers and state agencies

to follow in investigating and administering the COBRA/EMTALA law and this

issue is addressed directly in those guidelines. I read them today on the

ACEP web site (www.acep.org). As I understand it, EMTALA would apply to

hospitals with organized emergency departments, but also might apply to

other hospitals which provide certain acute care services, even if they

http://www.acep.org/







don't have an "emergency room". The law also applies if a patients seeks

care at a location at the hospital separate from the ED (they must have a

screening exam, stabilizing treatment, etc).


From: Michael Newdow <[email protected]>

To: Multiple recipients of list PED-EM-L <[email protected]>

Date: Wednesday, August 12, 1998 12:11 PM

Subject: Re: COBRA Question

>Daniel E. Kates, M.D. wrote:

>>

>> > What's a "hospital that has no real ER" mean? COBRA applies to "a

>> > hospital that has a hospital emergency department."

>> >

>>

>> This is true to an extent. COBRA applies not only to the ED, but to the

>> entire facility.

>

>Although Dr. Kates is correct that COBRA applies to the entire facility,

>I believe it applies to the entire facility only of hospitals that have

>hospital emergency departments.

>

>For more information, send mail to [email protected] with the



>The URL for the PED-EM-L Web Page is:

> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html




Date: Sat, 15 Aug 1998 14:04:54 -0400Reply-To: Mark Hostetler <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Mark Hostetler <[email protected]>Subject: Analgesia and Sedation

Dear Members:

I am interested in finding an approximation for the various methods of

analgesia and sedation currently being used for pediatric pts in the ED

undergoing painful procedures (fracture reduction, laceration repair,

incision and drainage, joint aspiration, etc.). I am NOT interested in

those patients requiring sedation alone for nonpainful studies such as

CT/MR scanning.

For those kind enough to take the 2.237 minutes required to complete

this brief survey, you may return them directly to me (email, fax, mail

below). I find there is a great deal of institutional variation

depending on where one practices, and would like a general estimate.






Thank you ever so kindly for your generosity,

I=92ve always relied on the kindness of strangers,

Mark

SURVEY

1. Approximate number of children seen in your ED/year? ________

2. Your estimate of approximate number of sedations/month? ________

3. What percent of the time do you/your faculty use the following drug

regimens?

IV Ketamine (with or without atropine / versed) ________

IM ketamine (with or without atropine / versed) ________

Rectal ketamine (with or without atropine / versed) ________

IV Fentanyl and Versed________

IV Morphine and Versed________

IV Versed +/- topical/local________

PO Versed +/- topical/local________

PO Fentanyl? ________

Nothing? ________

Other________

Other________

Your name/affiliation (Optional) ____________________________________

Mark A. Hostetler, M.D.

University of Rochester

Departments of Emergency Medicine and Pediatrics

Division of Pediatric Emergency Medicine

601 Elmwood Avenue, Box 4-9200

Rochester, NY 14642

Office: 716/275-2090

Fax: 716/473-3516

E-mail: [email protected]




Date: Wed, 19 Aug 1998 10:49:25 -0400Reply-To: Jeffrey F Linzer <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jeffrey F Linzer <[email protected]>Subject: Re: Outpatient management of meningitisX-To: "Daniel E. Kates, M.D." <[email protected]>In-Reply-To: <[email protected]>

On Tue, 18 Aug 1998, Daniel E. Kates, M.D. wrote:

> ...receive a gram of Rocephin daily...






If you were going to treat a patient with meningitis on an outpatient

basis, would anyone use Chloromycetin (PO chloramphenicol)?

(For those on the list who do not have personal experience or know the

history of this drug, it is the only [as far as I am aware] oral

antibiotic that has been shown to sterilize the CSF).

Jeff Linzer MD MICP

Division of Emergency Medicine

Egleston and Hughes Spalding Children's Hospitals

[email protected]




Date: Fri, 21 Aug 1998 09:48:46 -0400Reply-To: "George L. Foltin, MD" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "George L. Foltin, MD" <[email protected]>Organization: NYU Medical CenterSubject: Re: Outpatient management of meningitisX-To: Richard Hemmer <[email protected]>

--------------FE514BE0CFC614A14D90BC0C

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Content-Transfer-Encoding: 7bit






Richard Hemmer wrote: Over the past few years we have seen way too many cases of

> "aseptic meningitis" that was managed at home that were now admitted to the

> PICU. (All of these were referrals from multiple facilities) Most of these

> children died. Those that did not die, were left with life long problems

> including severe developmental problems, loss of fingers/toes/hands because

> of gangrenous processes.

>

>

Sounds like an excellent opportunity to report these observations in a peer review journal.An

objective report of this phenomena in this setting would have a strong effect on standard of

care.

George Foltin

--------------FE514BE0CFC614A14D90BC0C

Content-Type: text/html; charset=us-ascii


<HTML>

<P>Richard Hemmer wrote: Over the past few years we have seen

way too many cases of

<BLOCKQUOTE TYPE=CITE>"aseptic meningitis" that was managed at home that

were now admitted to the

<BR>PICU. (All of these were referrals from multiple facilities)

Most of these

<BR>children died. Those that did not die, were left with life

long problems

<BR>including severe developmental problems, loss of fingers/toes/hands

because

<BR>of gangrenous processes.

<BR>

<BR><A HREF="http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html"></A> </BLOCKQUOTE>

Sounds like an excellent opportunity to report these observations in a

peer review journal.An objective report of this phenomena in this setting

would have a strong effect on standard of care.

<P>George Foltin

<BR> </HTML>

--------------FE514BE0CFC614A14D90BC0C--






Date: Sat, 22 Aug 1998 21:27:16 -0700Reply-To: Must have been a Wild Angel <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Must have been a Wild Angel <[email protected]>Subject: Re: outpatient meningitis rxIn-Reply-To: <[email protected]>

> I respectfully dissent: To me it is a money issue and there is no art.

> It is (or should be, I believe) simply a matter of arithmetic. We

> should agree on how much we can afford to spend, and then use the

> dollars where we get the greatest return. What art is there to saving

> one life (or case of deafness or whatever) at a cost of $X, when that

> same $X could have saved two others elsewhere?

Greetings,

I rarely reply to this list, but this above paragraph just really burned

my back side.

So, becuase Child 1 has one type of, oh hell lets say cancer, and Child 2

and 3 have another type, are you aluding to forgo aggressive treatment or

management of Child 1's cancer because you can treat #'s 2 and 3 for the

same or lesser cost?





If this is the correct inturrpertation of this, then please do let me know

just where it is you pratice at so I can make sure I dont move there in

the future. Heaven forbid should one of my 3, or any child I throw in the

back of my ambulance come down with something.

> The "art" (to me) is an excuse for not having (or else ignoring) the

> data. The only logical way to practice is to come up with some cut-off

> (sort of like Oregon's plan, but more evidence-based) in terms of

> badness prevented per dollar. We need to know the probabilities that

> admitting a generally well-appearing patient with a given pleiocytosis

> will save bad things, and then simply see if the cost of admission is

> below or above the cut-off.

Hmm, I would have assumed that the only logical means of proceeding would

be to allow the physically attending Dr. to base thier decisions upon

thier pt's presentation and thier Dx instead of having to make thier

decision based upon a phone call to a HMO provider who's only interest is

seeing that thier CEO's pocket is lined with at least a 8 figure number

that year.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

[email protected] IRC Admin LasVegas.NV.US.Undernet.org


------------------------------------------------------------------------------

Grant me the ability to give Emergency Care. With skillfull hands, and

knowledgeable mind, and tender love and care. Help me deal with

everything, when lives are on the line. To see the worst, administer aid,

and ease a worried mind. So help me as I go today, accept what fate may

be. Touch these hands, use this mind, help this EMT...Amen

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~




Date: Thu, 27 Aug 1998 16:03:21 -0400Reply-To: "J. Glustein, MD" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "J. Glustein, MD" <[email protected]>Subject: Back-up plans

I know I have seen this question posted before, and I hate to drag it up

again, but our department is being asked to come up with a back-up plan

to increase staffing in the ED when we are faced with an overwhelming

volume of patients. Would anyone be willing to share with us a copy of

their plan if they have faced this issue? Also, has anyone faced this

issue and not come up with a plan? How did you handle it, if so?

Thanks





Ray Pitetti, MD

Children's Hospital of Pittsburgh

[email protected]




Date: Tue, 1 Sep 1998 00:20:17 -0700Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "John O. Evered" <[email protected]>Organization: UCSFSubject: Hyperkalemia in CAH

A question for the group: Do you use insulin and glucose in the

management of severe hyperkalemia in congenital adrenal hyperplasia

(CAH) crisis? The Fleisher/Ludwig peds ER texts state that most

neonates with CAH tolerate K's of 10 remarkably well and that most of

the time, saline and steroids will resolve the hyperkalemia; and that

insulin is contraindicated because of the risk of causing hypoglycemia.

Someone responded in conference today that this was nonsense and that

you should treat very high K (and all high K with marked EKG changes or

arrhythmias) with insulin, as well as calcium, kayexelate, bicarb and

other means, as always. I have not been able to find case reports or

reviews that help weigh the risks of hypoglycemic seizures vs.






hyperkalemic arrhythmias for these babies. Can anyone comment, or point

me towards some literature? How would the presence of arrhythmias

affect your decision? (Our case patient had had a potassium of 10 and a

brief run of V-tach, for example, but then had a normal 12-lead despite

a repeat K of 10).




Date: Tue, 1 Sep 1998 23:39:18 EDTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Randolph J Cordle <[email protected]>Subject: Herniation ? from LP.

Hello,

I have been following this unfortunate thread on this and the PICU list and

have an academic question for the group. What is the true evidence that the

LP in the cases cited actually caused the herniation? Certainly a temporal

relationship has been suggested by the literature and I am not saying that

cause and effect are not present, but I am not yet convinced that this is the

case. Obviously, this has serious medical and legal ramifications. Could it

be that the LP just happened to be done at about the time these children were

going to herniate? From a pure physics standpoint if you truly create this





great lumbar vacuum why doesn't herniation occur immediately? When it does I

think the temporal argument speaks much more conclusively to cause and effect

but when it is 12 or 24 hours later I think it is difficult to say. I do not

have the citation at my finger tips but I remember one of our pediatric

neurosurgeons considering a lumbar, yes lumbar, drain on a pediatric trauma

patient with increased uncontrollable elevated ICP because of recent

literature demonstrating its ability to lower ICP even in patients with bolts

already in the lateral ventricle ( Sorry, I do not remember all the

specifics).

I do not disagree with some of the suggested diagnostic and theraputic plans

only with the evidence on which we may be basing our decisions and the

possible legal ramifications to our colleagues who might practice differently

based on the same literature. If anyone knows of good literature proving

cause and effect or statistically significant differences in outcome in

matched cohorts please let me know.

Respectfully,

Randy Cordle MD

Lehigh Valley Hospital

Department of Emergency Medicine






Date: Thu, 3 Sep 1998 18:04:53 -0300Reply-To: Richard Hemmer <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Richard Hemmer <[email protected]>Subject: Re: Question for the groupX-To: Maureen McCollough <[email protected]>In-Reply-To: <[email protected]>

||||||||||||||||||||||||||||||||||||||||||||||||||||FLAME SHIELD ON

OK.. Let me get into hot water again...

I believe that if the child is in severe distress and is not intubated by

the paramedic, then the closest facility is the answer. If the child is

intubated by the paramedic and there is a clear understanding that the tube

is in, (i.e.: SaO2, EtCO2, Chest Rise/Fall, EQUAL Lung Sounds), then I

believe that the closest PEDS HOSPITAL is the answer. IF THE DIFFERENCE

FROM THE SCENE TO THE PEDS HOSPITAL IS LESS THAN 3-5 MINUTES, THEN THE PEDS

HOSPITAL IS THE ANSWER.

However, If an Emergency Physician / Medical Control Physician has any

doubt as to the airway, then the closest hospital is the ONLY ORDER THAT IS

APPROPRIATE AS A TRANSPORT DECISION ORDER!!! If that physician knows the

paramedic and feels that his/her pediatric skills are not EXCELLENT, then

the transport to the CLOSEST hospital.

I have worked on all three aspects.. the paramedic, the community non-peds



specialty ER and the Peds ER. This is just my $0.02.

Rich Hemmer


From: Pediatric Emergency Medicine Discussion List

[mailto:[email protected]]On Behalf Of Maureen McCollough

Sent: Thursday, September 03, 1998 3:51 AM

To: Multiple recipients of list PED-EM-L

Subject: Question for the group

Question for the group (and I will try to ask it as neutrally as possible).

Hypothetical situation - child in "severe respiratory distress" in the field

(as per a paramedic's evaluation).

Is it better for the child to be transported by paramedics 30 minutes (or

many times longer) in order to get to a "Pediatric Critical Care Center"

(may not necessarily be soley a "children's hospital") or is it better for

the child to be transported only a few minutes to a general emergency

department staffed with board certified and/or residency trained emergency

physicians?? The PCCC ED is staffed by emergency physicians but has a PICU

and intensivists and specialists. Other examples of cases like this would

include a cyanotic child or child in status epilepticus.

There are over 80 general emergency departments at your disposal and only 9

Pediatric Critical Care Centers for 10 million people with unbelievable

traffic jams at times. Large areas of your county do not have a PCCC and

therefore long transport times to PCCC's are the rule, not the exception,

for these areas. Existing policy states over 20 minute transport time

requires helicopter to be called in which can take significant amounts of

time for it to arrive on scene which can extend total transport time. It is

proposed that allowable ground transport time to a PCCC be extended to 30

minutes, at which point a helicopter would be called. I am not looking at

trauma cases, just medically ill children.

Interested in what the group thinks. Remember, I am staying neutral so tone

down the hate mail (just kidding - I can take it)

Maureen McCollough

OliveView-UCLA Medical Center










Date: Fri, 4 Sep 1998 19:08:33 -0400Reply-To: Jason Cerovac <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jason Cerovac <[email protected]>Subject: Re: PED-EM-L Digest - 2 Sep 1998 to 3 Sep 1998X-To: MARTIN I HERMAN <[email protected]>In-Reply-To: <005901bdd82a$b929eac0$07349cd1@default>

On Fri, 4 Sep 1998, MARTIN I HERMAN wrote:

> I would agree that transport to the nearest facility would be appropriate

> for a child in distress.especially with airway compromise and the other

> situations cited.I do have confidence that any residency trained emergency

> doc should be able to stabilize a children distress. Telephone consults are

> easily obtained and if the emergency physician needed any advice from the

> PCCC , he /she could call..

>

> Why would anyone leave a patient in jeopardy during along transport when

> competent help is nearby??

As a paramedic, I take the position of "transport to the nearest

appropriate facility." This sometimes entails passing other hospitals





that may be able to provide the care, but in passing them I am going to a

hospital that CAN provide the care. Not all ED's staff pediatric

personnel, or even have on call specialists that might be needed. It is

the duty of the paramedic or EMT to know what resources a particular

hospital has available.

If I had a sick child, it would benefit that child to go to an ED with

pediatric practioners. If I can provide life-supporting care to

facilitate that extended transport, I will. If the care can not be

provided, I divert to the nearest facility. In the latter case, if need

be, the child can later be transfered to the better facility.

As far as telephone consultation goes: In the emergency medical services

are specially trained physicians whose job is to provide on-line support

for field personnel. These doctors help us determine the best course of

treatment, give us orders, and sometimes act as a resourse when we are

stumped. Every EMS system has in place a 'medical control' system.

Through off-line protocols and on-line support they extend the physician

into the field. (A paramedic is a physician extender).

My .02

Jason

[email protected] | I will defend to the death | New York State EMT-P

finger for contact | your right to free speech, | Woodstock 94 Medical Team

information. | You shall be free | Learn CPR - Ask me how!


<All unsolicited E-Mailers (spam) will be charge a $20 processing fee>




Date: Tue, 8 Sep 1998 19:52:57 EDTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Randolph J Cordle <[email protected]>Subject: Sore Elbow

I am not sure that a sed rate can accurately differentiate sickle cell from

infecton in such a case. I wonder how useful ultrasound would be in this case

to first show effusion and then give some indication of possible

osteomyelitis. Although I do not believe US has great sensitivity in early

cases of osteo I believe its specificity is probably better than that of a

bone scan in patients with crises, unless possibly if tagged wbc are used.

Possibly one of our pediatric radiology colleagues could shed some light on

this for us.

Randy Cordle MD










Date: Fri, 11 Sep 1998 01:06:02 -0500Reply-To: jay pershad <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jay pershad <[email protected]>Subject: FU elbow

I appreciate you all's input. For those interested in a follow up, I did

get a ESR on this patient in the ED. It was 34. Started IVF and gave some

MS for analgesia. Eventually ended up admitting her to Hematology, who knew

her well. She gradually improved over the next two days with full range of

motion with fluids and analgesia and was discharged today. The working

diagnosis was vasoocclusive crisis in the left elbow. While in hospital the

elbow was not tapped nor was any bone scan/USG done.

Jay Pershad, MD




Date: Mon, 14 Sep 1998 20:24:19 -0700Reply-To: Henry Ngo <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Henry Ngo <[email protected]>Subject: Rapid Strep test







Personally I think Rapid strep is very helpful in the ER esp. if a

positive test is in the context of strong clinical suspicion of strep

pharyngitis. However, if the clinical suspicion is strep infection and

the Rapid strep is negative, then one has to proceed doing a throat

culture. So in essence, the use of Rapid strep is for you to order PCN

for total of 10 days with full confidence once the test is positive. If

the Rapid test is negative, you may elect to wait for the throat culture

to come out and act on it appropriately.

Henry Ngo,MD

Member,ACP




Date: Tue, 15 Sep 1998 21:14:10 -0500Reply-To: Louis Geoffroy <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Louis Geoffroy <[email protected]>Subject: Re: Febrile seizure

parisa arman wrote:

>

> Hi everybody,

> I have a question, How do you decide on doing LP in a febrile child





> who presents with seizure?

>

***************

I treat a febrile child with simple febrile seizure like any other child

with fever only: If he looks sick, if he has stiff neck then I do a LP.

Sometimes a period of observation is needed (once the post-ictal state is

finished) before I make up my mind...

There is no more risk of meningitis among this sub-population.

----

Louis Geoffroy, m.d.

Emergency departement

Hopital Ste-Justine pour enfants

Montreal, Quebec, Canada

----

Si vous recherchez un BON camp de vacances,

allez =E0 cette adresse:

http://www.odyssee.net/~geoffroy/tekakwitha.html






http://www.odyssee.net/~geoffroy/tekakwitha.html

Date: Wed, 16 Sep 1998 14:34:28 -0300Reply-To: jorge alvarez <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jorge alvarez <[email protected]>Subject: LP and Strep swabs

Sorry if my opinion is a little simple.Here at La Plata Children's Hospital

we treat suspicious throats with a 10 day pen PO or benzatine injection if

the patient is not going to return.We have a pretty good lab facilities but

we don't use quick methods, we must plate all swabs.Could anybody describe

such quick methods and advantages for me?

As to L.P. I've been doing LP to any postconvulsive febrile child who is

not clearly a febrile convulsion.I agre with that clinical impression or

gestalt as was mentioned as the most sensitive resource we have.Here at

Argentina we have a saying that goes like this: "If anyone(doctors or

nurses) thought of a LP ,do it"Of course we have done a lot of negative LP

but one opportune

diagnosis may be life-saving.We often consult a pediatric neurologist who

is on call in the Hospital and we have never disagreed.

It is good to read your messages,I'm learning a lot and losing my

fears to write my owns.

Dr.Jorge Alvarez

Chief Pediatric Interns

Children's Hospital Sor Maria Ludovica

La Plata Argentina

[email protected]




Phone 54-1-522075




Date: Thu, 17 Sep 1998 14:06:11 -0500Reply-To: Harvey Louzon <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Harvey Louzon <[email protected]>Subject: Re: Rapid Strep test - Why?

>Why treat strep with antibiotics at all?

Because it's been shown in placebo controlled studies to shorten the

duration of illness.

How's that for a novel idea?

h










Date: Sun, 20 Sep 1998 02:35:02 -0500Reply-To: jay pershad <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jay pershad <[email protected]>Subject: Re: Febrile seizures

Dr Hennes wrote:

"The guidelines from the AAP and the ACEP are just guidelines and I hope to

God they will stop publishing them.

I'm just tired of these so called guidelines which may cause unnecessary

risks to kids and is a financial burden for some parents."

Mega ditto's Halim!!!

The other concern that I have with such promulagations is that they have

medicolegal implications for all of us who are practicing real world

medicine ( & not "ivory tower" recommendations); I do understand that they

are only guidelines that need not be followed in all cases and tend to be

conservative in their intent, but when one has a large national

organization representing children in our country, come out with a

consensus statement, it makes things very awkward indeed. More so, if faced

with an outcome that does not follow one's honest clinical judgement....

Emotions aside, where is the clinical data to support this age cut offf??.

It seems strange to me that in the "fever" guidelines clinical judgement

was recommended to decide need for an LP above the age of 2- 3 months but



the same judgement cannot be utilized for a febrile child with a seizure

who is 9 months old and is now alert and and blowing bubbles at me???

I have been following this thread with avid interest and would add the

following comments not mentioned:

1. The decision analytic model used by Joffe, Deangelis & Mcormick

published in AJDC 1983; 137(12) entitled "Which children with a FC need

LP?" is worth reading. They reviewed 300 odd patients presenting (in the

pre-Hib era) with fever and seizure. The results had a 100 % NPV for

meningitis if these 4 criteria are used (a) presenting with an active

seizure to the ED (b) Abnormal neuro exam (c) focal seizure (d) Seen PMD

within the last 48 hours.

2. There is enough data out there to suggest that, depending on whom you

read, 30 -60 % of these FC are caused by HHV 6 ( same one causing Roseola).

A smaller % are also caused by HHV 7, adenovirus etc.

3. Occult meningitis was an issue with febrile kids with HFlu bacteremia.

With its virtual elimination, having an age cut off like 12 months makes no

sense to me.

I would also rely on a careful history & good clinical examination in such

cases. Have I caught the wrong end of this burning stick ??

Jay Pershad, MD

"Every noble thought in your mind brings you closer to God"




Date: Tue, 22 Sep 1998 11:58:01 CSTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Mark O. Davis" <[email protected]>Subject: Re: T chartsX-To: David Soglin <[email protected]>

Addressed to: David Soglin <[email protected]>

Multiple recipients of list PED-EM-L <[email protected]>

** Reply to note from David Soglin <[email protected]> Tue, 22 Sep 1998 10:53:52 -0700

> What are T-charts?

Check out www.tsystem.com.

Mark in San Angelo

[email protected]

09/22/98, 11:57:59


http://www.tsystem.com/












Date: Fri, 25 Sep 1998 12:07:23 EDTReply-To: Robert Wright 525-0352 <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Robert Wright 525-0352 <[email protected]>Subject: re GABHS

I am not sure of the value of the previous cost-benefit analysis by Dr.

Newdow.

If we assume that all ARF is caused by GABHS and that the bacteria is

100% sensitive to antibiotics, then the population attributable risk of "not

treating with ABX" is 100%.

Since the sensitivity and specifity of combined Rapid strep and culture

is quite high, and the prevalence of the disease among the select

population (children greater than 5 with sorethroats) is also high, then the

positive predictive value should be high. Very few cases will be missed and

less needless abx will be prescribed which is of clear benefit to the public.

My understanding is that the 1-2 day delay in treatment while waiting for

the culture does not increase the risk of ARF.

I can think of no argument to justify treating everyone, unless your





department refuses to do rapid streps and cannot do follow-up on patients

for socioeconmic reasions.




Date: Mon, 28 Sep 1998 10:39:07 -0400Reply-To: Jeffrey F Linzer <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jeffrey F Linzer <[email protected]>Subject: Re: pneumovaxX-To: jay pershad <[email protected]>In-Reply-To: <[email protected]>

I think it would be great if this vaccine works as well as the one for H.

flu. However did anyone catch the blurb on a national news program on

Friday that researchers in Finland are worried about a link showing an

increased risk of IDDM in vaccine recipients?

Jeff

Jeff Linzer MD MICP

Division of Emergency Medicine

Egleston and Hughes Spalding Children's Hospitals

[email protected]









Date: Mon, 5 Oct 1998 13:05:10 -0400Reply-To: Dina Ann Kouveliotes <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Dina Ann Kouveliotes <[email protected]>Subject: ED Leadership & Skip Barber RacingX-To: [email protected]

Have the time of your life=85and learn the skills that could save it!

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Date: Wed, 7 Oct 1998 09:22:58 -0400Reply-To: Jeffrey Mann <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jeffrey Mann <[email protected]>Subject: Re: Dermabond topical adhesive

To those of you who have been using the Dermabond adhesive in the ED -

how are ensuring adequate wound irrigation without using local

anesthesia?




http://www.cambridgehealth.com/


Secondly, are you using Dermabond for lacerations that are gaping more

than 5mm (which is an apparently widely accepted threshold indicating

that the wound is under significant static tension forces); and if you

are - what is your experience with subsequent wound dehiscences?

Jeffrey.




Date: Thu, 8 Oct 1998 16:21:13 +1000Reply-To: Patrick Linehan <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Patrick Linehan <[email protected]>Subject: Re: Dermabond topical adhesiveIn-Reply-To: <[email protected]>

>Date: Wed, 7 Oct 1998 20:59:18 -0400

>From: sudha-russell <[email protected]>

>Subject: Re: Dermabond topical adhesive

>

>I have been using LET (whenever appropriate and feasible), prior to

>irrigation.

>

>What 's the group's experience, with potential complications such spillage,

>and "unintended" application, of the Dermabond adhesive in children where


>the restraints may not hold?

>

>Sue

I have been using the Histoacryl Blue adhesive for the past 5 years,

usually treating a three or four patients a week, usually without

irrigation,and in that time I have never seen a wound infection. In order

to get a good result you have to stop the flow of blood and so I usually

apply LET or lidocaine with epi for 10 minutes. Once or twice I have glued

the tip of a glove to a child's face. If I am repairing a laceration near

the eye I usually cover the eye with gauze to make sure no glue falls in.

Histoacryl is supposed to be dropped on according to the manufacturer, but

I found it looks less clumpy and more professional if you "paint" it on.

Histoacryl comes in a single dose container, but everyone in Canada

converts it to a multidose container by putting a 25 or 28 G needle over

the tip of the container. The cost for a vial is about $25 and you can

usually treat 4 or 5 patients per vial.

The edges of the laceration will not be everted using glue, the direction

of forces are parallel to the suface of the skin and so won't pull the

wound margins upward.

I think the reason that I haven't seen many wound infections is due to

selection of wounds: if a wound needs to be cleaned due to contamination

(dirt, dogbite etc.) I would freeze the wound up and irrigate or debride

and then either suture or leave open.

I think there is a good case for not irrigating clean small wounds:

TITLE: Irrigation in facial and scalp lacerations: does it alter outcome?

AUTHOR: Hollander JE; Richman PB; Werblud M; Miller T

Huggler J; Singer AJ

AUTHOR AFFILIATION:

Department of Emergency Medicine, University Medical Center, State

University of New York at Stony Brook, USA. [email protected]

ABSTRACT:

STUDY OBJECTIVE: Animal and human studies suggest that irrigation

lowers the infection rate in contaminated wounds, but there is no

evidence that this common practice is beneficial for "clean"

lacerations. We tested the null hypothesis that there is no

difference in the infection rate for noncontaminated lacerations to

the face and scalp that are irrigated before primary closure compared

with similar wounds that are closed primarily without irrigation.

METHODS: We performed a cross-sectional study of consecutive patients

presenting to a suburban, academic emergency department between

October 1992 and August 1996. Patients with nonbite, noncontaminated

facial skin or scalp lacerations who presented less than 6 hours

after injury were included. Structured, closed-question data

collection instruments were completed at the time of laceration

repair and at suture removal. The primary outcome parameters were the

incidence of wound infection and the short-term cosmetic appearance

of lacerations in patients who did or did not receive irrigation.

RESULTS: A total of 1,923 patients were included in the study group;

1,090 patients received saline irrigation, and 833 patients did not.

The irrigation and nonirrigation groups were similar with regard to

time from injury to presentation (1.56 versus 1.42 hours,

respectively), frequency of linear wound morphology (82% versus 88%),

frequency of smooth wound margins (72% versus 82%), number of layers

of closure (1.14 versus 1.26), number of skin sutures applied (4.98

versus 4.65), number of deep sutures applied (.70 versus 1.05), and

use of oral antibiotic prophylaxis (2.8% versus 4.0%). With respect

to outcomes, the incidence of wound infection was not significantly

different between the two treatment groups (.9% versus 1.4%,

respectively; P = .28). Likewise, the percentage of patients who had

an "optimal" cosmetic appearance was similar in the two groups (75.9%

versus 81.7%, respectively; P = .07). CONCLUSION: Irrigation before

primary closure did not significantly alter the rate of infection or

the cosmetic appearance in our study population with clean,

noncontaminated facial and scalp lacerations.

SOURCE: Ann Emerg Med 1998 Jan;31(1):73-7

With regards to the anecdote about a facial cellulitis following Dermabond

glue dehiscence I suspect that the issue was wound cleaning and wound care

rather than type of closure.

Patrick Linehan, MDCM

now far from frigid Canada in sunny Saipan.




Date: Thu, 8 Oct 1998 12:06:09 -0400Reply-To: "Michael G. Tunik" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Michael G. Tunik" <[email protected]>Subject: Re: Dermabond topical adhesive

......I think there is a good case for not irrigating clean small wounds:

>TITLE: Irrigation in facial and scalp lacerations: does it alter outcome?

>AUTHOR: Hollander JE; Richman PB; Werblud M; Miller T

> Huggler J; Singer AJ

>AUTHOR AFFILIATION:

> Department of Emergency Medicine, University Medical Center, State

> University of New York at Stony Brook, USA. [email protected]

>ABSTRACT:

> STUDY OBJECTIVE: Animal and human studies suggest that irrigation

> lowers the infection rate in contaminated wounds, but there is no

> evidence that this common practice is beneficial for "clean"

> lacerations. We tested the null hypothesis that there is no

> difference in the infection rate for noncontaminated lacerations to

> the face and scalp that are irrigated before primary closure compared


> with similar wounds that are closed primarily without irrigation.

> METHODS: We performed a cross-sectional study of consecutive patients

> presenting to a suburban, academic emergency department between

> October 1992 and August 1996. Patients with nonbite, noncontaminated

> facial skin or scalp lacerations who presented less than 6 hours

> after injury were included. Structured, closed-question data

> collection instruments were completed at the time of laceration

> repair and at suture removal. The primary outcome parameters were the

> incidence of wound infection and the short-term cosmetic appearance

> of lacerations in patients who did or did not receive irrigation.

> RESULTS: A total of 1,923 patients were included in the study group;

> 1,090 patients received saline irrigation, and 833 patients did not.

> The irrigation and nonirrigation groups were similar with regard to

> time from injury to presentation (1.56 versus 1.42 hours,

> respectively), frequency of linear wound morphology (82% versus 88%),

> frequency of smooth wound margins (72% versus 82%), number of layers

> of closure (1.14 versus 1.26), number of skin sutures applied (4.98

> versus 4.65), number of deep sutures applied (.70 versus 1.05), and

> use of oral antibiotic prophylaxis (2.8% versus 4.0%). With respect

> to outcomes, the incidence of wound infection was not significantly

> different between the two treatment groups (.9% versus 1.4%,

> respectively; P = .28). Likewise, the percentage of patients who had

> an "optimal" cosmetic appearance was similar in the two groups (75.9%

> versus 81.7%, respectively; P = .07). CONCLUSION: Irrigation before

> primary closure did not significantly alter the rate of infection or

> the cosmetic appearance in our study population with clean,

> noncontaminated facial and scalp lacerations.

>SOURCE: Ann Emerg Med 1998 Jan;31(1):73-7

>Patrick Linehan, MDCM

Patrick,

I agree there is no statistical difference between saline irrigation and no

irrigation in this study. Did the authors do a power analysis ? To find a

differences between 2% infection and 1% infection (a decrease of 1%) with a

power of 80% that if the difference is there it will be found, you would

need a sample size of 2300 in the treatment AND the control groups. This

is a much larger sample than I have seen published for minor wound

infection rates with or without saline or other interventions (antibiotics).

Clearly the infection rate is low for both control and intervention

groups...the real question is IF a diffidence of 1 % exists, especially for

facial lacerations, is it worth using saline lavage for 99 patients to

prevent one episode of cellulitis? This study has not answered that question.

Mike Tunik

Michael Tunik, MD

Associate Director

Pediatric Emergency Medicine

Bellevue Hospital Center/NYU School of Medicine

212 562 3403 phone

212 562 2474 fax

Bellevue Hospital Center

Pediatrics 1 South 6

27th Street and First Avenue

New York, NY 10016




Date: Fri, 9 Oct 1998 10:27:31 -0500Reply-To: jay pershad <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jay pershad <[email protected]>Subject: AOM** reply

In a personal communication, I received this:

" Parents don't care about antibiotic resistance. They want symptomatic

relief ASAP."

But aren't WE supposed to care about resistance? I believe infectious


diseases will be the bane of our existence in another decade or so, with

patients dying from what should have been sensitive infections.

My practice is to not treat AOM if the patient reports <48h of pain. As

this is almost always the case ("Joey has been crying for the last 30

mins!!"), my approach has been to manage the pain aggressively with codeine

1-1.5 mg/kg q3h and to see the child in 24h. If pain persists or if the

re-exam looks worse, I treat. Since I started doing this, my use of Abx for

AOM has dropped by maybe 90%. The data you quote would seem to indicate

that I am not placing my patients at undue risk by doing this.

_____________________________________________________________________

I see your point. I would also agree that the data I have presented and

from some other European studies does not suggest a higher rate of

mastoiditis or meningitis with the conservative option.

However, it appears that the relief of fever and pain is shortened by a day

or so by adding abx. Also, I am uncomfortable witholding abx in the younger

infant and toddler for the reasons I mentioned in my original posting. Your

approach, in an older child, may be one way to go, if the parents are with

you on this. Unfortunately, in an ED setting (without prior rapport with

the family) as Dr. Sutton had stated, I must say, I too have a difficult

time changing parent's mindset on antibiotics in AOM. Especially, when that

is the very reason that prompted that 2 AM visit.

The issue of abx resistance is always there. My approach to that is, yes,

we do owe it to society at large to be responsible with our antibiotic

usage, but I would not choose to withold abx in this specific scenario of a

"red" hot symptomatic ear. I don't use antibiotics for asymptomatic

effusions for example, or that streaky infiltrqte on chest radiograph etc

etc.

My secret hope is one day we will have a revolutionary non invasive device

that could quickly tell us which AOM's are viral and which bacterial!!!

Would welcome further comments......




Date: Sat, 11 Oct 2098 17:03:20 -0400Reply-To: Ray Wiss <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Ray Wiss <[email protected]>Subject: Visit to Asia

Dear Fellow Members,

I will be vacationing in Hong Kong and Singapore during the first two weeks

of December/98. I would be very interested to visit Emergency Departments

in these two cities and would very much appreciate hearing from anyone who


could help make this possible.

Thank you,

Dr. Ray Wiss

Director, Emergency Department

Abitibi Regional Trauma Center

Amos, Quebec, Canada




Date: Thu, 15 Oct 1998 16:29:34 -0400Reply-To: Edward Conway <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Edward Conway <[email protected]>Subject: Re: Classification of ED'sX-To: Kenneth Frumkin <[email protected]>In-Reply-To: <[email protected]>

I am curious if anyne out there is familiar with a program that has a

Divison of Pediatric Emergency and Critical Care services as a combined

program. I have heard that there are 1 or 2 adult programs like this.

Pleae e amil me directly or voice 2128709692. Thanks in advance. Ed

Conway





Date: Sun, 18 Oct 1998 22:48:41 -0500Reply-To: jay pershad <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jay pershad <[email protected]>Subject: Re: Epi

I presume you are talking about SQ epinephrine. I reserve it as initial

therapy for the acutely dyspneic asthmatic while I am setting up the

albuterol aerosol. There is no reason to repeat it and favor its (non

selective beta agonist) use over the more selective beta2 agents. If you

were in an office setting say, where you may not have the facility to

quickly administer a nebulization, the dose of SQ epi may be repeated in 15

minutes. (see NIH guidelines on BA management form April 1997). Maximum

dose is 0.3 ml/dose of the 1:1000 preparation.

[I am not sure if "rebound" is an really an issue as with croup. The mode

of action of epi in BA unlike in croup, is not primarily the

alpha/vasoconstrictor effect but its beta effect on bronchial smooth

muscle]

Hope it helps

Jay Pershad, MD


"Safe kids are no accident"




Date: Tue, 20 Oct 1998 21:26:26 -0500Reply-To: MARTIN I HERMAN <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: MARTIN I HERMAN <[email protected]>Subject: Jobs

I am beginning to explore the possibilities of expansion..

Will need about 5-6 PEM docs to share with our group the responsibilities to

provide expanded coverage at some surrounding community ED's and may also

need docs who have significant pediatric experience and are comfortable with

adults to staff in urgent care or minor medical centers..

Anyone interested in more details contact me via private email or by phone

901 572 3010 or by fax 901 572 5025..

I would be glad to discuss our opportunities with anyone..

Martin Herman, M.D.

Assistant Medical Director LeBonheur Children's Medical Center

Assistant Professor of Pediatrics , UT College of Medicine





Date: Wed, 21 Oct 1998 13:43:34 -0400Reply-To: "Allen R. Walker" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Allen R. Walker" <[email protected]>Subject: Re: LP or no LPX-To: Doug Baker <[email protected]>

Given the description of "remarkably irritable", the uncertain history of

fever, the (assumed) lack of other physical findings to go with the

irritability, and the fontanel which is open and not bulging, I would tap

first then scan. I don't believe that the possibity of hydrocephalus

represents any contraindication. I believe the LP to be the first test in

this situation; I can't think of another test (peripheral WBC, for example)

which would alter the necessity of tapping this child.

Allen R. Walker, M.D.


Johns Hopkins

(410) 955-6143

----------

From: Doug Baker[SMTP:[email protected]]

Reply To: Doug Baker


Sent: Wednesday, October 21, 1998 7:44 AM


Subject: LP or no LP

I am polling the group.

Q: In the case that follows, would you perform an LP as a first test?

Case: A hypothetical 6 month old boy with a CC of fever at home today,

and irritability. No Vomiting, Diarrhea, Rash, or other Sx. Drinking OK.

PMH of BGS meningitis as a one month old, requiring a three week hospital

stay, resulting in some amount of developmental deficit (the extent unclear

from the mother's history). PE: Alert and drinking a bottle at tiage, but

intermittently irritable and lethargic in the exam room. T=37.8C. Unclear

if he had an antipyretic. Anterior fontanelle open (2cm), and full, but not

bulging. Crying when examined; appears remarkably irritable. Remainder of

HEENT exam grossly unremarkable, but head appears generous in size (no

measurement made). Chest, Abdomen, Skin, Extremities are grossly normal.

What do you test first?

If you suspect the child might have hydrocephalus, is a tap to rule out

meningitis contraindicated prior to obtaining a scan?

Thanks in advance for repies.

Doug Baker








Date: Sat, 24 Oct 1998 08:42:17 -0400Reply-To: Jeffrey Mann <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jeffrey Mann <[email protected]>Subject: Re: Dermabond

Hi Connie,

I am not suprised that the dermabond wound partially dehisced when the

child fell and impacted the area of the laceration. Dermabond is nothing

more than 'Crazy glue' which I have used extensively over the years to

repair household items. The glue has little strength - not because the

dried glue is not srong - but simply because of the limited strength of

the bond between the glue and the glued object. Try a simple

experiment:- Next time you dermabond a wound, use the remaining



dermabond adhesive to glue together two pieces of broken crockery and

then test how strong the glue-crockery bond is by pulling the two pieces

of crockery apart. The result of the expeiment will demonstrate the

weakness of the glue-tissue bond.

Dermabond (or other tissue adhesives) works well for lacerations where

the lacerations are linear, where the edges are flat and not

overlapping/inverted and where the wound edges lie in close apposition

with no gaping of the wound edges at rest. If you have to manually pull

the edges together with forceps, that should be a clue that the wound is

under significant static forces that will put the laceration at risk of

future dehischence. If you need to evert the edges of a laceration, that

means that the laceration is not suitable for dermabonding. The wound

edges should lie naturally flat and in close apposition.

A partially dehisced dermabonded laceration can be treated with repeated

layers of dermabond (expensive at $25 for one vial) or with steristrips

(few $'s). Steristrips will not really weaken the adhesive when it is

already dry - despite the opinions/admonitions of the ethicon reps, who

discourage the application of any other adhesive or lubricant to the

dermabonded wound.





Date: Mon, 26 Oct 1998 14:34:39 -0500Reply-To: Michelle Rotta <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Michelle Rotta <[email protected]>Subject: otitis and ceftriaxone

This is a multi-part message in MIME format.

------=_NextPart_000_000D_01BE00ED.C36B7080

Content-Type: text/plain;

charset="iso-8859-1"

Content-Transfer-Encoding: quoted-printable

It is always a relief when I read a message on the list and find it is a =

similar problem our department is trying to evaluate. We had a pow wow =

of sorts with falculty from Ped EM, Infectious disease, and ENT to =

discuss the use of Rocephin to treat OM. We were curious to the =

following given that OM is not an exclusion criteria to an occult =

bacteremia work up and came up with the following: 1) we do an OB work =

up (CBC and blood Cx) even for kids with a hot ear (so to speak) and if =

the WBC is < 15,000 we treat it with an oral antibiotic 2) same kid with =

a hot ear, WBC > 15,000, give the ceftriaxone and no further =

antibiotic. We did a literature review and the support is there that =

one dose of ceftriaxone is effective treatment for OM. However, we all =

agreed that unless there was a reason to give the ceftriaxone (increased =

WBC or patient won't take po) we would not use such a broad spectrum =

antibiotic to treat a disease that is likely viral. Here's the =

articles we reviewed. I hope this helps but it probably just confuses =

the matter. On a totally unrelated matter, I am new to the list and =

find everyone's comments helpful and imformative. Thanks.=20

Shelley Rotta,MD=20

Pediatric Emergency Medicine at The Children's Hospital of Buffalo

=20

1. Varsano I, Frydman M, Amir J, Gershon A, : Single IM Dose of =

Ceftriaxone as Compared to 7-Day Amoxicillin Therapy For Acute OM in =

Children,Chemotherapy 34, suppl.1,pp39-46 (1988).

2. Green Smm abd Rothrock SG, Singel Dose IM Cefriaxone for Acute OM in =

Children, Pediatrics 1993;Vol.91 No.1pp23-30.

3. Chamgerlain JM, Boenning DA, Waisman Y,Ochsenschlage DW, Klein BL, =

Single dose Ceftriaxone Versus 10 Days of Cefaclor for OM, Clinical =

Pediatrics, Nov. 1994, pp642-646.

4. Barnett ED et al, Comparison of Ceftriaxone and =

Trimethoprim-Sulfamethoxazole for Acute OM, Pediatrics, Jan. 1997, vol =

99 No. 1, pp23-28.

5. Varsano I et al, IM Ceftriaxone compared with oral =

amoxicillin-clavulanate for treatment of acute OM in children, Eur J Ped =

(1997) 156: 858-863.

------=_NextPart_000_000D_01BE00ED.C36B7080

Content-Type: text/html;



<!DOCTYPE HTML PUBLIC "-//W3C//DTD W3 HTML//EN">

<HTML>

<HEAD>

<META content=3Dtext/html;charset=3Diso-8859-1 =

http-equiv=3DContent-Type>

<META content=3D'"MSHTML 4.72.3110.7"' name=3DGENERATOR>

</HEAD>

<BODY bgColor=3D#ffffff>

<DIV>

<DIV><FONT color=3D#000000 size=3D2>It is always a relief when I read a =

message on=20

the list and find it is a similar problem our department is trying to=20

evaluate. We had a pow wow of sorts with falculty from Ped EM, =

Infectious=20

disease, and ENT to discuss the use of Rocephin to treat OM. We were =

curious to=20

the following given that OM is not an exclusion criteria to an occult =

bacteremia=20

work up and came up with the following: 1) we do an OB work up (CBC and =

blood=20

Cx) even for kids with a hot ear (so to speak) and if the WBC is < =

15,000 we=20

treat it with an oral antibiotic 2) same kid with a hot ear, WBC =

>=20

15,000, give the ceftriaxone and no further antibiotic. We did a=20

literature review and the support is there that one dose of ceftriaxone =

is=20

effective treatment for OM. However, we all agreed that unless =

there was a=20

reason to give the ceftriaxone (increased WBC or patient won't take po) =

we would=20

not use such a broad spectrum antibiotic to treat a disease =

that is=20

likely viral. Here's the articles we reviewed. I hope this helps =

but it=20

probably just confuses the matter. On a totally unrelated matter, =

I am new=20

to the list and find everyone's comments helpful and imformative. =

Thanks.=20

</FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2>Shelley Rotta,MD </FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2>Pediatric Emergency Medicine at The =

Children's=20

Hospital of Buffalo</FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2></FONT> </DIV>

<DIV><FONT color=3D#000000 size=3D2></FONT><FONT size=3D2>1. =

Varsano I, Frydman=20

M, Amir J, Gershon A, : Single IM Dose of Ceftriaxone as Compared to =

7-Day=20

Amoxicillin Therapy For Acute OM in Children,Chemotherapy 34, =

suppl.1,pp39-46=20

(1988).</FONT></DIV>

<DIV><FONT size=3D2>2. Green Smm abd Rothrock SG, Singel Dose IM =

Cefriaxone=20

for Acute OM in Children, Pediatrics 1993;Vol.91 =

No.1pp23-30.</FONT></DIV>

<DIV><FONT size=3D2>3. Chamgerlain JM, Boenning DA, Waisman =

Y,Ochsenschlage=20

DW, Klein BL, Single dose Ceftriaxone Versus 10 Days of Cefaclor for OM, =

Clinical Pediatrics, Nov. 1994, pp642-646.</FONT></DIV>

<DIV><FONT size=3D2>4. Barnett ED et al, Comparison of Ceftriaxone =

and=20

Trimethoprim-Sulfamethoxazole for Acute OM, Pediatrics, Jan. 1997, vol =

99 No. 1,=20

pp23-28.</FONT></DIV>

<DIV><FONT size=3D2>5. Varsano I et al, IM Ceftriaxone compared =

with oral=20

amoxicillin-clavulanate for treatment of acute OM in children, Eur J Ped =

(1997)=20

156: 858-863.</FONT></DIV></DIV></BODY></HTML>

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Date: Tue, 27 Oct 1998 21:09:38 -0600Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Kevin Kowaleski <[email protected]>Organization: Southwestern Bell Internet ServicesSubject: Re: Treatment of pediatric feverX-To: Jeffrey Mann <[email protected]>

In my experience, it has often been helpful to treat the child in triage with antipyretics so as

to facilitate the assessment of the child in the exam room, as the child will have often

defervesced by then. Even if the child is not irritable or drowsy in triage, it is not unusual

for such a child to look somewhat worse by the time the physician sees him/her.

Kevin Kowaleski

Toledo, Ohio

> The URL for the PED-EM-L Web Page is:








Date: Thu, 29 Oct 1998 07:51:48 -0600Reply-To: "Martin I. Herman" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Martin I. Herman" <[email protected]>Subject: Re: Tx of pediatric fever

TO Ray,,

I agree that 30 mg/kg loading dose of acetaminophen is more efficacious, I

would caution that it is difficult to feel completely comfortable because you

can never be entirely sure that there has not been any antecedent use.SO the

daily dose of 150 , may have in fact already been given.. More over, there

have ben cases of toxicity with regular use of APAP AT THERAPEUTIC DOSAGES.

MIH, Memphis




Date: Fri, 30 Oct 1998 11:50:26 -0500Reply-To: Doug Baker <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Doug Baker <[email protected]>Subject: APA Spring Meeting Planning Committee

<underline>APA PEM SIG PLANNING COMMITTEE NEEDS VOLUNTEERS...


</underline>

The APA Pediatric Emergency Medicine SIG will be holding it's annual

Spring Session in May (1999). As the SIG leader, I am still looking for

volunteers to participate as Planning Committee members. I have had a few

inquiries, and will contact those people soon. However, we need more

interested participants. This is a fun job, which provides some national

exposure for those involved.

Please contact me if you are interested in participating as a Committee

member.

Thanks,

Douglas Baker, M.D.

PEM SIG Chairperson


Yale-New Haven Children's Hospital

20 York Street

New Haven, CT 06504

203-688-7970

203-688-4195 (fax)

[email protected]




Date: Sat, 31 Oct 1998 11:36:13 +0000Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Miles Nelson <[email protected]>Subject: Re: treatment of pediatric feverX-To: [email protected]

Miles Nelson wrote:


> I musta skipped that day in medical school cause I don't recall any contraindication for the use

> of ibuprofen in varicella. What exactly is the risk? I don't believe Reye has been observed.

>

> Miles Nelson, M.D.

>

> steven szabo wrote:

>

> > All of us who have children at home know by now how miserable they are when

> > febrile and how wonderful is having some Ibuprofen at hand ...Triage

> > protocols are usually for Tylenol because of fear of using Ibuprofen in

> > case of varicella or the possibility of surgery(coagulation).

> > I think antypiretics were invented to treat fever and I am all for it at

> > triage. There is nothing wrong "treating" the parents as well...after all

> > they are the ones judging the quality of care given ( and paying the bill

> > too..)

> > Steven Szabo, M.D.

> >

> > For more information, send mail to [email protected] with the message: info PED-EM-L

> > The URL for the PED-EM-L Web Page is:

> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html





Date: Sun, 1 Nov 1998 14:29:57 -0600Reply-To: MARTIN I HERMAN <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: MARTIN I HERMAN <[email protected]>Subject: Aerosols

I am puzzled..

How many are using MDI with spacers for infants and kids < 5?

the literature seems to support the use of MDI..

1. RANDOMISED TRIAL SPACER V. NEBULISER FOR ACUTE ASTHMA Parkin, P.C., et

al, Arch Dis Child 72(3):239, March 1995

METHODS: This randomized, prospective study, from the Hospital for Sick

Children in Toronto compared outcomes in 60 children aged one to five

hospitalized for moderate acute asthma who were treated after initial

stabilization with IV or oral steroids plus albuterol with ipratropium

bromide given by either MDI/spacer or nebulizer. For children treated with

the MDI/spacer, the dose of albuterol was four puffs (400mcg), five puffs,

or six puffs for those weighing less than 12kg, 12-16kg, or 16kg or more,

respectively, and the dose of ipratropium was two puffs (40mcg). For

children treated with the nebulizer, the doses of albuterol and ipratropium

were 0.15mg/kg and 125mcg, respectively. RESULTS: The baseline asthma


score (on a scale of 1-10) was higher in the MDI/spacer group (5.7 vs. 4.8,

p=0.02). Nine of the 30 MDI/spacer patients were ultimately treated with

nebulized bronchodilators, but only four were considered to be MDI/spacer

failures. Asthma scores demonstrated similar improvement in both groups and

were nearly identical from 24-60 hours after initiation of treatment. The

mean total number of doses administered was 20 in the MDI/spacer group and

17 in the nebulizer group, and the mean time to discharge was 53 and 46

hours, respectively. Treatment was assessed by nurses to be easier and

better tolerated in the MDI/spacer group. There were no significant

differences between the two groups in the percentage of patients who were

asymptomatic at seven and fourteen days. CONCLUSIONS: As has been observed

in adults and older children, administration of bronchodilators by

MDI/spacer appears to be as effective as administration by nebulizer in

preschool age children with moderate acute asthma. 6 references *Copyright

1995 by Emergency Medical Abstracts - All Rights Reserved

07/95 - #34

2. METERED-DOSE INHALERS WITH SPACERS VS. NEBULIZERS FOR PEDIATRIC ASTHMA

Chou, K.J., et al, Arch Ped Adol Med 149(2):201, February 1995

BACKGROUND: Patients with acute exacerbations of asthma are frequently

treated with nebulized bronchodilators. However, studies conducted in

adults have shown that delivery of beta agonists by metered dose inhaler

(MDI) with an attached spacer, which eliminates the need for coordination of

breathing and MDI actuation, is as effective as more labor-intensive

nebulizer therapy. METHODS: This randomized, prospective study, from the

Bronx Municipal Hospital Center in New York, compared the effects of

standard nebulized albuterol (0.15mg/kg to a maximum of 5mg given in 3ml of

normal saline), and albuterol delivered by MDI with a spacer (Aerochamber,

Monaghan Medical Corp.) in 152 children aged two or older presenting with

acute exacerbations of asthma. Children in the MDI/spacer group received

standard doses of three 90mcg puffs per dose. Each puff was dispensed into

the spacer, after which the child was instructed to breathe normally five

times through either the mouthpiece of the spacer or the spacer mask (for

children under the age of five). In both groups, doses were given at 20-

minute intervals. RESULTS: There were no significant differences between

the two groups in changes in asthma severity scores or PEFR, oxygen

saturation, number of treatments administered, use of steroids during acute

treatment, or percentage of patients who required hospitalization. Mean

treatment time in the emergency department was 66 minutes in the MDI/spacer

group compared with 103 minutes in the nebulizer group (p<0.001), while

patients in the nebulizer group had a higher incidence of vomiting (20% vs.

8%, p<0.04) and a greater mean increase in heart rate (15% vs. 5%, p<0.001).

CONCLUSIONS: These findings suggest that in children, as in adults, MDIs

with spacers are as effective as nebulizer therapy for the management of

acute exacerbations of asthma. 21 references *Copyright 1995 by Emergency

Medical Abstracts - All Rights Reserved

06/95 - #35

3. RESPIRATORY ASTHMA PEDIATRIC

ALBUTEROL DELIVERED VIA METERED-DOSE INHALER WITH SPACER FOR OUTPATIENT

TREATMENT OF YOUNG CHILDREN WITH WHEEZING Hickey, R.W., et al, Arch Ped Adol

Med 148(2):189, February 1994

BACKGROUND: Several studies have demonstrated clinical improvement in young

children with wheezing when adrenergic therapy was administered

subcutaneously or via nebulization. METHODS: This double-blind,

prospective, placebo-controlled crossover trial, from the Children's

Hospital of Pittsburgh, examined the clinical efficacy of albuterol

delivered via metered-dose inhaler with a spacer for the treatment of

acutely wheezing infants aged 1-18 months. Forty-two infants were

randomized to two groups. One group received two albuterol treatments (two

puffs, 180mcg) followed by two placebo treatments, and the second group

received two placebo treatments followed by two albuterol treatments. The

treatments were administered every 20 minutes via a MDI and a "homemade"

spacer. The MDI-spacer was held over the child's mouth and nares for six

breaths following each puff. Clinical assessment (heart and respiratory

rates, wheezing and retraction scores, and oximetry) was performed prior to

each treatment and 20 minutes after the last treatment. RESULTS: Both

groups demonstrated a statistically significant improvement in wheezing

scores after two treatments with albuterol, and the second group showed a

statistically significant improvement in retraction scores. There were no

significant changes in heart rate or oxygen saturation. CONCLUSIONS:

Treatment of acutely wheezing infant outpatients with albuterol via a MDI

and spacer decreases the severity of retractions and wheezing. Thus,

albuterol therapy with a MDI and spacer may be as efficacious as more

expensive and cumbersome nebulization therapy. 41 references *Copyright

1994 by Emergency Medical Abstracts - All Rights Reserved

07/94 - #38

SO,, is there anyone using MDI's in infants..??

WHat about for bronchiolitis or croup???

Thanks,

Martin




Date: Mon, 2 Nov 1998 11:22:30 -0500Reply-To: Gary Joubert <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Gary Joubert <[email protected]>Subject: Rash Photos

I am presenting a talk at an acedemic day in emergency medicine. The

group of learners will include family doctors, ER MD's, residents and ER

nurses. Does anyone know of a good source of photographs of rashes

that can be down loaded and used as slide? Or does anyone in the


group have some material that they are willing to share?

If you do please send to

[email protected]

Thanks

Gary Joubert




Date: Tue, 3 Nov 1998 10:21:44 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: [email protected]: info on KED

I have just started attending a paramedic program, and I am looking for

information about the KED. Are there any printed articles that you know of

that may be of assistance?

Mark Bruno emt

email [email protected]





Date: Thu, 5 Nov 1998 23:54:56 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jackie Mador RN CEN <[email protected]>Subject: Observation UnitsX-To: [email protected]: [email protected]

We are in the process of opening a 7 bed Observation Unit as part of our

Pediatric Emergency Department for the 23 hour admits. It is located adjacent

to the current department (separated by a hallway) and will have dedicated

nursing staff.

I am looking for any words of wisdom from others who have opened similar

units. Specifically about things like a) do you use inpatient documentation

standards and forms? b) what are your inclusion/exclusion criteria? c) how

do you determine nurse:patient ratios? d) are there any rules and regs

specific to observation units that I should be aware of?

Any information would be greatly appreciated.

Thank you.


Jackie Mador RN CEN

Unit Manager, Pediatric Emergency Department

University Medical Center

1800 W. Charleston Blvd.

Las Vegas, NV 89102

Fax: 702-383-3747




Date: Tue, 10 Nov 1998 17:26:31 -0500Reply-To: Ray Wiss <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Ray Wiss <[email protected]>Subject: pneumothorax

Dear Joe et al,

For pneumothoraces <15%, I attempt needle drainage first. If I am able to

drain the pneumothorax, I then observe for twelve hours, re-xray, and d/c

if no recurrence.

Ray





Date: Sat, 14 Nov 1998 17:51:32 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Gil Winnik <[email protected]>Subject: Re: Tx of pediatric fever

I apologize for commenting on this so late, but since I just got to read my

Email after a long hard week I must relate the following:

A mother who brought the child to our ER last week was contacted by the

resident for F/u (this is our routine...) she reported that the child WAS

STILL FEBRILE and she gave the child during his febrile period acetaminophen

q4h the "same dose that was given in the ER" (AND WORKED SO WELL THERE)

In the ER the dose the dose was given by a doctor who believes in a high dose:

40mg/kg.

Here lies the danger: what are we going to tell the parent, are we going to

remember to instruct them to give different dose that the one given in the ER?






Date: Thu, 19 Nov 1998 11:15:17 -0800Reply-To: Francisco Javier Benito Fernandez <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Francisco Javier Benito Fernandez <[email protected]>Subject: Re: Dermabond MisadventuresX-To: "Loren Yamamoto, MD, MPH" <[email protected]>

We started using Dermabond six month ago. We have treated 35 lacerations with good results in 31

cases. Two cases shown a foreing body like reaction, one of them with intermittent spontaneous

drainage. Other two cases shown laceration dehiscence secundary to a new trauma over the same

place. In both we used Dermabond again.

Javier Benito

Chief , Division Pediatric Emergency Medicine

Hospital de Cruces. Bilbao. Spain

Loren Yamamoto, MD, MPH wrote:

> Anyone have any experiences with poor outcomes, adverse reactions, or

> other misadventures using Dermabond? If so, please send me your

> experiences by E-mail. I would like to put these cases together in a

> collection to report on these misadventures. If you can send me at least

> three new misadventures (that I've not already heard of), I would like to

> include you as a co-author on this report. Otherwise, proper

> acknowledgement for the contribution will be included in the report.

> Thank you very much.

> Sincerely,

> Loren Yamamoto, MD, MPH

> Professor of Pediatrics, Univ. Hawaii John A. Burns School of Medicine.

>

> For more information, send mail to [email protected] with the message: info PED-EM-L






Date: Fri, 20 Nov 1998 00:23:06 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "<Julian Orenstein>" <[email protected]>Subject: Re: Croup

In a message dated 11/19/98 2:30:40 PM Eastern Standard Time,

[email protected] writes:

> >4) Is there any scientific evidence to suggest that prednisone can be

> >readily substituted for decadron?

>

> ********** Not that I am aware of but there is no reason why an equivalent

> dose would not work (2 mg/kg)



Invariably, they all throw it up. Never fails.




Date: Mon, 23 Nov 1998 17:30:07 -0600Reply-To: "Richard O. Gray MD." <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Richard O. Gray MD." <[email protected]>Subject: medical studentsX-To: "EMED-L -- a list for emergency medicine." <[email protected]>

I have just been charged with revamping our medical student curriculum

and would be MOST grateful for any words of wisdom from those who have

been there and done that. How much of a core curriculum can one cover

in a month? We currently do a lab and one to two lectures/wk in

addition to the clinical time which has and will be the heart of the

experience we offer. How do people handle the fact that different

schools have different dates for their rotations? Please respond to me

directly so that we don't clutter the list.

Rich

--

Richard O. Gray MD. FAAEM


Assistant Professor Emergency Medicine

Hennepin County Medical Center

701 Park Avenue South

Minneapolis Minnesota 55405

[email protected]

[email protected]

"I think we're all Bozos on this bus."




Date: Mon, 30 Nov 1998 15:02:10 -0500Reply-To: "Norman C. Christopher, MD" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Norman C. Christopher, MD" <[email protected]>Organization: Children's Hospital Medical Center of AkronSubject: Survey of Oral Rehydration Therapy in your ED


--------------DA9731D283F0FCE7E3F9B29C



In preparation for a "debate" at the Spring SAEM meeting, I would like

to survey those who subscribe to this list about their use of Oral


Rehydration Therapy in children with mild to moderate dehydration. These

questions refer to children managed in the emergency department only.

1.) Do you have a specific policy directing the use (indications,

nursing interventions, type of ORT solution, length of therapy in the

ED, disposition criteria, etc etc) of oral rehydration therapy for

children WHILE IN YOUR ED?

1a.) Do you have a formal observation unit in your ED, staffed by the ED

physicians?

2.) Do you use ORT on an informal basis in your ED (for example, as a

trial prior to initiating IV therapy - "let's try something by mouth

first, and if he vomits again, we'll start an IV...")?

3.) In what hospital/program are you practicing?

4.) Do you have residents in your ED on a regular basis?

5.) Do you have currently fellows as a part of your EM program?

Thank you - I will summarize the responses and report to this list. You

may respond to me directly (preferred) to minimize clutter on the list,

or you may respond to the list. Thank you -

Norm Christopher

--------------DA9731D283F0FCE7E3F9B29C

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Content-Description: Card for Norman C. Christopher, MD

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begin:vcard

n:Christopher, MD;Norman C.

tel;fax:(330) 258-3761

tel;work:(330) 379-8452

x-mozilla-html:FALSE

org:Chairman, Department of Emergency Medicine, Northeastern Ohio Universities College of Medicine

version:2.1

email;internet:[email protected]

title:Director, Emergency/Trauma Services, Children's Hospital Medical Center of Akron

adr;quoted-printable:;;One Perkins Square=0D=0A;Akron;OH;44308;

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end:vcard

--------------DA9731D283F0FCE7E3F9B29C--




Date: Fri, 4 Dec 1998 07:51:39 -0800Reply-To: David Soglin <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: David Soglin <[email protected]>Organization: Cook County Children's HospitalSubject: GI Decontamination

The reference for the consensus statement is...

Clinical Toxicology, 35(7), 699-762, 1997.

It is very useful and is actually 5 statements one each on ipecac,

cathartics, charcoal, lavage and WBI.

David

_____________________________________________________________________

David F. Soglin, M.D.

Chairman, Pediatric Emergency Medicine

Cook County Children's Hospital

Chciago, IL





Date: Mon, 7 Dec 1998 07:01:36 -0600Reply-To: MARTIN I HERMAN <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: MARTIN I HERMAN <[email protected]>Subject: Re: PED-EM-L Digest - 5 Dec 1998 to 6 Dec 1998

I am inclined to go to IVF instead of OR when working in the ED as Gloria

has indicated, it is more expedient..BTW I would argue that a child that is

5-8 & is much sicker and deserves IVF,, Most kids with dry mouth, decreased

mouth wetness, decreased urine output are more like 3-4%.

The nephrology papers on rehdration will bear this out.. The actual recovery

of body weight has indicated that we way over estimate degree of

dehydration..

The old paradigm of 5-10-15 is actually too generous and we should scale

back to 3-6-9 %...

IMHO

Martin Herman,M.D>






Date: Tue, 8 Dec 1998 10:40:45 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Scott H. Freedman, MD" <[email protected]>Subject: Re: Asthma, Hypercapnia and Airway ResistanceX-To: [email protected]

Jay(s)-

Also had a very similar case (yesterday) to what you describe in the gasping

adol with hypercapnia but good oxygenation....I gave him (as well as all

conventional asthma therapy) Ketamine 0.5 mg/kg IV and MgSO4 50 mg/kg IV- both

for bronchospasm and anxiolysis (anxiety, I felt was contributing to his

"Status")....

Anyway, he dramatically improved...went to PICU "nearly clear" but at least

had ABG to "prove" to critical care staff how ill he initially was......

Scott Freedman MD

Wolfson Childrens Hospital

Jacksonville FL

[email protected]




Date: Tue, 8 Dec 1998 21:43:48 -0600Reply-To: MARTIN I HERMAN <[email protected]>


Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: MARTIN I HERMAN <[email protected]>Subject: Re: PED-EM-L Digest - 6 Dec 1998 to 7 Dec 1998

Regarding the use of nebulized epi for bronchiolitis..

If you compare the dose of epi delivered from 3 cc nebulized 1:1000 and 0.5

cc of racemic epinephrine , you will find that they both deliver enormous

amounts of epinephrine.. Certainly much more adrenergic stimulation than

from the topical dose of albuterol ( 0.15mg/kg)

Math

racemic epi --2.25 % -----22.5mg/ml of d,l epi

0.5 ml -------------------------11.25 mg

now since only l is active isomer, that me approx. 11.25/2 or 5.62mg of epi

is delivered

for epi 1:1000

this is the same as 0.1% or 1mg/ml

so 3 cc delivers 3 mg epinephrine..

Now how do you compare 3-5 mg of epinephrine to 0.15mg/kg of albuterol??

Is it any wonder that the airway edema responds to the epi and not the

albuterol??

Just my humble thoughts...

BTW, I use epi 1:1000 for bronchiolitis, I just wonder what happens to them

once they leave the ED>

MIH

Memphis




Date: Fri, 11 Dec 1998 02:06:00 -0500Reply-To: xallue <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: xallue <[email protected]>Subject: GENDER DIFFERENCES

Gender differences in pediatric emergency care demand have been

documented many times. However, no explanation for these differences

is usually offered. We have registered a male predominance in all age

groups and for almost all diagnostic groups with the only exception

of the 12 year/old group and the diagnosis of non-specific abdominal

pain, both coming out about even.

We would appreciate comments and suggestions.

Xavier Allue


Pediatric Service

Hospital Universitari de Tarragona Joan XXIII

Tarragona, Spain.




Date: Sat, 12 Dec 1998 12:39:02 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Troy Brown <[email protected]>Subject: Re: Oral rehydration therapy in the ED.

In a message dated 98-12-11 21:27:53 EST, you write:

<< Would you like to torture a child for hours by squirting, against his will

some fluid into his/her mouth or would you go for the 10'' pain of an IV

followed by a blissful sleep while your body gets filled up ? >>

Please! First of all, I think that we need to be looking at this issue with

the eyes of a child. I highly doubt that a child is going to prefer the pain

of having his skin stuck with an IV needle, (let's not forget body integrity

and the perceptions a child has of painful procedures) and all that entails,

to being held in someone's arms and fed oral rehydration solution. If you

have any experience with children at all, and are reasonably compassionate and


skilled with children, it is possible to hold them in your arms (chances are

they will sleep and/or doze, if comforted by you), and gently dribble in a few

cc's of fluid without disturbing them very much, if at all. I know, because

I've done it-more than once, and with more than one different child. It CAN

be done.

If you are truly concerned with the child's comfort (as opposed to your own

workload or ED patient flow patterns) I don't know how you could conclude

otherwise. I'm speaking about those situations where either solution is an

option-not about cases of truly 'intractable' vomiting. And I realize that by

the time some kids get to the ED, the PO approach may not be a viable option.

Troy Brown, RN




Date: Mon, 14 Dec 1998 09:39:16 -0500Reply-To: "Goepp, Julius" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Goepp, Julius" <[email protected]>Subject: Re: Oral rehydration therapy in the ED

Folks, i've been watching with interest the discussion of ORT. For me it

feels a lot like "deja vu all over again!" This discussion has been held in


the pediatric and international health literature for over 20 years, and for

some reason continues to arouse passion among adherents of both camps. The

AAP, as Jeff notes, has issued practice parameters not once but twice,

updated most recently in 1996. This article was an effort to collect

experience and data from the national as well as global experience. It is

surprising to me how many people are unfamiliar with the recommendations, or

are surprised by their content.

The facts are simple - most of the debate comes down to personal preference.

THe overwhelming majority of children who present to EDs in the USA are in

fact minimally dehydrated, presenting with either diarrhea alone or diarrhea

and vomiting. Rapid repletion of circulating volume is indeed desirable,

regardless of the degree of dehydration, and both oral and IV are

appropriate means to do so (Hirschhorn wrote the best review of this subject

in the American Journal of Clinical Nutrition, 1980; 33:637-663 - a

masterful treatise on basic physiology and clinical practice). Using

technology from the developing world, it is indeed possible to provide rapid

rehydration orally (or nasogastrically) at a steady rate of 5cc/minute (or

300 cc/hour, which is 30cc/kg in a 10 kg infant). Oral rehydration

solutions contain not only appropriate amounts of glucose and sodium to

activate the intestinal co-transport system for maximal fluid absorption,

they also contain base at 30mEq/Liter and potassium at 20mEq/L, neither of

which are found in meaningful quantities in the typical IV rehydration

solutions.

Nasogastric feeding of oral solutions is an underutilized option in the US.

A 5 french silastic feeding tube is relatively innocuous to an infant,and

once placed is rarely disturbing to the child.

Older children of course pose a slightly harder challenge, in that they

often refuse to drink the sweet-salty ORS. There are two approaches, in

addition to the use of IV fluids. The first is to observe that the child

who is truly dehydrated (again, using some formal measure) rarely refuses

oral fluids (absent mouth sores or some other confounder) and so refusal to

drink in a normally mentating child supports the idea that the child is only

minimally dehydrated. The second is to use what i've referred to as "belly

ORS," in which the constituents of ORS are mixed in the child's stomach.

This can be done by offering half strength apple juice (to reduce the

osmolality) along with saltine crackers. Formally, 240 cc of half strenght

juice mixed with 10 saltines produces a solution with, per Liter, 72 mEq of

sodium, 15 mEq of potassium, and 80 grams of complex carbohydrate. for

comparison, WHO ORS has 90 of sodium, 20 of potassium, and 20 grams of

glucose, in addition to the base mentioned.

Regardless of the route chosen, a formal calculation of degree of

dehydration ought to be performed BEFORE beginning rehydration. My

observation is that many practitioners don't do a formal calculation of

deficit, but immediately begin attempts to rehydrate, either orally or

intravenously. This often results in uneccessary IVs or hours spent

"rehydrating" a pretty normal child, whose only offense has been to vomit or

have diarrhea. After the deficit has been calculated, it should be repleted

in under four hours. This can be done either orally or IV, and there are

all of the pros and cons noted in this discussion. The point that i want to

make is 1) be sure a child is really DEhydrated before attempting to

REhydrate, and 2) at least try the oral route using appropriate fluids and

technology before simply slamming in the IV. MOST children, even those

vomiting, can be orally hydrated. If IV is chosen, then starting oral

fluids simultaneously is wise, and will hasten recovery (this is not a

matter of debate, but the result of numerous well-documented studies).

Yes, feeding shoudl be begun immediately after rehydration is complete -

again there are several landmark studies that demonstrate this - resting the

gut is a non-physiologic concept that should be retired.

Despite the AAP recommendation against it, many children have lab tests

drawn. THis is not only painful for hte child, but adds delay to the

clinical course, and may alter therapy in the wrong direction (i have seen

many a properly re-hydrated child kept for additional hours in the ED

because of a low bicarb, often not returned from the lab until the child is

clinically fully recovered.).

I'm glad to see so much discussion about this topic, but i do recommend that

the participants take a few minutes to read the available literature - we

don't need to re-discover much here. Start with the AAP recommendations in

Pediatrics, 1996, then read Hirschhorn's article. For theoretical as well

as practical considerations try the chapters in the Oski or Hoekelman

textbooks.

Julius Goepp

> ----------

> From: Jeffrey Mann[SMTP:[email protected]]

> Reply To: Jeffrey Mann

> Sent: Sunday, December 13, 1998 7:45 PM

> To: Multiple recipients of list PED-EM-L

> Subject: Re: Oral rehydration therapy in the ED

>

> Mike Gerardi suggests reading the article by Reid in the September 1996

> issue of the Annals of EM re: rapid IV hydration of dehydrated pediatric

> patients in the ED. I noticed that the authors stated that there was a

> correlation between a low serum bicarb (<13) and the failure of a trial

> of po hydration after IV rehydration. I also noted that a "failure" was

> defined as vomiting after giving 30-90cc's of fluid within 30-60 minutes

> - which is (I think) too short a trial-period of outpatient po therapy.

> I see that Luten - correctly, I think - questions whether there is any

> correlation between the initial serum bicarb and the failure of po

> hydration after rapid rehydration. I am not convinced that measuring the

> serum elec's and bicarb is necessary in a mildly/moderately dehydrated

> infant. What do you think? Also, over what time period should the IV

> rehydration volume of 20-30cc's/Kg be given? Is there a small downside

> risk to too rapid IV rehydration - eg. if the infant was relatively

> hypernatremic at the time of ED arrival? What is the advantage to using

> 0.5NS rather than NS? How does giving small amounts of IV glucose in the

> form of 0.5NS/5DW help? Also, are there advantages to Sue's suggestion

> that patient po hydration is the way-to-go - in the sense that it is

> non-invasive, and also educational for the parents to understand how to

> calculate the volume deficit and how persistently patient they need to

> be to succesfully follow the protocol of administering small volumes of

> po pedialyte (5 cc's every 1-2 minutes) over a protracted time period

> (hours)?

>

> I have read the American Academy's parameter guidelines for the

> treatment of infant gastro-enteritis and I noted that they recommend

> immediate consumption of oral feeding of milk and formulae and do not

> recommend 'resting' the small intestine. Apparently, the belief that

> infants become lactose-intolerant because of damage to the intestinal

> villi's brush border lactase enzyme during gastro-enteritis is not

> entirely valid, and they suggest that it is not necessary to withold

> full-strength formulae or milk. What do you think?

>

> For more information, send mail to [email protected] with the

> message: info PED-EM-L



>






Date: Mon, 14 Dec 1998 23:13:05 -0500Reply-To: Michelle Rotta <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Michelle Rotta <[email protected]>Subject: crying infant


------=_NextPart_000_0047_01BE27B7.4DE4EEE0




Jeff-I'm always amazed that when I precept a resident about a "crying =

infant" and I ask the resident if they "got the baby naked", the typical =

reply is no. Along with your list of "usuals" I check for hair =

tourniquets, any bruising, pin point pain. I don't always get an =

abdominal film or flourescein the eyes, but I do insist on a rectal; =

checking for fissures, hard stool, guiac for blood ( and yes, I know =

that some intussusceptions will be heme negative, so critics be kind). I =

have to admit, that a crying infant is one of the toughest cases. I try =

not to do too much lab evaluation. I also admit (not proudly) that on a =

busy Sunday night, when I hear that screaming baby, sometimes I'm hoping =

for a fever along with that cry!=20

Shelley Rotta

The Children's Hopital of Buffalo

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<HTML>

<HEAD>


http-equiv=3DContent-Type><!DOCTYPE HTML PUBLIC "-//W3C//DTD W3 =

HTML//EN">


</HEAD>


<DIV><FONT color=3D#000000 size=3D2>Jeff-I'm always amazed that when I =

precept a=20

resident about a "crying infant" and I ask the resident if =

they=20

"got the baby naked", the typical reply is no. Along with your =

list of=20

"usuals" I check for hair tourniquets, any bruising, pin point =

pain. I=20

don't always get an abdominal film or flourescein the eyes, but I do =

insist on a=20

rectal; checking for fissures, hard stool, guiac for blood ( and yes, I =

know=20

that some intussusceptions will be heme negative, so critics be kind). I =

have to=20

admit, that a crying infant is one of the toughest cases. I try not to =

do too=20

much lab evaluation. I also admit (not proudly) that on a busy Sunday =

night,=20

when I hear that screaming baby, sometimes I'm hoping for a fever along =

with=20

that cry! </FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2>Shelley Rotta</FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2>The Children's Hopital of=20

Buffalo</FONT></DIV></BODY></HTML>

------=_NextPart_000_0047_01BE27B7.4DE4EEE0--




Date: Tue, 15 Dec 1998 13:30:42 -0500Reply-To: "Conners, Gregory" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Conners, Gregory" <[email protected]>Subject: pennies and stomach ulcers


Because of my interest in the management of the swallowed coin, I have been

asked by a few people about the recent news reports that swallowed pennies

can give stomach ulcers. I thought I would therefore supply and comment on

the evidence. I have seen a brief article in Time Magazine about it, and

heard radio news reports of this.

The reports are based on an abstract presented at the Radiological Society

of North America's 1998 Scientific Program in Chicago 2 weeks ago. The

abstract appeared in a supplement to the 11/98 issue of Radiology, and is

appended. In summary, the authors describe seeing a child who had swallowed

a penny a few days before, had presented with abdominal pain, and was found

to have a fairly deep stomach ulcer where the penny had lain. They

hypothesized that the zinc content of the penny had reacted with stomach

acid, and eroded the gastric lining. They tested this theory by putting a

bunch of pennies in HCl, some minted before 1982 (low zinc content), some

minted after 1982 (high zinc content). The newer ones decomposed

impressively in a few days.

What does this all mean? First, although many coins removed from children

are somewhat eroded, I have never heard of nor seen a child with a gastric

ulcer from this. Considering that thousands of pennies are swallowed each

year, it must be a fairly low probability event for it to just come up now,

after 17 years of zinc-laden penny production. Second, it should be noted

that the research model is not that great, since the stomach is not just an

HCl bath, but often receives Pedialyte, Saltines, and other food items.

Third, although most coins that make it through the esophagus end up

traversing the GI tract uneventfully, we already knew that a few do not, and

parents should be instructed that if the child who has swallowed a coin has

abdominal pain or some other GI complaint, they should see the doctor. The

child in this abstract had exactly that course, and the appropriate thing

was done.

Radio Doctor Dean Adell (sp?) suggested that all kids who swallow a penny

should have an x-ray because of this case. One case report is a lot to base

this on. I have been working on a cost-effectiveness model for the x-ray/no

x-ray decision in asymptomatic children. A paper of ours that is scheduled

for the 3/99 issue of Academic EM sheds some light on this as well.

Certainly all symptomatic children, and all children, even asymptomatic

ones, who show up in an ED, should have an x-ray.

Sorry to go on at such length...

Greg

Gregory P. Conners, MD, MPH, FAAP

Assistant Professor, Emergency Medicine and Pediatrics

University of Rochester School of Medicine & Dentistry

[email protected]




Date: Wed, 16 Dec 1998 07:17:29 -0700Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Daniel E. Kates, M.D." <[email protected]>Subject: Re: pennies and stomach ulcers

Dr. Conners wrote:

> Certainly all symptomatic children, and all children, even asymptomatic

> ones, who show up in an ED, should have an x-ray.

Dr. Conners,

Your statement regarding the use of x-ray in asymptomatic children is

somewhat puzzling. Clearly any child with symptoms after swallowing a

coin should have an x-ray, but why even asymptomatic children? This

seems to be playing into the fear and anxiety of the parent. Considering

that probably 99% of ingested coins pass uneventfully (most are never

even seen in the ED), why take an x-ray on an asymptomatic child?

--

Daniel E. Kates, M.D.

[email protected]

Thunderbird Samaritan Medical Center

Phoenix, Arizona

U.S.A.





Date: Thu, 17 Dec 1998 09:15:47 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Lorraine Gari <[email protected]>Subject: Consultants snug in their beds with sugarplums dancing in their heads

How many of you have paged consultants several tiimes and had this

conversation:

ED Doctor: Dr. X I have paged you several times over the past hour and you

have not answered. Is there something wrong with your beeper?

Dr. X (in extremis): Of course I haven't answered my page. It's blankety blank

1 o'clock in the morning. I was sleeping!

duh!!!!!!!!!






Date: Sun, 20 Dec 1998 07:09:32 -0500Reply-To: Jeffrey Mann <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jeffrey Mann <[email protected]>Subject: IV hydration of admitted dehydrated infants.X-To: EM online <[email protected]>

I attended a lecture by Mike Gerardi at the 1996 ACEP Scientific

Assembly on pediatric metabolic emergencies. Mike described how to IV

rehydrate a child in hospital using a system of calculating the actual

water/electrolyte deficits and then translating the calculations into

real-life IV formulaes and rates of administraton. Although I could

follow the logic of his talk, I knew that I would soon forget the

details. Because I am infrequently called upon to perform these

calculations (and therefore cannot remember the details of how to do the

calculations); I have devised a very simplified personal (arbitary)

strategy. Do you think that my approach is too simplified and that the

resultant inaccuracies could result in iatrogenic morbidity if applied?

The first part of my approach to dehydration therapy is to give an

aliquot of 10-20cc/kg of NS over 15-60 minutes if the infant is severely

dehydrated and in a pre-shock or "shocky" state - repeated prn until

stabilized. Once the child is stabilized the following simple formulae

is applied:-

I calculate the total daily fluid required = replacement fluid of

10cc/kg/% fluid deficit + maintenance requirements (100cc/kg for each of

the first 10kg's + 50cc/kg for each of the second 10kg's + 20cc/kg for

each kg over 20kg of actual body weight.

1/3 of the total fluid requirement is give over the first 6 hours, 1/3

of the total fluid requirement is given over the next 6 hours and 1/3 of

the total fluid requirement is given over the final 12 hours. The amount

of fluid given during the stabilization period is subtracted from the

total daily fluid requirement.

Types of fluid:-

For isonatremic dehydration - 0.45ND/5DW for the first 12 hours and

0.25NS/5DW for the next 12 hours.

For hyponatremic dehydration - 0.9NS/5DW for the first 12 hours and

0.45NS/5DW for the next 12 hours.

For hypernatremic dehydration, I would plan to give the total allocated

fluid over 48 hours and start the infant on 0.25NS/5DW in the ED at a

rate of 1/48th of the total fluid requirement/hr after the infant had

been stabilized.




Date: Wed, 23 Dec 1998 18:05:57 -0500Reply-To: "Marcus, Dr. Steven" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Marcus, Dr. Steven" <[email protected]>Subject: Re: Nurse Practitioners in Urgent Care SettingX-To: steven taylor <[email protected]>

I am so glad you responded. I never really thought that I would bring

out these obvious feelings into the open. But, i launched my message in

hope that the true feelings of the NP population would come out, it

obviously did in your case. The physician is at the top of the pyramid.

If you do not believe it then how can you work in a medical setting.

Who writes your protocols and under whose direction do you work? The

fact that physicians and non medical as well as non-physician providers

can work together collaboratively does not at all limit the role of the

physician as the leader of the team. No committee ever got anything

accomplished without a chairman or a leader. It just happens that the

leader in this situation MUST be the physician. I know of no where that

this is not the regulation if not the law. Even with the advent of

telemedicine there is a PHYSICIAN ultimately responsible for the care of

every patient. I hope that whatever physician you work with understands

your viewpoint. I would never want to sign off on a chart without

reviewing the case, I do not care if the care was delievered by a

resident, student or a nurse. If I sign the chart, if I am the ED

attending on, it is my moral and legal responsibility.



From: steven taylor [mailto:[email protected]]

Sent: Wednesday, December 23, 1998 5:49 PM

To: Marcus, Dr. Steven

Subject: Re: Nurse Practitioners in Urgent Care Setting

Marcus, Dr. Steven wrote:

>

> Your final paragraph is what I just love to see. It puts my comments

> out on the table. Do you really believe that NP provide "equal or

> higher quality care at a lower price"? That is what you said. I

could

> say trhe same thing for a chiropracter, a herbalist, a naturopath and

a

> homeopath. We either respect the training a physician receives and

tghe

> fact that he/she is at the top of the pyramid or we abandon education

> and let all the bleeders loose on society.

>

Yes, I do believe that, with one remark. NPs provide that type of care

"in the specialty in which they were trained". I would think that an

internal med MD would be able to provide adequate care for a broken arm,

but I would not say the same for a family care NP taking care of a

cardiac patient.

But I must take exception to the pompus statement you made here.

Physicans are NOT at the top of the pyramid, is as much as there is no

pyramid. Physicans, NPs and RNs all work together to achieve a certain

goal, that of quality healthcare. We abandoned the "me doctor, you

nurse" philosophy a long time ago. If this were a pyramid, then a doctor

would be able to perform as a nurse and then some. I know of no doctor

arrogant enough to think he can step into the shoes of a nurse and

perform adequately.

Steve Taylor, RN




Date: Sun, 27 Dec 1998 10:58:10 -0500Reply-To: "Angela Foehl, J.D., M.P.H." <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Angela Foehl, J.D., M.P.H." <[email protected]>Subject: Re: Nurse Practitioners in Urgent Care SettingX-To: "Marcus, Dr. Steven" <[email protected]>

It is interesting to see this same dynamic (again) that appeared in =

another list when the subject of the role of nurse practitioners arose. =

The nurses typically demand that people view them as equal to physicians =


with arguments such as 'everyone spends many hours learning...' or =

'there are good and bad professionals in every category...' The =

physicians typically refer to their relatively greater degree of =

education/training and note that they become increasingly humble about =

their medical knowledge as they learn more.

Our hyperdemocratized society prompts some people to lose their ability =

to distinguish between the extremely different quantity and quality of =

education and training that goes into becoming a physician vs. a nurse =

practitioner. If we do not value it, then what is the point of having =

it as a requirement. =20

When HMOs or facilities replace physicians with nurse practitioners and =

allow them to practice without physician supervision, I regard this as =

fostering malpractice for financial gain. I strongly urge physicians to =

blockade this trend, which is gaining ground to feed HMO CEO salaries of =

millions, while providing substandard medical care to patients. If =

anyone is interested in reading the more detailed presentation of my =

case against substituting nurses for physicians, the article (with many =

citations) is:

(It may now be available full-text online at =

http://www.cost-quality.com)

(If not, there is contact info at the site. Please do not ask me for =

reprints, as I am unable to provide them.)

http://www.cost-quality.com/

Foehl, A. Nurse Practitioners as Primary Care Providers: Should the =

Oxford-Columbia Pilot Fly? Cost & Quality Quarterly Journal, 4(1); Mar. =

1998; 12-20. =20

Angela Foehl, J.D., M.P.H.

Consult, Inc. [Medicolegal Consultants & Expert Witnesses]

Arlington, VA ph. 703) 685-0035 fax 703) 271-0980

For details on Consult, Inc.'s services & activities, visit our online =

brochure:

http://www.inc.com/users/CONSULT.html


From: Marcus, Dr. Steven [SMTP:[email protected]]




I am so glad you responded. I never really thought that I would bring

out these obvious feelings into the open. But, i launched my message in

hope that the true feelings of the NP population would come out, it

obviously did in your case. The physician is at the top of the pyramid.

If you do not believe it then how can you work in a medical setting.

Who writes your protocols and under whose direction do you work? The

fact that physicians and non medical as well as non-physician providers

http://www.inc.com/users/CONSULT.html

can work together collaboratively does not at all limit the role of the

physician as the leader of the team. No committee ever got anything

accomplished without a chairman or a leader. It just happens that the

leader in this situation MUST be the physician. I know of no where that

this is not the regulation if not the law. Even with the advent of

telemedicine there is a PHYSICIAN ultimately responsible for the care of

every patient. I hope that whatever physician you work with understands

your viewpoint. I would never want to sign off on a chart without

reviewing the case, I do not care if the care was delievered by a

resident, student or a nurse. If I sign the chart, if I am the ED

attending on, it is my moral and legal responsibility.


From: steven taylor [mailto:[email protected]]


To: Marcus, Dr. Steven


Marcus, Dr. Steven wrote:

>

> Your final paragraph is what I just love to see. It puts my comments

> out on the table. Do you really believe that NP provide "equal or

> higher quality care at a lower price"? That is what you said. I

could

> say trhe same thing for a chiropracter, a herbalist, a naturopath and

a

> homeopath. We either respect the training a physician receives and

tghe

> fact that he/she is at the top of the pyramid or we abandon education

> and let all the bleeders loose on society.

>

Yes, I do believe that, with one remark. NPs provide that type of care

"in the specialty in which they were trained". I would think that an

internal med MD would be able to provide adequate care for a broken arm,

but I would not say the same for a family care NP taking care of a

Date: Mon, 28 Dec 1998 00:10:35 -0800Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Nathan Kuppermann <[email protected]>Organization: UC DavisSubject: fever and bronchiolitis

A brief comment regarding fever and bronchiolitis (in response to Jay

Pershad). Sorry for the delay Jay, I was out of town...

The risk of important bacterial infections in nontoxic-appearing febrile

children with bronchiolitis evaluated as outpatients is frequently

discussed, given that fever is seen in ~ 30% of these children (AJDC

1991;145:151-155). Serious bacterial infections in young febrile

children with bronchiolitis have been described, including children

younger than 3 months of age (PIDJ 1987;6:1134-5, AJDC 1988;142:834-6).

The children with bacterial coinfection in these reports, however, were

mostly hospitalized and frequently had radiographic pneumonias.

To further address this question, we prospectively studied a relatively

large (n=156) cohort of children younger that 2 years with bronchiolitis

and fever (> 390 if 3 months and older, > 380 if younger than 3 months)

evaluated in the ED (Arch Pediatr Adolesc Med 1997;151:1207-1214). We

compared the risks of bacteremia and UTI with a cohort (n=261) of

children of similar age and degree of fever, but without bronchiolitis.

All patients with lower respiratory symptoms had CXRs performed and were

excluded from the study if lobar infiltrates were identified. None of

the 156 children with bronchiolitis had bacteremia (versus 2.7% of

controls) and 2% of the children with bronchiolitis had UTIs (versus 14%

of controls). No patient in the study had bacterial meningitis.

There were only 36 patients with bronchiolitis in the study, however,

who were 2 months of age or younger. Although none of the 36 had

bacteremia or UTI, the 95% one-sided confidence interval (0-8%) includes

a clinically-important risk of bacterial infection. Therefore, no firm

conclusions could be drawn for the infants younger than 2 months.

In order to address this question with more power, we are currently

conducting a multicenter (5 centers) study of febrile infants with

bronchiolitis younger than 2 months of age. The study is being led by

Deborah Levine and Shari L. Platt at Bellevue Hospital Center. We hope

to have a better assessment of the risks of serious bacterial infections

in these infants within 1-2 years.

Nate Kuppermann




Date: Fri, 1 Jan 1999 15:53:49 -0700Reply-To: Murry & Loralei Sturkie <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Murry & Loralei Sturkie <[email protected]>Subject: Who can give ketamine


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Recently I have come into a little conflict with nursing administration =

of ketamine. Originally, I.V. ketamine has been given by the physician =

at the bedside. However, I.M. has been given by the nurse. Now, my =

nurses are saying that the I.M. injection must be given by the =

physician. They are basing this on the principles of general =


anesthesia. How can I combat this situation? Or, am I fighting a =

loosing battle?

Murry Sturkie, D.O.

St Lukes Regional Medical Center

(The local pediatric referral center)

Boise, Idaho

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<HTML>

<HEAD>




</HEAD>


<DIV><FONT color=3D#000000 size=3D2>Recently I have come into a little =

conflict with=20

nursing administration of ketamine. Originally, I.V. ketamine has =

been=20

given by the physician at the bedside. However, I.M. has been =

given by the=20

nurse. Now, my nurses are saying that the I.M. injection must be =

given by=20

the physician. They are basing this on the principles of general=20

anesthesia. How can I combat this situation? Or, am I =

fighting a=20

loosing battle?</FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2></FONT> </DIV>

<DIV><FONT color=3D#000000 size=3D2>Murry Sturkie, D.O.</FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2>St Lukes Regional Medical =

Center</FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2></FONT><FONT size=3D2>(The local =

pediatric=20

referral center)</FONT></DIV>

<DIV><FONT color=3D#000000 size=3D2>Boise, =

Idaho</FONT></DIV></BODY></HTML>

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Date: Mon, 4 Jan 1999 13:58:09 -0500


Reply-To: "Friedland, Leonard" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Friedland, Leonard" <[email protected]>Subject: POSITION AVAILABLEX-cc: "Grant M.D., Howard R." <[email protected]>

Temple University Children's Medical Center

in Philadelphia is seeking applications from PEDIATRIC EMERGENCY PHYSICIANS.

The new Temple University Children's Hospital has an 11 bed Pediatric

Emergency Department, 50 acute care, 10 critical care, and 27 neonatal

intensive care beds.

The Division of Pediatric Emergency Medicine currently has 6 board

certified Pediatric Emergency Medicine physicians and 2 Pediatric Emergency

Medicine nurse practitioners. ADDITIONAL PEM physicians are being recruited

because the department's patient volume is growing rapidly.

Responsibilities include patient care, teaching of medical students and

Emergency Medicine residents, and new program development.

Interested individuals should be sub-board eligible/certified in

Pediatric Emergency Medicine. Academic appointments are in the Department

of Pediatrics, clinical-educator tract. We offer a highly competitive

salary and excellent benefits.

Submit CVs to:

Leonard Friedland, MD

Temple University Children's Medical Center

Director, Pediatric Emergency Medicine

3509 N. Broad Street, Philadelphia, PA 19140

voice mail: 215-707-6479

fax: 215-707-6033

[email protected]




Date: Tue, 5 Jan 1999 10:29:05 -0600Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: [email protected]: Infantile Botulism Case At St. Paul Children'sX-To: "EMED-L -- a list for emergency medicine." <[email protected]>In-Reply-To: <[email protected]>

Hi Everyone!

Sorry to intrude; however, I thought you might find the following article

interesting. What struck me most (besides what looked like great

"doctoring" by the folks at St. Paul Children's) was the coincidence of t=

his

article (published on 1/1) and the QAD topic for 12/31 - Infantile Botuli=

sm.


Brandon

--

H. Brandon Guest, Chief | [email protected]

Hamel Vol. Fire Department |

92 Hamel Road | Voice (612) 723-5400

Hamel, MN 55340 | Fax (612) 478-8588

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Question-A-Day for Thursday, December 31, 1998 (4 of 7)



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___________________

o Today's Question:

What are the typical symptoms of a patient with infant

botulism?

_________

o Answer:

The primary symptom is usually constipation (3 or more days

without a bowel movement). This is often the first symptom.

Other symptoms include listlessness, lethargy, difficulty in

sucking and swallowing, hypotonia, weak cry, poor feeding,

pooled oral secretions, generalized muscle weakness and poor

head control, which gives the infant a characteristic floppy

appearance.

____________

o Reference:

emedicine.com - http://www.emedicine.com/emerg/topic64.htm

____________

o Thanks to:

Jonathan A. Handler, M.D.

Northwestern University Department of Emergency Medicine



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---- The National Center for Emergency Medicine Informatics

---- Question-A-Day server

---- NCEMI Directors

---- Mark Smith, MD

---- Craig Feied, MD

---- QAD editor:

---- Jon Handler, MD

Visit http://ncemi.org to see previous issues of QAD

http://ncemi.org/

http://www.emedicine.com/emerg/topic64.htm

To subscribe or unsubscribe from QAD-emed, use the Published Friday, Janu=

ary

1, 1999

Baby is beating rare case of infantile botulism poisoning

Jill Burcum / Star Tribune

Somewhere on the icy roads between Bemidji and St. Paul on Dec. 22, Sarah

and John Paul were overcome with a feeling that their prayers would be

answered -- that doctors would find an explanation, and a cure, for the

mysterious illness robbing their 5-month-old daughter Amelia of her abili=

ty

to breathe.

Shortly before, about 6 p.m., the young couple had tearfully placed Ameli=

a

on a medical helicopter that would fly her to Children's Hospital in St.

Paul.

Sarah and John Paul's 5-month-old daughter, Amelia, was diagnosed with a

rare case of infantile botulism poisoning on Christmas Eve

There, doctors would discover that she had a rare and potentially deadly

case of infantile botulism poisoning, which causes muscle paralysis. The

only known treatment is an experimental and expensive drug only available=

in

California.

On Christmas Eve, a combination of events that the Pauls call a "Christma=

s

miracle" resulted in their daughter getting the drug she needed. Not only

would doctors make a difficult diagnosis, but also Children's officials

would be able to make arrangements to pay for the $23,000 drug on Christm=

as

Eve, and get it on a plane to Minneapolis.

"We're so very thankful for all that they did," said Sarah Paul, 22. "It =

was

Christmas Eve, and they should have been home with their families, but th=

ey

were all here helping us."

In the days leading up to Christmas, Sarah had kept a close eye on Amelia=

,

who seemed weak and had a raspy cry. Uncertain if it was a cold or someth=

ing

more serious, she took Amelia to the doctor Dec. 21. Shortly afterward,

Amelia was hospitalized in Bemidji for dehydration.

"She wasn't getting better," said John, 23. "She was floppy and she had a

droopy face. It was almost like she'd had a stroke."

Although they couldn't be sure, the Bemidji doctors suspected infantile

botulism poisoning, which may be linked to eating honey.

They told Sarah and John that Amelia needed specialized care, so they

quickly arranged to fly Amelia to Children's in St. Paul.

Narrowing the suspects

When Sarah and John arrived in St. Paul, doctors told them they, too,

thought the likeliest suspect was infantile botulism poisoning -- a disea=

se

so rare that only one of the doctors had ever seen a case before, accordi=

ng

to Dr. James McCord, a pediatrician at Children's.

Botulism is caused by a bacterium that manufactures a substance toxic to

humans. In the body, the toxin blocks nerve signals and paralyzes muscles=

,

including the ones needed to cry, swallow and breathe. The disease is

treatable but requires weeks of intensive hospital care. Victims often ne=

ed

a ventilator to breathe.

Only about 100 cases occur each year in the United States, according to t=

he

Centers for Disease Control and Prevention. Fewer than five cases have

occurred in Minnesota in the last 25 years, according to Mike Osterholm,

state epidemiologist.

Doctors were able to narrow possibilities to a handful of conditions that

cause loss of muscle control, said Dr. James Levin, an infectious disease

specialist at Children's.

Spores create problems

Adults develop botulism poisoning when they ingest the toxin directly, su=

ch

as from contaminated canned goods. But in children under a year old, the

bacterial spores, which are like seeds, can also create problems, Levin

said. The spores are in the air, dirt and other substances, such as honey.

When inhaled or eaten, they can grow in an infant's underdeveloped

intestinal tract and produce the toxin there.

Because honey often contains spores from the botulinum bacteria, health

experts warn that children under the age of 1 should not eat honey produc=

ts.

Levin, however, doesn't believe that honey caused Amelia's illness.

Medical detective work

A test to confirm the botulinum bacteria takes about four days because th=

e

bacteria must be cultured in mice, according to McCord. In the meantime,

Amelia's muscle weakness was becoming so serious that she was admitted De=

c.

24 to the intensive care unit, where physicians feared she might need a

ventilator.

By this time, physicians felt they'd ruled out every condition but botuli=

sm

poisoning, even though the final test wasn't completed.

But once the diagnostic detective work was over, another hurdle loomed --

which was made more difficult by the approaching holiday weekend.

Amelia couldn't take the antitoxin given to adults because it causes an

allergic reaction in infants, Levin said. Without the drug, babies with

botulism poisoning face up to a month in intensive care, most likely on

mechanical ventilation.

But doctors recalled hearing about an experimental drug developed by the

California Department of Health. The drug, according to McCord and Levin,

can significantly shorten the time infants' bodies need to fight off the

poison. But it must be taken within about 72 hours of symptoms' onset.

"The sooner Amelia got the drug, the better," McCord said.

Paperwork barriers

Getting an experimental drug is never easy, Levin said. "There's a lot of

paperwork," he said, involving the Food and Drug Administration, the

hospital and the patients.

With the holiday approaching, the Children's physicians were racing again=

st

time, compressing into hours a process that can take days.

Then the cost presented a snag.

The California Department of Health charges $23,000 for one dose of the

drug. The fee offsets the cost of its development, said Dr. Robert

Schechter, a California state epidemiologist.

Before the department would ship the drug, it required a purchase order

guaranteeing payment. So far it has been shipped to 12 states and the

purchase-order requirement has never been a problem, Schechter said.

"Most hospitals have administrators on call 24 hours a day who can do thi=

s,"

he said. "This hasn't been a barrier to date. Our goal is to get the

medicine to the kids as quickly as possible."

On Children's end, a purchase order that large meant more paperwork and m=

ore

signatures from top-level officials. Chief Financial Officer Jerry Massma=

nn,

who was celebrating the holiday at home with his family, helped orchestra=

te

the paperwork, and Children's faxed the purchase order to California in t=

ime

to get the medicine on a Northwest flight to Minneapolis.

The medicine arrived at the airport at 10:30 p.m. At midnight Christmas D=

ay,

doctors injected the experimental drug into Amelia.

Getting stronger

It didn't take long for her to respond to the drug. McCord and Levin said

breast-feeding also may have enhanced Amelia's recovery. Today she is out=

of

intensive care and slowly getting stronger, and may go home this weekend.

Sarah and John Paul said they're still stunned by it all.

"It's amazing. We thank God for everything and everyone involved," John P=

aul

said. "It makes you realize what Christmas is all about."

=A9 Copyright 1999 Star Tribune. All rights reserved. 9

automatic form at the NCEMI website, or send email to

[email protected]

with 'subscribe qad-emed' or 'unsubscribe qad-emed'

in the body of the message. We hope you enjoy QAD-emed!



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Date: Wed, 6 Jan 1999 15:23:11 -0800Reply-To: "Brown, Julie C." <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Brown, Julie C." <[email protected]>Subject: ibuprofen

The best study I know of on the safety of ibuprofen in children is the

Boston University Fever Study (over 12,000 children) . Unfortunately,

it only looked at children between 6 months and 12 years of age, and only

evaluated safety with short - term ibuprofen (vs. acetaminophen) use.

In a meta-analysis of three pediatric studies, the difference in antipyresis

between ibuprofen 10 mg/kg and actaminophen 10 mg/kg was stastistically

significant, but, I believe, clinically insignificant (maximal difference

was 0.4 degrees Celsius after four hours). In an additional study, there

was

no difference in antipyresis between ibuprofen 10 mg/kg and

acetaminophen 15 mg/kg. I have not reviewed the evidence (if any)

regarding pain relief.

In the absence of data saying ibuprofen is better in children, without good

safety data under the age of six months, and with the age-old questions


about whether or not we should be treating fevers at all, I would have to

argue in favour of using acetaminophen under the age of six months.

For more information and references for the above studies, you might be

interested to see a Critically Appraised topic (CAT) I did on ibuprofen

vs. acetaminophen for pediatric fever. It is on the Pediatric

Evidence-Based Medicine website at the URL below. Look under

critically appraised topics / general pediatrics. Feedback is welcome.

http://weber.u.washington.edu/~ebm

I just discovered that the meta-analysis is missing from this CAT, so while

I rectify this error, I would be happy to send this to anyone interested.

(I tried to attach it as a jpg file, but failed).

Julie Brown, MD

Pediatric Emergency Medicine Fellow, box CH-04

Children's Hospital and Regional Medical Center

Seattle, WA 98105

e-mail: [email protected]

fax: 206 527 3892





http://weber.u.washington.edu/~ebm

Date: Fri, 8 Jan 1999 10:17:02 -0500Reply-To: Gershon Segal <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Gershon Segal <[email protected]>Subject: Re: ibuprofen -ReplyX-To: [email protected]

Regarding ibuprofen and renal insufficiency -

In the latest issue of Pediatric Emergency Care (I just got it yesterday), =

there is a case series from CHOP of 4 patients who developed nonoliguric =

renal failure while taking NSAID's (ibuprofen and naproxen). One patient =

had pyelonephritis and one patient had deliberately overdosed on naproxen. =

The patients ranged in age from 3.5-19 years. Clearly, they were not able =

to establish cause-and-effect, just an association.

Gershon Segal




Date: Sun, 10 Jan 1999 15:20:50 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Gil Winnik <[email protected]>Subject: any suggestion


The following case was told to me and I was no help, does any one else have a

suggestion:

A 4 week old presented with fever (38.7) .

PE was normal (the only abnormal VS was the fever)

PMH was normal

The infant had a "full sepsis w/u" and the CBC, U/A and CSF cell count were

all normal.

The infant received ampicilline 50mg/kg IV followed by Claforan (cefotaxime)

50 mg/kg) IV. Both drugs were given via Soluset over 10-15 minutes.

3 minutes into the Claforan, the child became mottled, bradycardic , and

asystolic (all under the medical staff's eyes).

Despite immediate appropriate CPR the infant expired.

Blood and CSF cultures were 'negative'.

Gross pathology on PM was 'normal'.

any ideas?

Giora Winnik MD




Date: Sat, 16 Jan 1999 13:47:46 -0800


Reply-To: Must have been a Wild Angel <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Must have been a Wild Angel <[email protected]>Subject: Pedi. resus. tapeIn-Reply-To: <[email protected]>

I do not remember who asked about where to get the pedi. tape, try

checking http://www.galls.com

We have purchased several throught Galls' over the last couple years.

angel




Date: Tue, 19 Jan 1999 10:53:07 -0600Reply-To: jay pershad <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jay pershad <[email protected]>Subject: Re: Case For DiscussionX-To: [email protected]

I would also do option 5 & 6 i.e. do a sepsis workup and observe the

patient in hospital on antibiotics. The birth history clearly makes this

infant high

risk for early GBS sepsis as Terry Adirim and Mike Gerardi stated. Mike, I

am not sure I would do a CT before the LP though. I don't think there is


http://www.galls.com/

any risk of doing the LP, especially with a soft open AF.

Without prenatal care, I would also keep early herpes meningo-encephalitis

in mind

(suggested by LFT abnormalites and disproportionate numbers of RBC in the

CSF). Since, she does not appear terribly sick yet, I would hold on the

acyclovir, unless laboratory abnormalities suggest otherwise.

With the jaundice and emesis, I too like Dr Hostedler, am concerned about

some inborn error like galactosemia, HFI, adrenal insufficiency,

aminoacidopathy etc. Would check, as stated, for hypoglycemia, acidosis,

dyselectrolytemia, urine RS, and NH3 too. Remember, a bili of 11 on day 1

is clearly pathologic. I am surprised it did not rise any higher in the

nursery!!

I would include in the differential of non bilious regurgitation?/emesis?

in this first week of life, subtotal GI obstructions above the ampulla of

Vater, like a duodenal stenosis. Especially, if this emesis is persistent,

with FTT etc consider doing an upper GI contrast study.

"Subdural" as Mike stated sounds like a good thought too. The delivery

even though emergent, did not sound traumatic. Were there any external

signs of bruising or cephalhematoma? Was the AF tight?

Observation in hospital for 24-48 hours should quickly clarify all issues.

I WOULD NOT rely on absence of fever in the ED or a normal CBC to rule out

serious illness in this 4 day old especially in the face of a high risk

history!!

Randy, I am curious how she did eventually??

Jay

Jay Pershad, MD




Date: Wed, 20 Jan 1999 13:26:39 -0500Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Zach Kassutto <[email protected]>Subject: Elective Sedation in EDIn-Reply-To: <[email protected]>

Another administrative question...

How many centers offer pediatric conscious sedation on an elective basis

to referring sub-specialist (e.g., for a rheumatology patient who comes in

for elective knee tap)? In the past we have offered this service during

less busy hours. Recently, nursing has been questioning the practice.

They argue that elective care potentially distracts from their primary

mission (readiness and availability for true emergency patients) and that


these cases should be referred to the Short Procedure Unit.

I would like to generate a list of centers where this sort of service is

offered (or not) by the ED as well as arguments for and against the

practice. Please reply to me directly via email, I will compile a list,

summarize the arguments, and post these on the list.

Zach

Zach Kassutto, M.D. eMail: [email protected]

St. Christopher's Hospital for Children Tel: 215-427-5989

Philadelphia, PA Fax: 215-427-4668




Date: Fri, 22 Jan 1999 07:58:53 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Deborah Woolard <[email protected]>Subject: Re: acute otitisX-cc: [email protected]

Jonathan Bennett wrote:


>I would agree that in general the literature supports the notion that delayed

>treatment of aom is unlikely to result in increased complications(hearing

>loss, recurrences, and most likely mastoiditis) but it does seem that some

children

>will recieve benefit in terms of pain relief.(The Del Mar meta-analysis shows

>this, as does a trial by Burke(BMJ 1991;303:558-62), although admittedly

>most(?all) of placebo trials did not use local analgesia such as auralgan.

>

>I was curious if Kaiser has attempted to identify more "mild" aom, as for

>example done by Kaleida(Pediatrics 1991;87:466-74). If not they are

>essentially asking parents to take a chance of increased pain for their child

>in order to decrease antibiotic use. This may or may not be a reasonable

>thing depending on the parents preferences.

I believe the treatment of otalgia is a separate issue from the question

of antibiotic treatment of OM. Antibiotics alone are not adequate for

pain treatment. I rarely have a child leave the ED without a prescription

for Auralgan unless contraindicated. I also tell the parents to save the

Auralgan for future use in those 3am _screaming pain_ earaches. The quick

relief of earache is almost as satisfying as reduction of nursemaid's

elbow :-)

Deborah Woolard

Fayetteville, NC




Date: Sat, 23 Jan 1999 10:39:05 -0500Reply-To: Allen Walker MD <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Allen Walker MD <[email protected]>Subject: Re: Auralgan for earache secondary to AOMX-To: Jeffrey Mann <[email protected]>In-Reply-To: <[email protected]>

Dr. Mann:

I've always understood that the main source of pain in acute otitis media

is stretch and inflammation of the tympanic membrane itself. On several

occasions, I have done a tympanocentesis in a child with acute om with

virtually instantaneous relief of pain.

Auralgan is apparently absorbed well enough by the inflamed tympanic

membrane to reduce or eliminate the pain fairly convincingly. Rarely have

parents found a need to give more than one or two doses during an episode

of AOM. Apparently, once absorbed, the Auralgan persists long enough for

the condition causing the pain to resolve to the point where pain is no

longer an issue.

In a fairly long career (including five years of Pediatric office

practice in which I had very good followup), I have rarely had to

prescribe anything more than ibuprofen for ear pain after using Auralgan.

Has your experience with Auralgan been unsatisfactory?


Allen R. Walker, MD


Johns Hopkins

On Sat, 23 Jan 1999, Jeffrey Mann wrote:

> How is auralgan supposed to help the pain secondary to otitis media? It

> is my understanding that the pain occurs secondary to the inflammatory

> process in the middle ear cavity (behind the intact eardrum) and from

> the pressure of fluid in the middle ear cavity causing outward

> displacement of the eardrum. It is also my understanding that auralgan

> is only a topical analgesic, which cannot penetrate the eardrum - so how

> would it help? I have always prescribed po tylenol and codeine elixir

> for the severe earache associated with some cases of AOM. What is the

> best analgesic approach to treating the pain secondary to AOM?

>

> Jeffrey

>




>





Date: Mon, 25 Jan 1999 15:01:28 -0500Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Emory Petrack <[email protected]>Organization: Case Western Reserve UniversitySubject: PEM Faculty Position

The following position was inadvertently omitted from the December

"Pediatric Emergency Care":

____________________________________________


Faculty Position

The Department of Pediatrics at Rainbow Babies and Children=92s Hospital

is seeking an academic, career oriented physician to join its Division

of Pediatric Emergency Medicine. Rainbow serves as the pediatric

emergency and critical care referral center for Northeast Ohio and is a

Level I Pediatric Trauma Center.

o Approximately 30,000 visits annually

o Strong teaching program with a PEM fellow and Pediatric, Emergency

Medicine and Family Medicine residents and students


o Many opportunities for collaborative research

o Major ED Renovation to be completed 1999

o Dynamic group to work with and great place to live

The ideal applicant will have a strong interest in teaching and

research, as the position includes a significant amount of protected

time for these purposes. Applicants must be sub-board eligible or

certified in Pediatric Emergency Medicine. A competitive salary and

benefits package will be offered. =20

Please respond with curriculum vitae to:

Emory M. Petrack, M.D., M.P.H.

Chief, Division of Pediatric Emergency Medicine

Rainbow Babies and Children=92s Hospital

11100 Euclid Avenue

Cleveland, OH 44106

216-844-8716

Case Western Reserve University is an Affirmative Action, Equal

Opportunity Employer.




Date: Tue, 26 Jan 1999 14:56:58 -0600


Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Linda Kalinowski <[email protected]>Organization: HRP, Inc.Subject: ER Nurse Manager Opportunity

Job opportunity St. Louis Children's Hospital, St. Louis, Missouri for a

Team Leader (Manager).Fax resume:Debbie Ross (314) 454-4775/phone:

(314) 454-2015/www.bjc.org.




Date: Fri, 29 Jan 1999 08:17:59 +1100Reply-To: Peter Barnett <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Peter Barnett <[email protected]>Subject: Re: oral midazolam / nasal midazolam

One suggestion put forward was to use a dose of a nasal

anaesthetic/decongestant such as Co-Phenylcaine. This will anaethetise the

nasal area and cuts out the burning feeling. It stings abit initially but

find kids better toerate it. We tend to use 1mg/kg of oral midazolam with

again varying results, most are OK.

Peter Barnett


>Approved-By: [email protected]

>Approved-By: Jason & Nicola Acworth <[email protected]>

>Date: Thu, 28 Jan 1999 21:21:20 +1000

>Reply-To: Jason & Nicola Acworth <[email protected]>

>Sender: Pediatric Emergency Medicine Discussion List

> <[email protected]>

>From: Jason & Nicola Acworth <[email protected]>

>Subject: Re: oral midazolam / nasal midazolam

>X-To: "[email protected]" <[email protected]>

>To: Multiple recipients of list PED-EM-L <[email protected]>

>

>Sandy,

>

>I share your hesitation over joining in the intranasal midazolam chorus.

I've found it sometimes useful but never predictable. I'm sure that part

of the variable onset/effect may be explained by different proportions

being absorbed transmucosally:orally(swallowed).

>

>In Brisbane (RCH) we give 0.4mg/kg and now use a metered dose spray device

delivering 0.2ml (1mg) per spray in an effort to spread a finer mist over

the nasal mucosa and have less swallowed. The kids still don't like the

stuff! - the parenteral preparation has a pH of 3.0-4.0 (I sprayed it up my

nose - it burns!).

>I understand that this pH is required to retain some of its physical

properties but I'd love to see a more concentrated solution (volume can be

a problem too) at a kinder pH which was suitable for intranasal

administration.

>

>Anyone got an idea ?

>

>Jason Acworth

>PEM Fellow

>RCH Queensland

>***************************************************************************

**************

>

>[email protected]

>

>PHONE + 61-7

>

>Home : 3356 5832

>

>Work : 3253 8311

>

>For more information, send mail to [email protected] with the





>

>

Dr. Peter Barnett MBBS FRACP MSc(epid) FACEM

Deputy Director


Royal Children's Hospital

Flemington Rd,

Parkville, Victoria

Australia, 3052

Telephone + 61 3 9345.6592

Facsimile + 61 3 9345-5938

E-mail [email protected]




Date: Mon, 1 Feb 1999 15:08:10 -0800Reply-To: merlin8 <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: merlin8 <[email protected]>Subject: Re: Occult Pediatric Fever, NEW, suitable for flaming.X-To: Karen Camasso-Richardson <[email protected]>


Thank you for your response.

Indeed the article was meant to be somewhat inflammatory. Don't worry it's

not intended for publication, the purpose was to help me better understand

the mechanism of fever in the pediatric patient and the protocols designed

for diagnosis and treatment of this condition. It was caused primarily by

several bad encounters with primary care providers with infant children and

their families and is a fairly accurate description of those encounters. The

error of "occult fever" has been noted and corrected.

I suggest your response is positive as it shows your level of concern on

this issue. Though you must admit that there is a true concern that

occasionally an febrile infant will get only a cursory examination in favor

of full septic workup. Also that the literature supports that a thorough

exam and detailed history can negate the need for many invasive and painful

diagnostic procedures. The fear of the parents is real, don't doubt that.

It's our job to comfort them, show compassion, and answer all their

questions clearly to support them through a very difficult time. But most

importantly we must come off as thoughtful. That seemed to be the biggest

problem among the parents is they felt the physician was following a

mandatory and rigid protocol and didn't stop to think and do a thorough exam

and history. Now you must admit these are problems we all, paramedic and

doctor and nurse alike, must be on guard against.

As inflammatory as that first draft opening paragraph was you might find the

current manifestation of the paper alittle more interesting as I've had time

to work on it a little bit. Please let me know if anyone would like a copy.

It's still not finished but I think I've cleaned it up a little.

Merlin Curry

Paramedic

Portland, OR


From: Karen Camasso-Richardson <[email protected]>

To: 'merlin8' <[email protected]>

Date: Monday, February 01, 1999 9:52 AM

Subject: RE: Occult Pediatric Fever, NEW, suitable for flaming.

Dear Mr. Curry,

I found your write-up to be irresponsible and uninformed. It was paramount

to yelling "fire" in a crowded building. I found it similar to the

inflammatory sensationalistic medical "news" coverage found on TV shows such

as "20/20" and such. A person with a little knowledge is a dangerous thing,

and you are a prime example (your write-up asked for such responses).

I think all of the other physician responses so far have been right on

target. Whatever forum this write-up is for, a more informed responsible

approach is needed. You need a lot more experience in reviewing literature

and statistics. Also, you need to understand that medicine is a continually

evolving scientific and artistic process practiced differently by

individuals, countries and regions. No one needs this type of addition to

the literature as it reads now. Please consider further education before

tackling this problem of occult (well-appearing patient) bacteremia. The

literature is already proving a need for revision of these guidelines

because of the success of H flu. vaccine (are you aware of this recent

meta-analysis?). Maybe the revised guidelines soon to follow will quell

your urge to frighten people, and cause possible unrecognized illness and

death.


From: merlin8 [SMTP:[email protected]]

Sent: Monday, January 25, 1999 7:50 PM


Subject: Occult Pediatric Fever, NEW, suitable for flaming.

I would like to submit this, the opening paragraph of a paper I'm in the

process of writing, for the review of the members of this list as it

certainly pertains to practitioners of pediatric emergency medicine. Please

feel free to flame, suggest, comment, edit, provide statistics or debate

with me on this issue. I know this issue has been hashed and rehashed in the

recent past. However I think I present a new and controversial argument

worthy of discussion. Thank you in advance for your time and energy.

Merlin Curry

Paramedic

Portland, OR

Occult Pediatric Fever

The modern diagnosis and treatment of pediatric fever of occult origin is

troubled. Low grade fevers in infants can initiate a cascading effect of

batteries of tests, from minimal to fully invasive, as the liability driven

protocol is followed out to an extreme, often in a misguided effort to

placate unnerved parents and minimize potential for litigation. This

disturbing process, investigation of occult fever, is frequently initiated

by the parents primarily because of a lack of information or resources to

help them make a calm, informed decision. 911 is activated or the crying

child is taken to the emergency department (ED) by the nervous parent. They

wait for hours with brief interjections by staff to poke their child with

needles, probe them with tubes, and perform procedures for which the parents

do not have an adequate understanding, all amounting to torture while they

are made to stand away powerless only to be given vague useless answers and

prescribed drugs that don t seem to work and often cause further problems

down the road. Obviously to say that all encounters are this painful and

useless is untrue. It must be acknowledged that a certain percentage of

these occurrences lead to the discovery of a serious and treatable illness;

a certain percentage are attended by caregivers with extraordinary

compassion, patience, dedication to their patients best interests so that

the overall experience is positive. Nevertheless often parents walk away

from these health care encounters angry, confused and more anxious about the

febrile status of their child than ever and therefore are more likely to

reinitiate the process, with the utmost angst, in the near future.








Date: Wed, 3 Feb 1999 10:47:31 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Mark Gersten <[email protected]>Subject: Re: A Case of Child (physical) Abuse

In a message dated 2/2/99 1:53:36 PM Eastern Standard Time, [email protected]

writes:

<< [email protected] >>

Gene,

How's life in NW Ohio? Things are about the same in NE Ohio. I would vote no

abuse on this one.

As for your other posting....at Mercy in Canton we see between 2.5 and 3.5

pts/hr, but we have PA coverage for 22 hours a day. We still have to see



those patients, but the PA's definitely help get them seen faster.

Take care.

Mark Gersten




Date: Thu, 4 Feb 1999 21:20:25 -0600Reply-To: Scott Nau <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Scott Nau <[email protected]>Subject: Influenza

I routinely offer amantadine to family contacts of patients with

influenza A, both adult and pediatric. The parents are grateful as the

spectrum of missing a week of work with more sick kids or of being sick

themselves is unattractive. For what it's worth, no one has complained

of any adverse effects to me, and I ask. Scott Nau MD




Date: Fri, 5 Feb 1999 22:14:22 -0500Reply-To: [email protected]



Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "j. m. connors" <[email protected]>Subject: Re: DERMABOND

Is anyone using forceps to approximate the wound or fingers alone?? Has

anyone tried the wound approximaters being marketed by Bionix for use

with Dermabond??

Mick Connors




Date: Mon, 8 Feb 1999 09:57:26 +0000Reply-To: [email protected], [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Michael Levy <[email protected]>Subject: Re: dermabond and billing

A while back someone had posted a note saying that they were coding

dermabond use as "suturing" (or that is my recollection). Our coders

have now told me that there is no guidance from HCFA/AMA on this and

that we cannot code this as suturing. We are to code it under a Misc. code.

Does anyone have different info?


Thanks

Michael Levy MD




Date: Tue, 9 Feb 1999 07:44:16 -0500Reply-To: Jeffrey Mann <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jeffrey Mann <[email protected]>Subject: Re: Test-minimizer

Dave - as a card-carrying member of the 'test-minimizer" group, why have

you raised your temperature threshold from 39C to 40.5C and why have you

raised the WBC threshold from 15,000 to 18,000?

Why not simply go all-the-way and be a fully-fledged "test-minimizer"

and just rely on clinical judgement - and also consistently avoid the

use of prophylactic antibiotics? Do you have evidence to show that

occasional prophylactic amoxicillin use has any real value in preventing

meningitis in that subgroup of pediatric patients with temperatures

>40.5 and WBC > 18,000?


Jeffrey.




Date: Fri, 12 Feb 1999 17:49:48 -0500Reply-To: "Conners, Gregory" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Conners, Gregory" <[email protected]>Subject: Rochester PEM fellowship program

I am pleased to announce that the PEM fellowship program at the University

of Rochester has been accreditated by the ACGME's Residency Review Committee

for Emergency Medicine.

We offer fellowship training to graduates of EM or Pediatrics residencies.

The program places an emphasis on strong academic training; many fellows go

on to obtain MPH degrees. Those interested in more information or

application may call 716-275-0075 or see our website at

http://www.urmc.rochester.edu/smd/EmergMed/Specialty/PedsEM.html

Gregory P. Conners, MD, MPH, FAAP

Director, PEM Fellowshp Program

Assistant Professor, Emergency Medicine and Pediatrics

University of Rochester School of Medicine & Dentistry

http://www.urmc.rochester.edu/smd/EmergMed/Specialty/PedsEM.html


[email protected]




Date: Mon, 15 Feb 1999 16:41:19 -0600Reply-To: Milton Tenenbein <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Milton Tenenbein <[email protected]>Subject: FW: Bronchodilators and Bronchiolitis

The actual cause of the deaths in those asthma patients in that era

was never sorted out with certainty. It was likely multi-factorial

which was the intent of the last paragraph of my original posting.

The most prevalent catecholamines used for that indication in that

era were isoproterenol and epinephrine. Both can produce V/Q

abnormalities in patients with acute reactive airways disease. This,

along with the hypoxia of the disease and the arrhythmiagenic

properties of halogenated hydrocarbons were thought to be the

pathogenetic factors. As to whether all are necessary is anybody's

guess.

The fact remains that sudden death in patients with reactive airways

disease using fluorocarbon powered inhalers delivering nonselective

beta agonists is well documented in the literature.


Since albuterol's use experience supports a much more benign safety

profile, there is not the same grounds for concern. Maybe the reason

is its beta-2 selectivity.

----------

From: Harold J. Farber, MD[SMTP:[email protected]]

Sent: Monday, February 15, 1999 12:56 PM

To: Milton Tenenbein

Subject: Re: Bronchodilators and Bronchiolitis

Dr. Tenenbein,

Very interesting point about the Flourocarbons. Should we be

worrying

about potential toxicity of CFCs with the current trend towards

"multi-dose" albuterol MDI (with individuals recommending anywhere

from

4-20 puffs of albuterol for acute asthma flare ups).

Thanks for your comments.

Hal.

At 04:15 PM 2/14/99 -0600, you wrote:

>Regarding current discussion of epinephrine versus albuterol for

>bronchiolitis....

>

>The literature definitely favours epinephrine. Several respondents

>have addressed the issue of what to do for the epinephrine

responders

>whom can be sent home. There are no obvious answers for this one.

> This has lead to a few postings wondering about Primatene Mist.

>

>This is problematic because of the fluorocarbon propellant used in

>this product. Fluorocarbons are associated with the syndrome of

>Sudden Sniffing Death in inhalant abusers (solvent abusers). There

>are many consumer products that can be cited with one example being

>non-stick cooking sprays such as Pam(r). The mechanism is a fatal

>arrhythmia induced by hydrocarbons such as fluorocarbons.

>

>In the late 1960s and early 1970s catecholamine inhalers with

>fluorocarbon propellants were often prescribed for asthma because

>albuterol was not yet available. There was a rash of sudden and

>unexpected deaths in these patients. The fluorocarbons were

implicated

>but not proven as the cause.

>

>Risk factors for arrhythmia in these patients include the

>fluorocarbons, the hypoxia of the respiratory disease and the V/Q

>abnormalities produced by the inhaled catecholamines in patients

with

>acute obstructive lung disease.

>

>For more information, send mail to [email protected] with

the



>


>

>

Harold J. Farber, M.D.

email (home): [email protected]

email (work): [email protected]




Date: Tue, 16 Feb 1999 19:24:33 -0800Reply-To: parisa arman <[email protected]>Sender: Pediatric Emergency Medicine Discussion List



<[email protected]>From: parisa arman <[email protected]>Subject: A case

I thought this is an interesting case, sharing with the group;

16 years old female with no significant PMH, presented with severe

pain in lower right extremity. She gave a history of trauma while

playing soccer to the same side ankle three days prior to

presentation. Also given a week history of flu like symptoms and one

or tow episodes of vomiting one week prior to ER for which she got

Tylenol-flu. On exam she is obese 114 kg, 160 cm V/S:

HR 114, BP 86/40 RR 20, temp 37.5C in distress and complaining of pain

in leg and calf. physical exam is significant for non pitting edema in

right lower extremity, up to calf area, severely tender to touch.

there is a local area of warmness on medial surface of ankle. also she

had mild eczema lesions on both lower and upper extremities, but skin

is not broken.

X-rays of lower ext. shows massive soft tissue swelling and no broken

bone.

CBC WBC 27000, HB 11.6 Hct 34 Plat: 145 Blood Cx Pending

BUN 26 creat. 3 rest of chemistry showing albumin of 2.6 and Ca of 8.0

LFT WNL PT, PTT WNL

We admit the Patient with DX of Septic shock, ruling out Toxic shock

syndrome. What do you think?

PS I as a resident was also thinking of DVT, and ruling out

compartment syndrome, but ortho and my attending were not agree!

Will appreciate comments.

==

Parisa Arman,MD

Pediatrics Resident

Brookdale University Hospital

Brooklyn, NY

_________________________________________________________

DO YOU YAHOO!?

Get your free @yahoo.com address at http://mail.yahoo.com


http://mail.yahoo.com/



Date: Fri, 19 Feb 1999 19:12:39 -0600Reply-To: "Richard O. Gray MD." <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Richard O. Gray MD." <[email protected]>Subject: Re: LET recipeX-To: David DuBois <[email protected]>

We use the following:

Viscous Xylocaine 4%

Adrenaline 1:2,000

Tetracaine 0.5%

David DuBois wrote:

> Does anyone know an easy recipe for making "LET" topical anesthetic

> solution (lidocaine 4%, epinephrine 0.1%, tetracaine 0.5% {final

> concentrations})? I've tried to get my 2 hospitals to make it but the

> pharmacist wants the recipe since the combining of the three meds which

> start at the above concentration results in a more dilute solution.

> Also, how do you make the gel of LET? Is there info on shelf life

> and storage conditions required? Is there a commercially available LET

> solution or gel product?

> Thanks,


> Dave DuBois, MD

>




--

Richard O. Gray MD. FAAEM

Assistant Professor Emergency Medicine

Hennepin County Medical Center

701 Park Avenue South

Minneapolis Minnesota 55405

[email protected]

[email protected]

"I can't complain but sometimes I still do."




Date: Mon, 22 Feb 1999 12:22:57 -0700Reply-To: Roger Galbraith <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Roger Galbraith <[email protected]>Subject: Re: Nitrous oxide in the ED



>

>This comment is regarding the use of nitrous oxide in the ED as an

>"analgesic." Nitrous is an inhaled agent appropriate for sedation and its

>adminstration should NOT be confused as providing analgesia. The "analgesia"

>reported is due more to apathy and sedation than pain relief due to binding of

>an agent at pain receptors.

I agree that Nitrous does work offer sedation and is an anxiolytic. But

Mike, when I look at the article that you co-authored with Al Sacchetti and

others in Annals of Emerg Medi (Feb 94) Nitrous is discussed as an analgesic

with references provided. In addition in the recently revised APLS course we

teach that it has potent analgesic effects. Clinically the effect that I

see is also one of analgesia plus sedation. In fact I find that for short

procedures it works much better if the child is not particularly anxious as

they are better able to cooperate with my instructions both before and

during the procedure.

>One

>must than be aware of the danger of combining an opioid with nitrous which is

>the risk of moving down the sedation continuum towards general anesthesia -

>with loss of respiratory response to rising pCO2 and loss of protective

>airway reflexes.

This is always a concern we need to remain aware of. But if you are giving

the Nitrous first -- say to a kid presenting to triage with an isolated

fracture -- then it is so rapidly eliminated that by the time the fracture

is immobilized, the kid is up into a bed in a room and an IV started the

Nitrous is not going to amplify the effects of a narcotic.

I don't use it if I have already established an IV and need something extra

for the procedure.

>

>I suggest that you try a trick told to me years ago by that ol' sage Al

>Sacchetti - IM, not IV, morphine. When a patient hits the door with a

>painful or painful looking fracture, I immediately order 0.1 -0.2 mg/kg IM MS.

>It is safe and easy and always works in relieving significant amounts of

>anxiety and pain.

Does it work as fast as the Nitrous does? (Plus it takes 2 nurses to draw

up and check a narcotic vs one to roll over the tank of Nitrous) How do the

kids feel about getting the shot as opposed to the mask?

We have a standing protocol for the administration of Codeine at triage that

has worked very well and we have talked about developing one for Nitrous.

But I would be a bit hesitant about putting one in place for IM Morphine at

triage. Thus using IM Morphine at triage also means that these kids need to

be initially seen by a physician before receiving the morphine.

If they need extra analgesia/sedation for a procedure what do you then offer

them if you've gone with the IM route?

Rog says "Mikey: Try the Nitrous...you'll like it".

Cheers,

Rog

*****************************************************************************

Roger Galbraith MDCM, FRCPC

Attending Pediatrician

Emergency Department

Alberta Children's Hospital

1820 Richmond Road S.W.

Calgary, Alberta, Canada

T2T 5C7

Phone: (403) 229-7070

Fax: (403) 229-7398

E-dress: [email protected]




Date: Wed, 24 Feb 1999 10:25:46 -0800Reply-To: Margaret Walker <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Margaret Walker <[email protected]>Subject: Tympanocentesis

Sorry. I hit the "send" button prior to signing my prior message. Margaret Walker MD, Hayward Kaiser, California, USA.




Date: Mon, 1 Mar 1999 19:03:42 +0000Reply-To: "Dr. Nikolaus Lutz-Dettinger" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>Comments: Authenticated sender is <[email protected]>From: "Dr. Nikolaus Lutz-Dettinger" <[email protected]>Subject: nutmeg ingestion

Dear colleagues,

a mentally retarded child has ingested half of a nutmeg (ungrinded);

nutmeg contains myristicine, an halucinogen. Anybody out there, who



has experience with this or any opinion? Can one expect a minimal

toxicity, because the ungrinded nutmeg will only partially be digested

and rather leave the body per vias naturales more or less unchanged?

Would you give ipecac (the child could not be in hospital within 90

minutes

after ingestion)? would you hospitalize?

Thanks,

Dr. Nikolaus Lutz-Dettinger

PICU

Dept. of Intensive Care

University Hospital Gent

De Pintelaan 185

B 9000 Gent

Belgium

tel.: **32 - 9 - 240 21 11

fax: **32 - 9 - 240 49 95

email: [email protected]





Date: Thu, 4 Mar 1999 11:15:40 +1000Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Sarah Epstein/Sandy Hopper <[email protected]>Subject: Re: spacer devices

Our department is presently moving away from the use of nebulised B2

agonists in favour of MDI and spacer device. (only the child with severe

asthma will be given nebs) This raises the problem of after hours

availability of spacers for the patient who is to be discharged. Right

now we give them away after hours and send the family to the local

pharmacy whenever they are open. I find this approach piecemeal and

inconsistent not to mention incovenient for us and the families

involved. Does anyone on the list have a different approach? Maybe

selling at cost price from the dept?

BTW the "Aerochamber" from Allersearch is now $55 Aust (about $US

35) . How does this compare to US prices? Are there cheaper

alternatives?

PLease feel free to reply privately or on the list.

Sandy Hopper. Registrar Sydney Children's Hospital , Aus




Date: Sun, 7 Mar 1999 17:26:00 -0500


Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: [email protected]: Re: Etomidate-only RSI.X-To: Jeffrey Mann <[email protected]>

I have followed the discussion of RSI with interest and would offer my opinion on two aspects. In the situation of anesthesia "frowning" on the use of SCH, I see it differently. When I intubate a patient, I want them "down and back" as soon as possible with a minimal effect on ICP. As ED patients, these chilren usually have evolving disease or injury processe which I want to be able to monitor and intervene for, whether the patient is in the CT scanner, having a procedure done or simply waiting to go to the PICU. If anesthesia is present and taking the patient directly to the OR, that's a different story. In that situation, use of a longer-acting NMB is entirely appropriate The paralyzed child cannot struggle if he/she becomes hypoxic or develoos an ET tube complication (not an uncommon situation in the ED patient who may need to be moved several times, has multiple care providers, and may have blood, secretions or debtis in their airway!). With paralysis, you are !

totally reliant on the pulse ox to monitor oxygenation but if the patient has had atropine, neither the pulse ox nor the pupil exam (for ICP) are reliable for 30 minutes .I am particularly uncomfortable paralyzing for long periods the child with seizures or the potential for seizures. I would rather see them sedated with a benzodiazepine and add Dilantin as needed. I also take the same view when preparing an intubated patient for transport .

For many ED intubations actual, or potential for increased ICP is a consideration and it is my understanding that this is the benefit of using a free-radical scavenger which also lower neuronal metabolic demand (like thiopental or etomidate). I feel comfortable with etomidate or thiopental for seation in this situation and the anesthesiologists in our institution prefer to use etomidate when they come to the ER to assist with an intubation. However I also teach pediatric residents RSI. When I talk to them, I tell them they may not do an RSI on full-stomach, non-neonate for five years but when ther do, potentially in a small, local hospital with an inexperienced staff, they will be exoected to have the same outcome as an anesthesiologist in a large, well-prepated OR. Hence, unless they'll be doing a lot of intubations in controlled settings, they should become familiar with the use of sedatives and paraltics that are widely available and familiar like SCh and thiopental.

----Original Message-----

>From: Jeffrey Mann <[email protected]>

>To: Multiple recipients of list PED-EM-L <[email protected]>

>Subject: Re: Etomidate-only RSI.

>Reply-To: Jeffrey Mann <[email protected]>

>Date: Friday, March 05, 1999 2:46 PM

>

>Harvey and Jay - Thanks for your responses. I agree that the optimum

>conditions for RSI are created by the combination of general anesthetic

>(eg, thiopental or propofol or etomidate) + NM paralysing agent.

>

>I brought up the issue of 'etomidate-only' intubation because I came

>across a letter in the American Journal of Medicine (January 1998) on

>this subject, where the proponents of its use suggested that it was

>useful in the situation where the patient had a situation of antecedent

>hypoxia and/or cardiovascularly instability + ? abnormal upper airway

>anatomy with a "possible" difficult airway situation. The author

>suggested that etomidate-alone created sufficient muscle relaxation and

>depression of conciousness to create a good intubating-situation without

>having to paralyse the patient. I have personally never used etomidate

>so I did not know whether this recommendation was valid. I have read

>that etomidate causes myoclonus and I wondered whether it also

>occasionally caused bruxism => thereby actually increasing the

>difficulty with intubation.

>

>Jay - do you think that using rocuronium in the ED setting, where it is

>difficult to 100% anticipate a "difficult" airway and a "CVCI" (cannot

>ventilate-cannot intubate) situation, carries too great a risk - becuase

>it causes such a prolonged state of neuromuscular paralysis?

>

>Jeffrey

>

>For more information, send mail to [email protected] with the message: info PED-EM-L



>




Date: Wed, 10 Mar 1999 21:37:52 -0800Reply-To: parisa arman <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: parisa arman <[email protected]>Subject: A case

I got an interesting case in ER

3.5 months old baby girl PMH significant for full sepsis workup at

birth due to Breathing difficulties and GBS positive mother. FT, NSVD

Present with lethargy and poor sucking, low temp according to mother.

No fever no vomiting or diarrhea perfectly fine till 2 hours prior to

presentation.

On exam she was lethargic only responds poorly to painful stimuli,

pale dusky color with poor peripheral perfusion. V/S 158 pulse 32 RR



98.4 rectal Temp.

Pulse Ox 100%. low muscle tone had otherwise good reflexes and normal

Physical exam including abdominal exam. She was admitted in ICU.

initial lab results showed Normal CSF, BS 450, 17600 wbc, 10 Hb, 37.5

Hct 531 plt. UA normal ABG ph of 7.13

Next day in ICU she developed massive bleeding from IV sites .CT scan

of head and abdomen Negative DIC workup negative, including PT PTT

Fibrinogen etc.

No rash. Surgery consult requested and kid was taken to OR turned out

to be Volvulus of Jejunum.

Questions:

What is the possibility of Volvulus presenting like this?What should

we have done to had an earlier diagnosis? why should she have Bleeding

and hematuria?

Appreciate comments.I would also appreciate literature regarding ER

presentation of volvulus in this age.

Regards,

==

Parisa Arman,MD

Pediatrics Resident

Brookdale University Hospital

Brooklyn, NY

_________________________________________________________

DO YOU YAHOO!?

Get your free @yahoo.com address at http://mail.yahoo.com




Date: Tue, 16 Mar 1999 22:53:05 ESTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "<Julian Orenstein>" <[email protected]>Subject: Car seats and injury

To the group:

Apologies for being lazy and not doing the lit-search first, but are any of

you aware of data that describes injuries in children in car seats?

Specifically, are there any reports that state that the well-appearing child

in an intact car seat runs any risk of occult injury?

How about any anecdotal reports? I've never seen any, yet I have re-mobilized


http://mail.yahoo.com/

many, many kids brought in taped into the car seat, which was itself rolled in

usually alongside mom. Do any of you get films based on mechanism if there is

no apparent sign of injury?

Julian Orenstein, MD

Fairfax Hospital, Va




Date: Mon, 22 Mar 1999 16:41:39 -0600Reply-To: Steve Green <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Steve Green <[email protected]>Subject: ketamine & JCAHO - not again

>JCAHO rounded on our hospital last week and said that our 'at least one nurse,

>one doctor at the bedside' protocol was inadequate and that we now need TWO

>nurses and a doctor at the bedside.

Jay, sounds like you were unlucky enough to get JCAHO surveyors who don't

read JCAHO publications. Pick up a copy of a recent JCAHO book entitled

"Care of Patients: Examples of Compliance" (ISBN 0-86688-611-7; web site

www.jcaho.org).


There is a chapter in this book verifying the Loma Linda University ED

ketamine protocol as an "example of compliance", with one physician and one

nurse clearly delineated. We have gone through several JCAHO surveys with

this protocol without difficulty.

Steve Green, MD, FACEP

Director, Emergency Medicine Residency Program

Professor of Emergency Medicine

Loma Linda University Medical Center & Children's Hospital

Loma Linda, California




Date: Mon, 22 Mar 1999 18:08:09 -0500Reply-To: Cyndy WRIGHT <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Cyndy WRIGHT <[email protected]>Subject: Re: PED-EM-L Digest - 16 Mar 1999 to 17 Mar 1999


Julian and "the group"=20

Where to begin on Car Seats in Crashes ? As we type, most of the experts =

in the field are attending the NHTSA LifeSavers Conference in Seattle.

=20

Cases of occult injuries have been reported at least at Pediatric Trauma =

conferences for 10 years. None of them formed a pattern that could lead to =

a critical pathway or even guidelines.=20

Children's National Medical Center in Washington D.C. has been conducting =

crash reconstruction research on restrained children since the early 1990s =

and has published some of their data and presented widely. NHTSA funded =

this research as well as other adult centers in the SIREN group. ( I do =

not have the meaning of SIREN infront of me - but it is a group of =

university based centers that are collaborating on crash reconstruction =

research.) Cathy Gotschall Ph.D. is the contact at CNMC for this project. =

You can find her email on the "contact us" page of the national EMSC =

website at

www.ems-c.org/

Another major research projects is ongoing at CHOP on this specific =

issues. Flora Winston MD Ph.D. is the PI and has funding through State =

Farm to do a series of levels of reports and investigations on crashes =

where children were restrained. The quickest way to reach them is through =

their web site at Trauma Links www.med.upenn.edu/~trauma/ . Flora has =

also presented at EMSC and other meetings on their current experience at =

CHOP.=20

As a Pediatric Trauma Coordinator for 7 years, I saw both minor and major =

injuries in children who were found in car seats. Now as a Child =

Passenger Safety Training Instructor for NHTSA in Maryland, I better =

understand the patterns we have been seeing. Briefly:

90 % of carseat checked by trained CPS technicians are installed incorrectl=

y by well meaning families.

The child is in the seat the wrong way or the harnesses have not be =

adjusted as the child grew, allowing for too much head excursion and =

placing too much of the force from the crash on the chest and abdominal =

region. =20

The child may be in a seat that has been recalled or involved in a crash =

and no longer safe. The possibilities for too much movement or force are =

the most common problem BUT some recalls include the harness buckles =

failing - ie partial ejections.

The car seat is almost always too lose in the seat, installed incorrectly =

OR in seating position that is incompatible with a car seat. Many =

families have not read the car owners manual and do not know to have the =

dealers install additional restraint belts or buckles. These problems =

allow the seats to rotate into the front seat or the sides of the vehicle =

(sometimes the B or C post) within 1/10th of a second. We have seen many =

major injuries and a few fatalities across the country. At least 4 cases =

of fatalities have been reported in the DC metro area. These were crashes =

were the G forces were not considered fatal by the reconstruction team and =

where the other restrained passengers had minor injuries.=20

A major concern is the outdated teaching of packaging a child in a car =

seat after a crash. Across the standardized programs (PALS, BTLS, PHTLS =

ect) we are trying to remove this training and teach providers to transfer =

the child to an appropriate immobilization device. Two issues clinically =

:

Once packaged - it is hard to reassess the child in transport every 5 =

minutes as the new EMTB teaches. Most of the pictures in texts and =

training do not leave the chest and abdominal area accessible for repeat =

assessments. =20

Second - if the childs condition deteriorates, advanced airway and =

circulatory access is near to impossible with the child in a car seat. We =

all know children change rapidly.

Other concerns are more technical - if we tell the parents never to use =

the car seat again after a crash (per NHTSA and all of the car seat =

manufacturers) what example are we setting by transporting the child in =

that seat? =20

The legal consultants for the EMS services are quick to understand that if =

the manufacturer will not be responsible for the car seat use after a =

crash by parents, health care providers do not want the responsibility of =

use a seat involved in a crash for transport. =20

Sorry this is so long, but bottom line - until we have universal attachment=

s for all car seats and all cars (to start in 2000), there is no way to =

know how much force a child's internal organs absorbed. There are now =

Child Passenger Safety instructors in every MCHB/NHTSA region and most =

states. We would welcome more pediatricians and peds emergency physicians =

to our courses! Locally I would be happy to provide an abbreviate update =

at your next Ped ED regional meeting. (The full NHTSA course is 4 eight =

hour days which is needed to train technicians, the AAP is working on a =

shorter program for child car workers and practioners but we have not seen =

it yet). =20

Trauma Links has a list of resource people by state. =20

For patterns and clinical pathways - we need to see what Cathy and Flora =

research shows. I hope both will present at the 2000 National Congress on =

Childhood Emergencies in March.=20

=20

*********************************

Date: Tue, 16 Mar 1999 22:53:05 EST

From: "<Julian Orenstein>" <[email protected]>

Subject: Car seats and injury

To the group:

Apologies for being lazy and not doing the lit-search first, but are any =

of

you aware of data that describes injuries in children in car seats?

Specifically, are there any reports that state that the well-appearing =

child

in an intact car seat runs any risk of occult injury?

How about any anecdotal reports? I've never seen any, yet I have re-mobiliz=

ed

many, many kids brought in taped into the car seat, which was itself =

rolled in

usually alongside mom. Do any of you get films based on mechanism if there =

is

no apparent sign of injury?

Julian Orenstein, MD

Fairfax Hospital, Va

***********************************************

Cynthia J Wright-Johnson, MSN RNC

EMSC Program @ MIEMSS

653 W. Pratt St.

Baltimore, Md. 21201

410-706-1758

410-706-0853 Fax

[email protected]




Date: Sun, 28 Mar 1999 21:36:58 -0800Reply-To: Martin Oliver <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Martin Oliver <[email protected]>Organization: @Home NetworkSubject: Re: ketamine & JCAHO - not againX-To: Steve Green <[email protected]>

Steve Green wrote (major snip)

....an "example of compliance", with one physician and

one

nurse clearly delineated....

---------------

What about PAs administering Ketamine? Since PAs,

according to CA state law, "practice medicine under

the supervision of a physician", and we are allowed,

also by law, to perform procedures that are "usual and

customary to the supervising physician's practice",

and also by law, "any order...by the PA shall be

considered to be the order of the supervising

physician", JCAHO should have no problem with PAs

using Ketamine.


I have used Ketamine at least monthly, for suturing

foot and hand lacs, and large facial lacs (mostly for

glass vs foot). It is always on a "patient specific

protocol" - the doc approves it before hand, and is

present (somewhere) in the ED during the procedure.

I have found Ketamine to be a blessing for everyone

involved, especially the kids, and we have never had a

problem.

Martin Oliver, PA-C

Capo Beach, CA




Date: Wed, 7 Apr 1999 01:01:19 -0700Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Jay D. Fisher" <[email protected]>Subject: Re: Croup and DeathX-To: "Dr. Eugene Izsak" <[email protected]>

Post mortem exams were done on the 2 year old and the 9 month old. Nine

month old showed no evidence of bacterial tracheitis, foreign body,


myocarditis or cardiac anomaly, abuse, sepsis, MCAD, CNS disease or

poisoning. Two year old had S. aureus tracheitis with mild inflammation

and small pulmonary infiltrate.

Undoubtedly many cases such as these involve a component of bacterial

tracheitis but my point is that these cases appeared clinically

identical to 'croup' (viral LTB) until shortly before arrest to both

pediatricians and parents. It is also interesting to note that in none

of the cases was intubation difficult for the physicians involved. My

review of the literature suggest that arrest at home in such cases is

unusual.One of our hypotheses has been that our arid climate can lead to

severely inspissated secretions that a very small or fatigued child

cannot clear.

Jay Fisher




Date: Sun, 11 Apr 1999 14:35:55 -0500Reply-To: MARTIN I HERMAN <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: MARTIN I HERMAN <[email protected]>Subject: Kernicterus


A while back I had asked for some thought regarding the management of

Kernicterus. Sorry to be so slow in posting but I lost the file of responses

and recently recovered it.

Here they are:

The questions were:

> Dear List member,

>

> In a term baby, without underlying disease who developes

hperbilirubinemia,

> How long after the bilirubin rises above 30 does kernicterus occur?

>

> If a baby presents to the ED appearing markedly jaundiced, What is a

> reasonable time interval for the parents to wait for the lab results ?

What

> would you do in the interim? If the level returned 2 hours later > 30

,what

> would you do then?

>

> Would you start phototherapy in such a baby, pending the transfusion?

> What about IV fluids ?

> How much of a delay is expected prior to instituting the double exchange

> transfusion?

> What about Phenobarbital?

>RESPONSES:

1.I don't know how effective short-term phototherapy would be, but several

months ago we had a several day old infant present with a bilirubin of 37;

while awaiting exchange transfusion, the baby received vigorous iv hydration

and the bilirubin dropped into the mid-20s range with that therapy alone;

I'm sorry, but I'm unsure how long a delay there was until exchange

transfusion. Unfortunately, the neonatologists had evidence from studies

that there was CNS damage despite the rapid decline in the bilirubin Kevin

Kowaleski- San Antonio

2. I have been in this situation on a number of occasions. I understand

that kernicterus can occur at bili levels above 20, but that infants without

underlying disease such as breastfed infants almost never develop

kernicterus. (I don't have citations handy, sorry. There are a number of

post-mortem studies)

Practically speaking, if I have an infant that is markedly jaundiced, say

down to its toes, I light the infant in the ED. I light the infant in the

ED if it has a bili of over 20 and is being admitted to a floor bed. This

is because at our institution it could be a long while before the patient

gets to the floor. We often send these infants to the NICU which is a lot

quicker. Work up includes CBC, Bilis, Type and hold, DC (at least), finding

mom's blood type.

Now, for a bili > 30, the infant will be going to the NICU for exchange

transfusion (>25 actually). The time to exchange-transfusion is the time to

cross match blood and set up for the exchange assuming you are in an

institution with a NICU. If I have an infant with a bili over 20, I look

for underlying causes--ABO incompatability and other minor ag

incompatibilites, infection (sepsis), hypothyroidism, etc. I have heard of

cases of infants with a bili as high as 30 with breastfeeding, but is so

rare other causes need to be considered. (last week we had a full term

infant with "breastfeeding jaundice" billed as dehydrated who really had

sepsis) Terry Adirim Washington, DC

3.

A.I do not know how long does it take to get kernicterus...

B. .In our Institution, we get the bili back in 1 hr. max.While waiting,

I usually do nothing, except: if the baby looks dry, or there is a history

of poor feeding, lethargy- then I start IV fluids.

C..I admit them for bililights at bili of 20- for term babies

D..If bili is above 24- I admit them to the NICU- they will exchange in

the next couple of hours.Of course I start IV fluids pronto.

E.. .No experience with phenobarbital in this case.

F. No bili lights in the ER

I hope this helps Steven Szabo

4. much of the data for kernicterus i believe came from Rh incompatibility

studies of the 60's which demonstrated kernicterus on post mortum

examination. a pattern was discovered whereby those with serum bili's over

20 were more likely to have kernicterus than those below 20, which also lead

to the practice of exchange transfusions. these were also in very sick

infants. it is still rather controversial when to begin phototherapy in a

term newborn with a high bili. many of our neonatologist would start

phototherapy at 20. if the infant could feed, home phototherapy could be

arranged, if the infant was too lethargic, he would be admitted for fluids

and lights. exchange transfusion in a term infant is infrequent.

5. > In a term baby, without underlying disease who developes

hyperbilirubinemia,

> How long after the bilirubin rises above 30 does kernicterus occur?

> Unknown. Could happen earliar. Only controlled study from the late 1960's

suggests that in a term healthy baby upto 24 may be OK. To my knowledge,

cases of kernicterus have been only reported in babies with hemolytic

disease or premature sick neonates.

>

> If a baby presents to the ED appearing markedly jaundiced, What is a

reasonable time interval for the parents to wait for the lab results ?

> What would you do in the interim? If the level returned 2 hours later >

30 ,what would you do then?

>

> ASAP ideally. If I suspect hemolytic disease or a "symptomatic"/sick baby

then I would start phototherapy right away in the interim, and get the

neonatologist + ICU involved early. If they are healthy like you stated,

and are breast feeding and have icterus upto their feet(approximate level

>15-18)I would withold BF in the ED and may be > start phototherapy in the

interim.

>

> Would you start phototherapy in such a baby, pending the transfusion?

> Yes

> What about IV fluids ?

> Yes, in this situation with ExTx pending.

>

> How much of a delay is expected prior to instituting the double exchange

transfusion?

> Depends on the institution! A TxM with maternal blood takes 45 minutes

plus about an hour or two may be, to get set and insert umbilical line(s).

>

> What about Phenobarbital?

> Would use it in this situation with EXTX planned @ 5 mg/kg/day to >

enhance hepatic bilirubin conjugation.

BTW, did you have a case of this recently?

[Jay Pershad, M.D.]

6. * It is hard to say and the damage may have been done before 30 was

reached.

>If a baby presents to the ED appearing markedly jaundiced, What is a

reasonable time interval for the parents to wait for the lab results ?

* Even in a Neonatal ICU it can take an hour or more to get

results back. No reason to think it would take less in an ER.

>What would you do in the interim?

* If I thought clinically that this level was going to be

significantly elevated (greater than 15), I would call the Neonatal Service

immediately after admission to the ER (or office) and before results

available to get things started; admission, hydration, phototherapy, blood

for diagnosis and Type and Cross match. If I thought the level was not

going to be significant (less than 15) I would have waited until the result

came back. This can be a very difficult determination clinically and I have

been fooled both ways.

If the level returned 2 hours later > 30 ,what

would you do then?

* Call the Neonatal Service, arrange admission, obtain and send blood for

diagnosis and Cross Match. I would expect the Neonatal Service to do the

details of setting up the exchange.

>Would you start phototherapy in such a baby, pending the transfusion?

* Yes, on the ward.

What about IV fluids ?

* If the baby was dehydrated and/or unable to feed.

How much of a delay is expected prior to instituting the double exchange

tranfusion.

* Proabably, a minimum of an hour after the blood has reached the blood

bank for Cross Match.

What about Phenobarbital?

* Phenobarbital is used a a prophylactic measure and hours

(24) are needed for effect. There would be no indication for its use here.

Bill Hayden, MD ,Director, Rush-Cook County Hospital Pediatric Critical Care

Program

Chicago, IL USA

7. If an infant is yellow to the toes, I would light pending results. At

the very least, I would light once I knew the results while awaiting

disposition of the infant. I know of a case where a well regarded PED was

sued because an infant developed kernicterus while awaiting treatment.

Lighting early may not prevent the sequelae, but it may protect you from

liability. I would also wonder why it would take 2 hours to do a bili (not

a real question, I know why and we all grapple with labs that take too

long). So I would say no, the ED delay is not reasonable. Terry

8. I can't exactly recall, but it may have been 3-4 hours after the baby was

first evaluated - my recollection was it took 2+ hours to obtain lab results

(an all too common phenomenon in our ED) then a while longer to reassess the

baby and

establish iv access; we did not initially appreciate that the baby was

substantially dehydrated. To me, this was too long a period of time - the

goal probably ought to be to begin hydration within 2 hours of presentation.

What do you think?

Kevin Kowaleski, MD

Hope you are as intrigued by these replies as I was.

Martin




Date: Wed, 21 Apr 1999 15:28:08 -0500Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Brian Short <[email protected]>Subject: "Nurse-zine" Vol. 3, No 4 - Nurse Career Guide, Labor Statistics, Paralyzing Agents, Nursing and medical News and more!X-To: [email protected]

"Nurse-zine" (pronounced Nursing)

Vol. 3, No 4

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Wednesday, April 21, 1999

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Date: Thu, 29 Apr 1999 10:30:58 -0700Reply-To: Nathan Kuppermann <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Nathan Kuppermann <[email protected]>Subject: PEM CRC meeting

Dear PEM Colleagues:

The Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC)

will be meeting on Monday May 3 at 7 AM (instead of 8AM) as the PEM plenary

session starts at 8AM. We will be meeting at the San Francisco Hilton


Hotel, Continental Room 1 / 2. A continental breakfast will be served, and

the meeting will end in time for participants to get to the plenary

session. Sorry for the scheduling confusion.

Regards,

Nathan Kuppermann

Chairperson, PEM CRC




Date: Tue, 4 May 1999 12:05:23 -0700Reply-To: Francisco Javier Benito Fernandez <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Francisco Javier Benito Fernandez <[email protected]>Subject: Re: Acute bronchospasm and hypoxia during sleepX-To: [email protected]

In my practice is very frequent to observe wheezing patients with low pul=

se oximetry during

sleep. Many of these patients are less distressed than before and pulse o=

ximetry becomes higher

when they awake. At the begining we used to increase bronchodilator thera=

py wihout success or

even getting worse pulse oximetry values. Now we treat these patients wit=


h oxigen and less

intensive bronchodilator therapy. I think that VQ mismatch in wheezing pa=

tients may be increased

during sleep add to bronchodilator therapy.

Pulse oximetry is helpful in the wheezing patients management in the emer=

gency room but must be

interpreted carefully above all after bronchodilator therapy. I think tha=

t more agressive

treatment must be based mainly in the presence of distress and low PEF re=

cords.

Javier Benito MD

Bilbao, Spain

Jay D. Fisher escribi=F3:

> As the winter season begins to quiet down, our group would like to know

> how the members of the list approached the wheezing patient with low

> pulse oximetry during sleep this winter. In patients without a clear

> indication for admission at presentation (whatever your criteria may

> be), how do you approach the child with a room air pulse ox of 90%

> during sleep after 0.5 to 1 mg/kg of nebulized albuterol over an hour.

> For the sake or discussion, lets say that the initial pulse ox was 94%

> and the remainder of scenario is benign.

>

> Jay Fisher MD

> Las Vegas, Nv

> www.pediatric-emergency.com

>

> For more information, send mail to [email protected] with the =







Date: Sun, 9 May 1999 12:56:44 -0600Reply-To: Tony Wieczorek <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Tony Wieczorek <[email protected]>Subject: Shaken Baby/Spinal InjuriesX-cc: EMED-L <[email protected]>

I would like the feelings of the list regarding Shaken Baby Syndrome and the

likelihood of spinal injuries. Specifically, should prehospital providers

be immobilizing these patients? What is the occurrence of spinal injuries

in these patients? There is no mention of this in current prehospital

texts, that I know of, and a search engine query turned up nothing on this

topic.

As far as available immobilization devices go, I see the KED ( Kedrick



Extrication Device) and a long spine board as the most common. I guess some

places still use a short back board, but I haven't seen one in several

years. I see the KED as a problem because it would encompass the thorax and

abdomen preventing continued assessments. The long back board seems

impractical due to its size relationship to an infant. Additionally, unless

the child has a depressed level of consciousness, they probably won't

tolerate being strapped, taped, velcroed, or otherwise held down. If we do

try to force them down, we may be aggravating an injury.

Thanks in advance for your replies.

Tony Wieczorek, NREMT-P

ABQ, NM

[email protected]

I




Date: Fri, 14 May 1999 09:55:23 -0700Reply-To: Joseph Dobson <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Joseph Dobson <[email protected]>Subject: ER Waiting Times


Are there any established or written guidelines for maximum allowable

waiting times from time of triage to physician examination for children

based upon degree of illness. How long should a child wait from the

time they sign in to be triaged. To what degree should a ER physician

be held accountable if a child has a bad outcome as a result of a

prolonged waiting time, even if triage did not indicate signs of serious

illness. What legal precedents have been set? What are people's

feelings? Does anyone know of any published literature on the subject?

I would appreciate any references or opinions. My opinion has been

asked on this matter, and I would like to give a balanced "standard of

care" answer.

Joe Dobson




Date: Sun, 23 May 1999 11:23:26 -0700Reply-To: Joseph Gunn <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Joseph Gunn <[email protected]>Subject: otitis-again

just wanted to know if people have switched their otitis treatment based


on the new CDC recommended guidelines. (now recommend initial amox at

80-90 mg/kg/day). ped infect dis j jan 99

--

Joseph D. Gunn, MD


Fairfax Hospital

Falls Church, VA




Date: Thu, 27 May 1999 17:05:45 +1000Reply-To: Peter Barnett <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Peter Barnett <[email protected]>Subject: Parental education videos

Dear Group,

One of our nursing staff suggested we have a video for parents around the

issue of Croup. Does anyone know of this type of material out there??

Peter Barnett

Dr. Peter Barnett MBBS FRACP MSc(epid) FACEM

Deputy Director



Royal Children's Hospital

Flemington Rd,

Parkville, Victoria

Australia, 3052

Telephone + 61 3 9345.6592

Facsimile + 61 3 9345-5938

E-mail [email protected]




Date: Fri, 28 May 1999 02:00:41 -0500Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "John L. Meade, M.D., FACEP" <[email protected]>Subject: Re: drowningX-To: Richard Gabor <[email protected]>In-Reply-To: <008801bea8a2$d9c09d80$d077fbd0@richardg>

I have one of the electric pool covers on my own pool, and find it to be the

single best investment in our home, at least from the point of view of piece

of mind. I live in Florida, and pools are commonplace, as are drownings.

This type of cover is the best protection I could find, to protect my child,


as well as neighborhood children. Of course, one must be diligent in always

leaving the cover closed, unless you are actually at poolside.

The cover comes with a small sump pump that is to be left on top of the

cover whenever the cover is closed. This removes any accumulated rain water

automatically. Certainly, without the sump pump in place, the cover could

easily collect enough water on top to allow drowning, if a child was to

climb out on the cover.

John L. Meade, MD, FACEP

Emerald Healthcare Group, P.A.

[email protected]

www.statdoc.com




Date: Thu, 3 Jun 1999 20:38:08 -0400Reply-To: Thomas Zand <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Thomas Zand <[email protected]>Subject: Re: chicken poxX-To: David Soglin <[email protected]>

David Soglin wrote:


> OK admittedly a silly question unrelated to peds emergency medicine but

> my 6-year-old son asked me and I cannot find the answer. Why are

> chicken pox called ckicken pox?

>

> Thanks

>

> David

> --

> David F. Soglin, M.D.

> Chairman, Pediatric Emergency Medicine

> Cook County Children's Hospital

> Chicago, IL

>




According to H.A. Skinner in, "The Origin of Medical Terms", p.103, Williams & Wilkins Baltimore,

1961, Chicken Pox is "supposed to have been named from the mildness of the disease (cf.

chicken-hearted)." In 1767, William Heberden (the elder) was the first to accurately distinguish

the disease from smallpox.

So it seems that the chicken pox nomenclature is a metaphor for the cowardly nature of varicella

versus the boldness of variola!


Tom Zand M.D.

Westborough, MA




Date: Wed, 9 Jun 1999 09:40:49 -0400Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: Emory Petrack <[email protected]>Subject: Re: Reversal agentsX-To: Jay Fisher <[email protected]>In-Reply-To: <[email protected]>

We also have substantially increased our use of ketamine in comparison to

versed/fentanyl. We rarely add versed when using ketamine, and this seems

to work well for us. There are 2 groups of patients for whom I might

consider versed/fentanyl over ketamine:

1) Older kids. While previously we had stopped using ketamine after about

7-8 years old, we now use it fairly routinely up to 10-11 years. However, I

am aware that more and more folks are using it on older kids, and it may

turn out that the concerns about emergence reactions are not really

significantly more prevalent in older kids.


2) Kids with significant muscle mass requiring fracture reduction (these

tend also to be the adolescents). There is some concern about ketamine

increasing muscle tension and making reduction more difficult. I have seen

a couple times what seemed to be reductions that were more difficult than

expected with the use of ketamine in such adolescents. However, this is

anectodal and I am not aware of any literature that has shown this to be a

clear problem in clinical work.

Overall, I agree ketamine is a great sedating agent and I'm glad to see its

use increasing.

Emory Petrack, MD, MPH

Director, Pediatric Emergency Medicine

Rainbow Babies and Children's Hospital

Cleveland, OH


From: Pediatric Emergency Medicine Discussion List

[mailto:[email protected]]On Behalf Of Jay Fisher

Sent: Wednesday, June 09, 1999 3:53 AM


Subject: Re: Reversal agents

I am curious to know which procedures folks are using fentanyl/versed for,

as opposed to

ketamine/versed. My personal experience with ketamine/versed finds it to be

so superior for

fracture reduction, laceration repair, etc, that I will never go back to

fentanyl/versed. The

Kennedy et al. Pediatrics 1997 data, and Steve Green's bountiful ketamine

database seems to

support this as well.

Jay Fisher MD

Las Vegas




Date: Fri, 11 Jun 1999 13:53:06 -0500Reply-To: Jay Fisher <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Jay Fisher <[email protected]>Subject: face validityX-To: jay pershad <[email protected]>

--------------B93E2B3805CC6FA37C893CDE




Dr. Pershad-

I apologize for my lack of clarity. I don't refute that somebody,

somewhere, reported an 'association' between ketamine and hallucinations

in teenagers two weeks later. (Though I would still like to see the

papers). While I am not a neurochemist or a molecular biologist, and I

couldn't distinguish an organelle from a harpsichord, my point is that

this notion lacks 'face validity'. Or in the vernacular, it doesn't make

any sense to me.

Jay Fisher

jay pershad wrote:

> FYI Ref: "Nalmefene for elective reversal of procedural sedation in

> children: Results of an Open-Label Clinical Trial."Atima Chumpa, Ron

> Kaplan, Michele Burns, Michael ShannonEmergency Medicine, Children's

> Hospital, Harvard Medical School, Boston, MA.AAP Spring Meeting.

> Poster Session III. #463. Pg 80A. This was a small, & I suppose,

> ongoing study of 10 patients using "fenta-mida", that is evaluating

> the safety & efficacy of Nalmefene as an antagonist after procedural

> sedation. Patients had a complete response after 10 minutes, as

> measured by a standardized sedation scale. They indirectly looked at

> the "recurrence of pain" issue by measuring HR & BP post reversal and

> noted no significant change. What is interesting is, that they did not

> reverse the "mida"! May be one of the authors could comment on this

> more. W.R.T. Ketamine, Dr Fisher wrote"I think the notion of 'delayed'

> hallucinations is bogus and will be difficult to demonstrate even if

> true. What I am stating again, is that there is data out there, both

> in the dental and the ophthalmologic literature, that ketamine does

> have some association with delayed occurrence of dysphoria, especially

> in older patients. I fail to see why this notion is "bogus". Lack of

> current data proving causality, is NOT the same as no association. The

> analogy being, absence of disease is not the same as wellness. As I

> have said in a prior post, I love ketamine. Especially these days,

> with summer holidays and injuries galore, I am using it practically

> once a day, if not more. However, I would caution against making it

> the panacea of all pediatric sedation's!! BTW, I was amused at your

> supposition of 1 in 10 (10%) incidence of hallucinations (i.e.

> psychoses) in the general adolescent population. Some days it sure

> feels that way with teenagers! Ray Wiss wrote:"- Do you use midaz

> automatically when you use ketamine? If so, why? I

> always give it alone, and in three years am still waiting to see even

> a

> mild emergence reaction. No, I don't Ray. Part of the reason I don't

> is that, it tends to prolong the recovery phase, as compared to

> ketamine alone. Also, I too have not seen any dysphoric reaction yet

> in my 3 years of using it. But, I don't check on them that night or

> that week either. May be we should!! Take care Jay

>

> Jay Pershad, MD

--------------B93E2B3805CC6FA37C893CDE

Content-Type: text/html; charset=us-ascii


<HTML>

<BODY BGCOLOR="#FFFFFF">

<P>Dr. Pershad-

<P>I apologize for my lack of clarity. I don't refute that somebody, somewhere,

reported an 'association' between ketamine and hallucinations in teenagers

two weeks later. (Though I would still like to see the papers). While I

am not a neurochemist or a molecular biologist, and I couldn't distinguish

an organelle from a harpsichord, my point is that this notion lacks

'face validity'. Or in the vernacular, it doesn't make any sense to me.

<P>Jay Fisher

<BR>jay pershad wrote:

<BLOCKQUOTE TYPE=CITE> <STYLE></STYLE>

<FONT FACE="Arial"><FONT SIZE=-1><B>FYI

Ref</B>: "Nalmefene for elective reversal of procedural sedation in children:

Results of an Open-Label Clinical Trial."</FONT></FONT><FONT FACE="Arial"><FONT SIZE=-1>Atima

Chumpa, Ron Kaplan, Michele Burns, Michael Shannon</FONT></FONT><FONT FACE="Arial"><FONT SIZE=-1>Emergency

Medicine, Children's Hospital, Harvard Medical School, Boston, MA.</FONT></FONT><FONT FACE="Arial"><FONT SIZE=-1>AAP

Spring Meeting. Poster Session III. #463. Pg 80A.</FONT></FONT> <FONT FACE="Arial"><FONT SIZE=-1>This

was a small, & I suppose, ongoing study of 10 patients using "fenta-mida",

that is evaluating the safety & efficacy of Nalmefene as an antagonist

after procedural sedation. Patients had a complete response after 10 minutes,

as measured by a standardized sedation scale. They indirectly looked at

the "recurrence of pain" issue by measuring HR & BP post reversal and

noted no significant change.</FONT></FONT><FONT FACE="Arial"><FONT SIZE=-1> What

is interesting is, that they did not reverse the "mida"! May be one of

the authors could comment on this more.</FONT></FONT> <FONT FACE="Arial"><FONT SIZE=-1><B>W.R.T.

Ketamine</B>, Dr Fisher wrote</FONT></FONT><FONT FACE="Arial"><FONT SIZE=-1>"I

think the notion of 'delayed' hallucinations is bogus and will be difficult

to demonstrate even if true.</FONT></FONT> <FONT FACE="Arial"><FONT SIZE=-1>What

I am stating again, is that there is data out there, both in the dental

and the ophthalmologic literature, that ketamine does have some association

with delayed occurrence of <U>dysphoria,</U> especially in older patients.

I fail to see why this notion is "bogus". Lack of current data proving

causality, is NOT the same as no association. The analogy being, absence

of disease is not the same as wellness. As I have said in a prior post,

I love ketamine. Especially these days, with summer holidays and injuries

galore, I am using it practically once a day, if not more. However,

I would caution against making it the panacea of all pediatric sedation's!!</FONT></FONT> <FONT FACE="Arial"><FONT SIZE=-1>BTW,

I was amused at your supposition of 1 in 10 (10%) incidence of hallucinations

(i.e. psychoses) in the general adolescent population. Some days it sure

feels that way with teenagers!</FONT></FONT> <FONT FACE="Arial"><FONT SIZE=-1><B>Ray

Wiss wrote</B>:</FONT></FONT><FONT FACE="Arial"><FONT SIZE=-1>"- Do you

use midaz automatically when you use ketamine? If so, why? I</FONT></FONT>

<BR><FONT FACE="Arial"><FONT SIZE=-1>always give it alone, and in three

years am still waiting to see even a</FONT></FONT>

<BR><FONT FACE="Arial"><FONT SIZE=-1>mild emergence reaction.</FONT></FONT> <FONT FACE="Arial"><FONT SIZE=-1>No,

I don't Ray. Part of the reason I don't is that, it tends to prolong the

recovery phase, as compared to ketamine alone. Also, I too have not seen

any dysphoric reaction yet in my 3 years of using it. But, I don't check

on them that night or that week either. May be we should!!</FONT></FONT> <FONT FACE="Arial"><FONT SIZE=-1>Take

care</FONT></FONT> <FONT FACE="Arial"><FONT SIZE=-1>Jay</FONT></FONT>

<P><FONT FACE="Arial"><FONT SIZE=-1> </FONT></FONT><FONT FACE="Arial"><FONT SIZE=-1>Jay

Pershad, MD</FONT></FONT></BLOCKQUOTE>

</BODY>

</HTML>

--------------B93E2B3805CC6FA37C893CDE--




Date: Thu, 17 Jun 1999 16:06:41 -0500Reply-To: jay pershad <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jay pershad <[email protected]>Subject: ke...ta...mine


------=_NextPart_000_0024_01BEB8DB.63796000




Steve Green wrote:

In 1977 Modvig & Nielsen (1) found

>no differences in the incidences of nightmares, disturbed sleep,

>personality changes, etc over one month follow-up in 107 children

>randomized to receive either ketamine or halothane. Interestingly, the

>article recently cited by Roelofse (2) notes recovery hallucinations in =

14%

>of children receiving ketamine/midazolam, compared to 42% of those

>receiving midazolam alone!


=20

Steve & all:

=20

The Modvig article noted that 13/53 children on 1 month FU had negative =

personality changes compared to 9/50 in the halothane group. Even though =

the 2 anesthetic changes did not differ significantly, the bottom line =

is these do occur at significant frequency with ketamine!=20

=20

Also, on the same issue, curious if you noted the paper in Anestezio =

Reanimatol 1996 Nov-Dec (6):31-33 by Egorov VM et al entitled =

"Comparative characterization of psycho-injurious effect of GA using =

fluothane & ketamine in surgery of the face in children with congenital =

facial & palatal clefts." Here they reported long term reversible memory =

deficits (not dysphoria) upto 1-2 months out from surgery after ketamine =

maintenance. These were in 33 kids ranging in age from 7-15 yrs.

=20

My question to you & the group is:

1. Do you still believe that the association of hallucinations with =

ketamine is co-incidental & can be seen with any sedative/anesthetic?=20

2. Why is it not a popular induction &/or maintenance agent amongst the =

anesthesiology community? Even for pre-medication, benzos seem to get =

the nod over ketamine.=20

3. On the bright side, why is our experience in the ED so favorable =

w.r.t. emergence reactions with ketamine? Do you think it has to do with =

our dose and more importantly short duration of use? Or is it that we =

have no good controlled studies to refute the numerous direct or =

indirect references in the anesthesiology literature of dysphoric =

reactions associated with ketamine??=20

4. Have you been doing any delayed FU on your "ketamine study" patients? =

=20

=20

My personal bias, in selecting an agent with the best "recovery" =

profile, with no PONV, dysphoria etc etc, especially in older patients, =

is Propofol.

=20

Thanks for listening.

=20

Jay Pershad, MD

------=_NextPart_000_0024_01BEB8DB.63796000




<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">

<HTML><HEAD>

<META content=3D"text/html; charset=3Diso-8859-1" =


<META content=3D"MSHTML 5.00.2314.1000" name=3DGENERATOR>

<STYLE></STYLE>

</HEAD>


<DIV><FONT face=3DArial size=3D2>Steve Green wrote:</FONT></DIV>

<DIV><FONT face=3DArial size=3D2>In 1977 Modvig & Nielsen (1) =

found<BR>>no=20

differences in the incidences of nightmares, disturbed =

sleep,<BR>>personality=20

changes, etc over one month follow-up in 107 children<BR>>randomized =

to=20

receive either ketamine or halothane. Interestingly, =

the<BR>>article=20

recently cited by Roelofse (2) notes recovery hallucinations in =

14%<BR>>of=20

children receiving ketamine/midazolam, compared to 42% of =

those<BR>>receiving=20

midazolam alone!</FONT></DIV>

<DIV><FONT face=3DArial size=3D2></FONT> </DIV>

<DIV><FONT face=3DArial size=3D2>Steve & all:</FONT></DIV>


<DIV><FONT face=3DArial size=3D2>The <STRONG>Modvig </STRONG>article =

noted that=20

13/53 children on 1 month FU had negative personality changes compared =

to 9/50=20

in the halothane group. Even though the 2 anesthetic changes did =

not differ=20

significantly, the bottom line is these do occur at significant =

frequency=20

with ketamine! </FONT></DIV>


<DIV><FONT face=3DArial size=3D2>Also, on the same issue, curious if you =

noted the=20

paper in Anestezio Reanimatol 1996 Nov-Dec (6):31-33 by <STRONG>Egorov =

VM=20

</STRONG>et al entitled "Comparative characterization of =

psycho-injurious effect=20

of GA using fluothane & ketamine in surgery of the face in children =

with=20

congenital facial & palatal clefts." Here they reported long term =

reversible=20

memory deficits (not dysphoria) upto 1-2 months out from surgery =

after=20

ketamine maintenance. These were in 33 kids ranging in age <U>from 7-15=20

yrs</U>.</FONT></DIV>


<DIV><FONT face=3DArial size=3D2>My question to you & the group =

is:</FONT></DIV>

<DIV><FONT face=3DArial size=3D2>1. Do you still believe that the =

association of=20

hallucinations with ketamine is co-incidental & can be seen with any =

sedative/anesthetic? </FONT></DIV>

<DIV><FONT face=3DArial size=3D2>2. Why is it not a popular induction =

&/or=20

maintenance agent amongst the anesthesiology community? Even for=20

pre-medication, benzos seem to get the nod over ketamine. =

</FONT></DIV>

<DIV><FONT face=3DArial size=3D2>3. On the bright side, why is =

our=20

experience in the ED so favorable w.r.t. emergence reactions =

with=20

ketamine? Do you think it has to do with our dose and more importantly=20

<STRONG>short duration </STRONG>of use? Or is it that we have =

<STRONG>no=20

</STRONG>good <U>controlled </U>studies to refute the numerous direct or =

indirect references in the anesthesiology literature of dysphoric =

reactions=20

associated with ketamine?? </FONT></DIV>

<DIV><FONT face=3DArial size=3D2>4. Have you been doing any delayed =

FU on your=20

"ketamine study" patients? </FONT></DIV>


<DIV><FONT face=3DArial size=3D2>My personal bias, in selecting an agent =

with the=20

best <STRONG>"recovery" </STRONG>profile, with no PONV, dysphoria etc =

etc,=20

especially in older patients,=20

is <STRONG>Propofol.</STRONG></FONT></DIV>


<DIV><FONT face=3DArial size=3D2>Thanks for listening.</FONT></DIV>

<DIV><FONT face=3DArial=20

size=3D2> </FONT></DIV>

<DIV><FONT face=3DArial size=3D2>Jay Pershad, =

MD<BR></FONT></DIV></BODY></HTML>

------=_NextPart_000_0024_01BEB8DB.63796000--




Date: Sat, 19 Jun 1999 11:39:46 -1000Reply-To: "Loren Yamamoto, MD, MPH" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Loren Yamamoto, MD, MPH" <[email protected]>Subject: Re: new generation sedationX-To: kathleen seikel <[email protected]>In-Reply-To: <001401beb9f7$c08d50e0$13e00a3f@7>

I would be very enlightening for me if you would include your propofol

protocol, dosing, etc., for the chat group to review. I hope you are

publishing your report in the general literature as well to support the

use of propofol by emergency physicians. I believe this is probably the

best way to sedate most children since all the other sedation methods have

significant unreliability associated with them. Good work.


Sincerely, Loren Yamamoto, MD, MPH

On Fri, 18 Jun 1999, kathleen seikel wrote:

> Coming soon to an AAP EM Section meeting near you:

> an abstract on PROPOFOL use in the PED for painful procedures and imaging.

>

> The PEM docs at Mary Bridge Children's Hospital have been using propofol for

> 4+ years and use it almost exclusively for sedation. We recently looked

> prospectively at 200 propofol patients over 10 months and will describe our

> experience this fall in Washington DC at the annual AAP meeting. Needless

> to say, we are sold on it. Most of us subscribe to this list and have been

> monitoring the debate on sedation and reversal agents. We are all glad we

> are past those issues. Hope this addition to the body of experience will

> help the rest of you.

>

> See you in DC,

> Kathey Seikel, MD

> MBCH

> Tacoma, WA

>




>





Date: Tue, 22 Jun 1999 16:08:12 -0700Reply-To: Edward Walkley <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: Edward Walkley <[email protected]>Subject: Re: new generation sedation -ReplyX-To: Michael Forbes <[email protected]>In-Reply-To: <[email protected]>

Cost of the drug is trivial in th total cost of procedural sedation. While

ti was not part of Kathy Seikel's study per se we did look at it

separately. Time to wake up and time to discharge were significantly less

with Propofol than Fentanyl Versed or Ketamine ( with or without

versed) The later being shorter than the former. Decreases staffing costs

increases through put when Ed busy. Ther is an article from the radiology

literature that also supports this, and this is the experience with our

sedation service. Failed sedations are fewer than Fentanyl Versed.

On the issue of bagging while desaturation is common positioning and blow

by is all that is needed not bagging.

The most important aspect of this discussion is operator familiarity

with the agent. This like inahaltion anesthesia is an art more than a

science and it takes time and significant numbers to become familiar with

all the aspects of care


Ted Walkley

Medical Director

Mary Bridge Children's hospital




Date: Tue, 6 Jul 1999 19:27:48 -0500Reply-To: jay pershad <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: jay pershad <[email protected]>Subject: "BBAF" syndrome

Had another one of these! Probably the fourth or fifth of my brief career. A

febrile infant (8 month old) with a bulging fontanelle (noted by the parent

& confirmed by examining the baby sitting up with the baby not crying);

somewhat fussy but not "irritable". CSF was "stone cold" normal. The patient

looked well post tap.

I have chosen to call it the "Benign Bulging Anterior Fontanelle" syndrome.

Have folks seen this? What is the mechanism?

BTW, Jay (Fischer, MD) thanks for the references on C-Spine. I guess my

question is, what is the sensitivity of a lateral radiograph in a completely

lucid patient, with no distracting injuries, a non focal neurologic exam and


no midline c-spine tenderness, in a preverbal child. It is this age group,

where getting a good "odontoid" view is an ordeal. The frequently quoted

sensitivity of 70-80 % I believe, includes all comers, i.e even those who

may under the influence, have AMS etc ....etc.

Cheers

Jay Pershad, MD




Date: Tue, 13 Jul 1999 15:36:02 -0400Reply-To: "Dr. Eugene Izsak" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Dr. Eugene Izsak" <[email protected]>Subject: The T-System

Does anyone have experience with the T-System in a Pediatric ED?

The T-System vs. traditional dictation?

Eugene Izsak

Toledo Children's Hospital

[email protected]





Date: Fri, 16 Jul 1999 15:03:58 +0000Reply-To: "Dr. Nikolaus Lutz-Dettinger" <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>Comments: Authenticated sender is <[email protected]>From: "Dr. Nikolaus Lutz-Dettinger" <[email protected]>Subject: air stuck in oesophagus

Dear colleagues,

we recently saw a five year old child, coming to the emergency

department just before noon in severe respiratory distress. He had

never had such problems before; he had a cough for two days with low

grade fever; a family physician had prescribed beta-mimetic

inhalation .In the course of the morning he became increasingly

more dyspnoeic.

The clinical picture was that of a very severe attack of

laryngotracheitis. We found a bit atypical: the hour of presentation,

age at first presentation, clinical severity (the breathing sounds

were grotesque in relation to the objective respiratory problems). To

exclude a foreign body, we took X-rays and did a radioscopy; these

showed a penciltip-sign, but also an unexpected finding, for which I

would like your opinion: the stomach was filled with air, but not

very large; however, the left part of the diaphragm stood slightly

above the right part. The oesophagus was air filled and grossly


distended.

We placed a nasogastric tube, which reached the oesophagus without

problem, at which moment a lot of air escaped under some pressure via

the tube; after overcoming a limited resistance the stomach could be

reached, again with evacuation of air under pressure.

I know, that a dyspnoeic child can swallow a lot of air, but I don't

see a reason, why this should get stuck in the oesophagus.

After high dose dexamathason i.v. and some adrenalin inhalation the

child recovered completely within a few hours; the next day only a

slightly horse voice remained.

I'm curious about your opinions.

Thanks,

Nikolaus

Dr. Nikolaus Lutz-Dettinger

PICU

Dept. of Intensive Care

University Hospital Gent

De Pintelaan 185

B 9000 Gent

Belgium

tel.: **32 - 9 - 240 21 11

fax: **32 - 9 - 240 49 95

email: [email protected]




Date: Fri, 16 Jul 1999 23:02:58 -0500Reply-To: MARTIN I HERMAN <[email protected]>Sender: Pediatric Emergency Medicine Discussion List <[email protected]>From: MARTIN I HERMAN <[email protected]>Subject: Re: PED-EM-L Digest - 13 Jul 1999 to 15 Jul 1999

I am confused regarding the responses on LP consent. In children, do we

allow parents to refuse if there is just cause to do the test? This may be a

moot point for most docs as obe can usually get parents to agree to the test

but always bear in mind that if they refuse, you could ( should) get a court

order to do so.

This would seem to be a catch 22. If the parents sign the consent form, they

could later argue that they did not really understand the medical jargon ,

or that they were pressured to sign. Of course they could argue they were

under duress and that they were not given adequate time to consider

alternatives.

On the other hand if they refuse to sign, the doctor is placed in the

position of having to choose between the court order (and the conflict that

will arise with the parents) and the child's well being. If the doctor

recants and does not perform the test or it is delayed.Then if harm occurs

to the child because of missed diagnosis or delay in treatment, the parents

would have cause to pursue an action against the physician.


So it would seem to me that the prudent course is to explain to the parents

the reason for test, the expected complications, and make a note in the

chart that you discussed the procedure and then proceed. Getting a consent

signed would seem to be unnecessary then. and would only serve to slow down

the process. After all, the lumbar puncture is not an elective procedure

that can be delayed if one is concerned about meningitis.

Just my thoughts,

Martin Herman,M.D.

Associate Director Emergency Services

LeBonheur Children's Medical Center




Date: Tue, 27 Jul 1999 08:47:57 -0500Reply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "Mark A. Hostetler, MD" <[email protected]>Subject: SIDS and FAOs

One should always remember to consider IEM's as a cause for suddent unexpected


death - particularly the fatty oxidation

disorders.

It is estimated that at least 5% of SIDS are due to fatty oxidation disorders

(FAO's).

Screening is recommended for patients with any of the following risk

factors/markers:

- fatty infiltration of the liver

- unexplained cerebral edema

- "Reye's Syndrome"

- myopathy, family hx of sudden death

- a recent history of lethargy, vomiting, fasting, or hypoglycemia prior to

death.

Urine for organic acids may detect high levels of metabolites. Diagnosis is

confirmed on studies done on tissue obtained from

liver biopsy.

It is important to consider this diagnosis as siblings may be affected, and

prenatal diagnosis is possible.

References:

Boles RG, Buck EA, Blitzer MG et al: Retrospective biochemical screening of

fatty acid oxidation disorders in postmortem

liver of 418 cases of sudden unexpected death in the first year of life. J

Pediatr 1998;132:924-933.

Bennett MJ, Powell S: Metabolic disease and sudden, unexpected death in infancy.

Hum Pathol 1994;25:742-6.

Cederbaum SD: SIDS and disorders of fatty acid oxidation: Where do we go from

here? J Pediatr 1998;913-914.

Mark A. Hostetler, MD

Vanderbilt University

Depts of Emergency Medicine and Pediatrics




Date: Fri, 30 Jul 1999 07:05:12 EDTReply-To: [email protected]: Pediatric Emergency Medicine Discussion List <[email protected]>From: "(David A. Green, M.D.)" <[email protected]>Subject: Re: diabetesi-ii mailing list

In a message dated 7/30/99 11:03:34 AM !!!First Boot!!!, RAINBOWPED writes:

<< The goals of this moderated list are to have a safe home where we can

share and gather information about diabetes and offer support to all


diabetics and those who care about diabetics.

To subscribe send e-mail to <[email protected]> with the following command

in the body of your email message:

subscribe diabetesi-ii

To contact the owners of the list, send email to:

<[email protected]>

For more information, send email to: [email protected] (Marcie) >>





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