Pediatric Emergency Medicine Practice Clinical Pathways:
Evidence To Improve Patient CareIn Emergency Medicine
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Table Of ContentsAllergy/Endocrine EmergenciesClinical Pathway For Initial Evaluation Of Diabetic Ketoacidosis ............................................................................1Clinical Pathway For Treatment Of Diabetic Ketoacidosis .........................................................................................2Clinical Pathway For Emergency Care Of Patients With A Metabolic Disorder.................................................3Clinical Pathway For The Diagnosis Of Anaphylaxis ....................................................................................................4Clinical Pathway For The Treatment Of Anaphylaxis ...................................................................................................5
General Emergency MedicineClinical Pathway: The Evaluation Of The Lower Extremity .........................................................................................6Clinical Pathway: Noninvasive Ventilation In Children ................................................................................................7Clinical Pathway: Management Of Dehydration In Pediatric Gastroenteritis ....................................................8Clinical Pathway: Management Of The Critically Ill Neonate ...................................................................................9Clinical Pathway: Pediatric Pain And Anxiety In The ED ..........................................................................................10Clinical Pathway For The treatment Of Jaundice In 2- To 8-Week Old Infants ..............................................11
Infectious DiseaseClinical Pathway For The Treatment Of Enterovirus In The Neonate .................................................................122009-2010 Influenza Season Triage Algorithm For Children (≤ 18 years) With Influenza-Like Illness ....................................................................................................................................... 13-14
Neurologic EmergenciesClinical Pathway For The Management Of Pediatric Seizures ..............................................................................15Clinical Pathway: Patient With ANC < 500 Or Chemotherapy-Induced Neutropenia ................................16Clinical Pathway: Patient With Mild To Moderate Neutropenia ...........................................................................17Clinical Pathway For Evaluation And Treatment Of Cerebral Edema .................................................................18Clinical Pathway: Migraine Headache Neuroimaging ..............................................................................................19Clinical Pathway: Pediatric Migraine Clinical Treatment Pathway .......................................................................20
Toxicology And Environmental EmergenciesClinical Pathway: Oil Of Wintergreen, Pennyroyal Oil, Camphor, Eucalyptus, Imidazoline Decongestant ..............................................................................................................................................21Clinical Pathway: Diphenoxylate-Atropine ...................................................................................................................21Clinical Pathway: Organophosphates .............................................................................................................................22Clinical Pathway: Sulfonylureas .........................................................................................................................................22
TraumaClinical Pathway For The Treatment Of Pediatric Burns ..........................................................................................23Clinical Pathway For The Treatment Of Mammalian Bites .....................................................................................24Clinical Pathway For Treatment Of Traumatic Dental Injuries ...............................................................................25Clinical Pathway For Treating Pediatric Wounds ........................................................................................................26
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Clinical Pathway For Initial Evaluation Of Diabetic Ketoacidosis
• InitiatePediatricAdvancedLifeSupport
• Administer0.9%normalsalineorlactatedringers10mL/kgbolusover1-2hours.(Class II)
• Followinitialmanagementalgorithm(see Clinical Pathway For Treatment of Diabetic Ketoacidosis Pathway)
• Areresultsofhistoryandphysicalexaminationconsistentwithdiabeticketoacidosis(ie,polyuria,polydipsia,weightloss,fatigue,nausea/vomiting)?
• Doesrapidglucosetestingshowelevatedbloodglucoselevel?
• Areketonespresentinurineorblood?
Initiate evaluation for diabetic ketoacidosis.• Establishaflowsheet.(Class III)• Orderthefollowinglaboratorytests(Class III):
• Serumglucose• Arterialbloodgas• Electrolyteswithaniongapcalculation• Calcium,magnesium,phosphorus• Serumureanitrogen/Creatinine• Serumketones• Serumosmolality• Completebloodcellcountwithdifferentialcellcount• Urinalysis
Arethereanyairway,breathing,orcirculation
concerns?
Classify diabetic ketoacidosis severity (Class II).• Severe:pH<7.1orbicarbonate<5mmol/L• Moderate:pH7.1-7.2orbicarbonate5-10mmol/L• Mild:pH7.2-7.3andbicarbonate10-15>15mmol/L
Doesthepatientshowsignsof
shock?
YES NO
YES NO
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2009EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
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Clinical Pathway For Treatment Of Diabetic Ketoacidosis
• Determine the extent of dehydration.lConsideranestimateof5%-7%
dehydrationasmoderateand7%-10%dehydrationassevere.(Class III)
• Calculate fluid requirement.lConsider1.5-2.0timesmainte-
nanceplusdeficit.(Class III)lConsidersubtractingbolus(es)
previouslygivenforresuscitation.(Class III)
lCalculatetherateoffluidreplace-mentwithagoalofreplacinglossesover36-48hours.(Class II)
Isthepatient’sserumpotassiumlevel>5.5mmol/L?
• Placepatientonelectrocardiogrammonitor.(Class II)
• Initiate0.9%normalsalineorLRatcalculatedrequirements.(Class II)
• Considerevaluationforvoiding.(Class III)
• Recheckserumpotassiumlevel.(Class III)
• Beginfluidreplacementwith0.9%normalsa-lineorLRplus40mEq/Lofpotassiumchloride.(Class II)
• Consideralternativelystartingwith0.9%nor-malsalineorLRplus20mEq/Lofpotassiumchlorideand20mEq/Lofpotassiumphospho-rusifphosphoruslevelis<1mg/dL.
•Initiateinsulintherapy.lDonotusebolusinsulin.(Class II)lUseIVformofinsulin.(Class I)lStartat0.1U/kg/h.(Class I)
• Regularlyreassessthepatient’sneurologicstatus.(Class II)
• Monitorlaboratoryvaluesevery2-4hours.(Class III)
• Adddextrosetofluidifbloodglucoselevelhasdecreasedto<250mg/dL.(Class III)
• Considercerebraledemaevaluationandtreat-mentifneurologicexaminationresultschange(see Clinical Pathway For Evaluation And Treatment Of Cerebral Edema).(Class III)
• Considerdecreasingtherateofinsulininfusionifthepatient’sbloodglucoseleveldecreasesbymorethan50-75mg/dLperhour.(Indeter-minate)
• Considerdecreasingtherateofinsulininfusionifthepatient’sserumosmolalitydecreasesbymorethan3mmolperhour.(Indeterminate)
YES NO
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2009EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandef-fectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlypositiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence•Non-randomizedorretrospectivestudies:historic,cohort,orcase
controlstudies•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralternativetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:
•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradictory•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresentativesfromtheresuscitationcouncilsofILCOR:HowtoDevelopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcardiopulmonaryresuscitationandemergencycardiaccare.EmergencyCardiacCareCommit-teeandSubcommittees,AmericanHeartAssociation.PartIX.Ensuringeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
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Clinical Pathway For Emergency Care Of Patients With A Metabolic Disorder
Perform ABCDEsA–Airway-Evaluateandprotectairwayasneeded.B–Breathing-Ensureadequateventilation
• Non-invasiveventilatorysupportmaybeconsideredwhereappropriate.• Aggressivehyperventilationforcerebraledemashouldbeavoided.
C–Circulation-Volumeexpansionshouldbeprovidedwhenthereisevidenceofdehydrationorvolumedepletion.D–Disability-Bedsidebloodglucosetesting:
• Ifbelow60mg/dL,obtaincriticalsample,IVaccessandprovideglucoseorallyorviaIV• Lowosmolarityglucosesolutions(D5W,D10W)arepreferredwhereavailable• Criticalsample:serumglucose,insulin,cortisol,andgrowthhormone
E–Exposure-Evaluateforexposuretoinfectiousorganisms,drugs,toxicsubstances,ornewfoods
Consider Additional Laboratory TestingPrimary:(mostcanbeobtainedwithpointofcaretestingdevices)
• Arterialorvenousbloodgas• Electrolytes• Serumureanitrogenandcreatinine• Urinedipstick
Secondary:• General–completebloodcellcountwithdifferentialcount• Hypoglycemia–insulin,cortisol,corticotropin,b-hydroxybutryate• Encephalopathy–ammonia,aspartateaminotransferase,alanineaminotransferase,bilirubin• Suspectedgalactosemia–urine-reducingsubstances
Tertiary:• Quantitativeplasmaorganicacids• Quantitativeurineorganicacids• Plasmaacylcarnitine• Tandemmassspectroscopyfordisordersoffattyacidoxidation• Aminoacidsintheblood,urine,andcerebrospinalfluid• Oroticacidintheurine• Comprehensivenewbornscreenwithtandemmassspectroscopy
TreatmentIfthechildhasadiagnosedmetabolicdisorder,followinstructionsprovidedbytheirMetabolicspecialist.Hydration–D101/2NSat1.5timesmaintenanceuntilneedsforfluid,glucose,andelectrolytereplacementhavebeendetermined.
GlucoseMedications(asdirectedbyMetabolicspecialist,exceptasnoted)
• Fattyacidoxidationdisorders–L-carnitine• Hyperammonenia–sodiumphenylacetate,sodiumbenzoate,arginine• Neonatalseizures–pyridoxine(maybegivenempiricallywithconcurrentEEGmonitoringasavailable)• Organicaciddefects–biotin
Consider Consultations Or Referrals To:• CriticalCare• Genetics/Metabolism• Nephrology–asindicatedforrenalreplacementtherapyforhyperammonemia
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Clinical Pathway For The Diagnosis Of Anaphylaxis
YES
YES
YES
NO
NO
NO
Doespatienthaveacuteonsetofthefollowingwithoutamoreplausibleexplanation?• Mucocutaneoussigns(urticaria,generalizedflushing,
pruritis,angioedema)AND• Oneofthefollowing:Respiratorycompromise(wheeze,
stridor,hypoxemia,dyspnea)ORhypotension,collapse,syncope,incontinence
Initiatetreatmentforanaphylaxis.
Doesthepatienthaveatleast2ofthefollowingAFTERrecentexposuretoalikelyallergen?• Mucocutaneoussigns(urticaria,generalizedflushing,
pruritis,angioedema)• Respiratorycompromise(wheeze,stridor,hypoxemia,
dyspnea)• Hypotension,collapse,syncope,incontinence• Persistentgastrointestinalsymptoms(vomiting,crampy
abdominalpain)
Initiatetreatmentforanaphylaxis.
DoesthepatienthaveaknownallergenANDhypotension*withinhoursofexposuretothatallergen? Initiatetreatmentforanaphylaxis.
Consideralternatediagnoses
AdaptedfromSampsonHA,Munoz-FurlongA,CampbellRL,etal.Secondsymposiumofthedefinitionandmanagementofanaphylaxis:Summaryreport—SecondNationalInstituteofAllergyandInfectiousDisease/FoodAllergyandAnaphylaxisNetworksymposium.JAllergyClinImmunol.2006;117:391-397.
*ordropofatleast30%frombaselinebloodpressure
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Clinical Pathway For The Treatment Of Anaphylaxis
YES
NO
NO
NO
Ispatientincardiopulmonaryarrest? InitiatePediatricAdvancedLifeSupportorAdvancedCar-diacLifeSupport
Administerepinephrine1:1000(1mg/mL)0.01mg/kgtoamaximumof0.3-0.5mgintramuscu-
larly(Class II)PLUS
Oxygenandairwaymanagementasneeded
Arelife-threateningsymptomsofhypotension,respira-torydistress,orstridorresolved?
Repeatepinephrineevery3-5minutesasnecessary.Givefluidbolusasnecessary.
ConsiderinhaledB-agonistsforpersistentwheezing.
Aresymptomsresolved?
Considerintravenousepinephrinebolusesoranepi-nephrinedripforpersistenthypotension.
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2010EBPractice,LLCd.b.a.EBMedicine.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLCd.b.a.EBMedicine.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
• ConsideranH1blockerforcutaneoussymptoms(Class III)
• ConsideranH2blockerforcutaneoussymptoms(Class III)
• Consideracorticosteroidtopreventbiphasicreac-tions(Class Indeterminate)
YES
Ifpatientdoesnothaveriskfactorsforfatalorbiphasicanaphylaxis,observefor6hoursanddischargewithan
epinephrineauto-injector.
YES Consideradmissiontoamonitoredbed.
Admittopediatricintensivecareunit(PICU).
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PerformPALS/ATLSand/orABCs.Havethepatientevaluatedbyatrauma
surgeon.Transferpatientifneeded.(Class I)
Clinical Pathway: The Evaluation Of The Lower Extremity
Performacompletehistoryandphysical.Doespatientshowsignsoftraumaor
significantmechanismofinjury?
Orderappropriateimagingstudies.
(Class I)
Orderanemergentorthope-dicconsult.(Class I)
Ifsignsandpredictorsarenotapparent,dischargepatientwithfollowup
in24hours.(Class III)
Ifsignsandpredic-torsareapparent,admitpatientforobservationandserialexams.
(Class III)
NO
YES
Admitforobservation.Considerpediatricandrheumatologyconsults.
(Class II)
Doserialexaminationsshowworseningsymptoms? YES
YES
Doesthepatienthaveafunctional
deficit? Istheinjurynon-weightbearing?
(Class II)
Orderanorthopedicconsultandfollowup.(Class I)
YES
YES
NO
YES
NO
YES
NO
Clearpatientforactivityastoler-ated.FollowupwithPRN.
(Class III)
NO
NO
YES
NO
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2009EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.
YES
Isafracturepresent?
Orderlaboratorystudies:CBC,ESR,CRP,and
films.(Class II)
ExamineforKocherpredictorsandLuhmansigns.Makeaclini-
caljudgment.(Class III)
Issepticarthritislikely?
NO
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
ClassofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
ClassofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable
•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
ClassofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
ClassofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:
QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcardiopulmonaryresuscitationandemergencycardiaccare.EmergencyCardiacCareCom-mitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensuringeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
ClassOfEvidenceDefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
ArefilmsabnormalorisSCFEorLCP
present?
Isthepatienttoxicappearingand/or
limping?
Isthepatientstable?
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Clinical Pathway: Noninvasive Ventilation In Children
YES
NO
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2009EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
ClassofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
ClassofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
ClassofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
ClassofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
Explainproceduretopatient.Showpatienttheequipmentandmask.Ensurepatientisonmonitorandpulseoximeter.Ensureadequatepersonneltomonitorpatient.
Applymasktopatient.CPAP: Startwithlowpressures(5cmH20).Increasein
incrementsof1cmH2O.BiPAP:Startwithlowsettings.IPAPof8-10cmH2O
andEPAPof2-4cmH2O.Titratetoeffect.TypicalIPAPlevelsinchildrenare8-16cmH2O,andtypicalEPAPlevelsare4-8cmH20.
(Class Indeterminate)
Hemodynamicinstability?Alteredmentalstatus?Excessivesecretionsorvomiting?UpperGIbleeding?Recentfacial,upperairway,orupperGIsurgery?
Intubate.(Class I-II)
Positiveresponsetotherapy?• Decreasedrespiratoryrate?• Decreasedworkofbreathing?• Improvedoxygenation?
Worseningagitation?Poormaskfit?Worseninghypoxia?Worseningrespiratorydistress?
Continuenoninvasiveventilation.(Class III)
Intubate.(Class II)
NO
YES
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Clinical Pathway: Management Of Dehydration In Pediatric Gastroenteritis
YES
Whatclinicalsignsofdehydrationarepresent?
Isdehydrationresolved? Isdehydrationresolved?
StartORTat50-100mL/kg,plusre-placeongoinglosses.(Class II)
UseanoralantiemeticifvomitingispresentandlikelytoimpedeORT.
(Class II)
Admitpatient.
Givea20mL/kgbolusofnormalsaline;repeatuntilstable.(Class II)
Admittowardorobservationunit. AdmittoPICU.Ifpreviousdehydrationwasnoted,ob-serveforaperiodoftimeintheED.
Continuepatient’sregulardiet.
Dischargehomewithhydrationinstructionsandsignsofdehydration
tolookfor.
NONO YES
NONE MILD/MODERATE SEVERE
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2010EBPractice,LLCd.b.a.EBMedicine.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLCd.b.a.EBMedicine.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
ORT,oralrehydrationtherapy;ED,emergencydepartment;PICU,pediatricintensivecareunit
Abbreviations:
9
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Clinical Pathway: Management Of The Critically Ill Neonate
Doestheneonaterequireemergentresuscitation?
Whatisthesuspecteddiagnosis?Performhis-toryandphysicalexamination;checklaboratorytestandradiographresults;
conductfurthertestingas
needed.
StartPGE1at0.05µg/kg/min(Class 2);correctacidosis(Class 3);ifindi-cated,consider:furosemide1mg/kg,
dobutamine2to20µg/kg/min;packedredbloodcells10mL/kg.
Startampicillin/gentamicin(Class
1);startIVacyclovirifWBCsinCSF(Class 2).For
sepsis,startnormalsalinewith10-to20-mL/kgbolusesuntilpatientisstableor60mL/kgisreached
(Class 1).
Considersurgeryforperforation(Class 2);adminis-terantibiotics(Class 2);obtainradiograph
every6-8hours(Class 3).
InsertNGTorOGT;arrangeforsurgical
consult;IVF.
Correctcoagu-lopathy;consultneurosurgery;
contactDepartmentofChildandFamily
Services.
StartD10¼normalsalineat1.5timesmaintenance(Class
1);initiatesodiumbenzoateandso-diumphenylacetate
at0.25g/kg(Class 1);consider
L-carnitine(Class 3);correcthypoglycemia.
Securetheairway;performchestcom-pressionsifheartrate<60bpm;
checkglucoselevel(Class 1);initiateappropriatePALS
algorithm.
Cardiacdisease
GIdiseaseMetabolicdiseaseSBI
NEC Malrotation
Schedulesurgery.
NAT
NO
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2010EBPractice,LLCd.b.a.EBMedicine.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLCd.b.a.EBMedicine.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
Abbreviations:BPM,beatsperminute;CSF,cerebrospinalfluid;D10,dextrose10%;GI,gastrointestinal;IV,intravenous;IVF,intravascularfluids;NAT,nonaccidentaltrauma;NEC,necrotizingenterocolitis;NGT,nasogastrictube;OGT,orogastrictube;PALS,pediatricadvancedlifesupport;PGE1,pros-taglandinE1;WBC,whitebloodcells;SBI,seriousbacterialinfection.
YES
10
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Clinical Pathway: Pediatric Pain And Anxiety In The ED
InvasiveEDprocedurethatproducespain,anxiety,orboth
Thisclinicalpathwayisintendedtosupplement,ratherthensubstitutefor,professionaljudgementandmaybechangeddependinguponpatient’sindi-vidualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardcare.
Reprintedfrom:MatsunoWE,OtaFS.ManagingPediatricProceduralPainAndAnxietyInTheEmergencyDepartment.PediatricEmergencyMedicinePractice2006;3(5):1-28.(Review, Evidence-based)
Cantheprocedurebecompletedwithlocalanesthesiaalone?
Willtheadditionofchildlifeorotherbehavioraltechniquebeenoughtocompletetheprocedure?
Willinhalednitrousoxidebeahelpfuladjunct,andisthischildcooperative?
WillPOmidazolambeahelpfuladjunct?
IsthereanyreasonthatthepatientisnotanappropriatecandidatetobesedatedintheEDtocompletetheprocedure?
Topicalanesthesia,localanesthesia,orboth(Class II)
Localanesthesiaalongwithchildlifeorotherbehavioraltechnique(Class II)
Inhalednitrousoxidebydemandmask(Class II)
Oralorintranasalmidazolam(Class II)
Consultationortransfertoafacilitywithpediatricanesthesiaandsurgicalservices(Class II)
Chooseappropriatedrugregimen(Class II)AdministersedationintheEDunderappropriate,closemonitoring(Class II)Dispositionwhenappropriatelybacktobaselinementalstatus(Class III)
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
11
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Jaundicedinfant2to8weeksold
Isthepatientacutelyill?Requireurgentcare?
• Managetheacuteillness• Considerurinarytractorotherin-
fection,glactosemia,tyosinemia,hypopituitarism,fructosemia,ironstoragedisease,metabolicdisorders,acutecommonductonstruction,hemolysis.
Istheredirecthyperbilirubinemia?
Measureserumdirectbilirubin
CholestaticJaundice
Isthereevidenceofbiliaryobstruction?
Medicalevaluation:• Infection• Metaboolicdisorders• Geneticdisorders• Other
History,physicalexam,Urinalysis,urineculture
Findingsofspecificdisease?
Isthenewbornscreenpositiveforgalactosemiaorhypothyroidism?
Lowa-1antitypsin?
Consider:• Percutaneousliverbiopsy• Scintiscan• Duodenalaspirate• ERCP
• Consultpediatricsurgeon.
• Operativechol-angiogram
Choledochalcyst?
• ConsultPediatricGI• CBC,plateletcount• Totalanddirectbilirubin,ALT,AST,alkalinephosphate,glucose• Prothrombintime,albumin• a-1antitypsin• Urinereducingsubstances• Abdominalultrasound
Evaluatefurther
Referforfurthermanagement
• Pityping• Furthermanagement
Doesbilirubinnormalizeby6weeksofage?
Nohyperbilirubinemia
Indirecthyperbilirubinemia
Evaluatefurther(SeeAAPguideline)
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NONO
NORMAL
ABNORMAL
Clinical Pathway For The Treatment Of Jaundice In 2- To 8-Week Old Infants
FromMoyerV,FreeseDK,WhitingtonPF,etal.Guidelinefortheevaluationofcholestaticjaun-diceininfants:recommendationsoftheNorthAmericanSocietyforPediatricGastroenterology,HepatologyandNutrition.JPediatrGastro-enterolNutr.2004;39(2):115-128.UsedwithPermissionofWoltersKluwer.www.lww.com
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Clinical Pathway For Treatment Of Enterovirus In The Neonate
StronglyconsiderCSFPCR.Considerviralcultureforserotype.
ConsiderCSFPCRorviralcultureforserotype.
Signsofheartfailure?(cardiomegaly,prolongedfeeding,shock,cold/mottledskin,gallop)
Signsofliverfailure?(hepatomegaly,splenomegaly,bleeding/bruising)
ConsiderorderingECG,ECHO,andCXR.Consultwithcardiology
andtreatformyo-carditis.
Orderliverfunctiontests,
coagulation,andbilirubin.
Consultwithgas-troenterology.
Isthepatientfebrile?
Considerthefollowingteststoruleoutsepsis:CBCwithdiff,BCx,UCx,CSFCx,CSFprotein,
glucose,andcellcount.Startantibiotics.
Isthepatientexperiencingmild
congestion?
Considerviralculture.OrdernasalPCRif
possible.
Noworkupisneeded.Providesupportivecareandclosefollowupwith
PMD.
Considerthefollowingteststoruleoutsepsis:CBCwithdiff,BCx,UCx,CSFCx,BCx,UCx,
CSFCxCSFprotein,glucose,andcellcount.
Startantibiotics.
Istheweathertemperatewhereyouare?
NOYES
YES NO
NO NOYES
Doespatientdemonstrate:
Providesup-portivecareandclose
followupwithPMD.
Providesup-portivecareandclose
followupwithPMD.
YES
NOYES
CBC:completebloodcount;BCx:bloodculture;UCx:urineculture;CSF:cerebralspinalfluid;CSFCx:cerebralspinalfluidculture;EV:En-terovius;PCR:polymerasechainreaction;ECG;electrocardiogram,ECHO:echocardiogram;CXR:chestx-ray;PMD:primarymedicaldoctor
YES
Doestheneonateappeartoxic?
NO
13
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Ifchild<2yearsold,areallofthefollowingpresent?1. Feverorfeelsfeverish(ifnothermometeravailable)*2. Irritabilityorcoughorvomiting/unabletokeepfluidsdown
Ifchild≥2yearsold,areallofthefollowingpresent?1. Feverorfeverishness*2. Coughorsorethroat*Ifantipyreticsaretaken,thismayinhibitapatient’sabilitytomountafever.Ifantipyreticshavebeentaken,thepatientcanbereassessed4to6hoursafteracetaminophenor6to8hoursafteribuprofen.
Isthechildyoungerthan12weeksold?
Areanyofthefollowingsignsorsymptomspresent?†Age 12 weeks to < 5 years• Fastbreathing‡ordifficultybreathingorretractionspresent• Dehydration(nourineoutputin8hours,decreasedtearsornotearswhenchildiscrying,
ornotdrinkingenoughfluids)• Severeorpersistentvomiting/unabletokeepfluidsdown• Lethargy(excessivesleepiness,significantdecreaseinactivitylevel,and/ordiminished
mentalstatus)• Irritability(cranky,restless,doesnotwanttobeheldorwantstobeheldallthetime)• Flu-likesymptomsimprovedbutthenreturnedorworsenedwithinonetoafewdays• Paininchestorabdomen(forchildrenwhocanreliablyreport)Age ≥ 5 years• Fastbreathing‡ordifficultybreathing• Dizzinessorlightheadedness• Severeorpersistentvomiting/unabletokeepfluidsdown• Flu-likesymptomsimprovedbutthenreturnedorworsenedwithinonetoafewdays• Paininthechestorabdomen
Isthechildatleast12weeksoldbutlessthan2yearsold?
seenextpage
Althoughsomechildrenwithinfluenzamaynotexhibittheusualinfluenzasymptomsincludingfever,thischild’ssymptomssuggestthatinfluenzaislesslikely.Theydonotmeetcriteriaforthisalgorithm.Thechildshouldbeassessedforalternativediagnoses.
Recommendimmediatemedicalevalu-ationforchild,preferablywithchild’smedicalhome/primarycareprovider,orreferforemergencymedicalcareor911ifanysignsorsymptomsoflifethreateningillness.
Recommendimmediatemedicalevalu-ationforchild,preferablywithchild’smedicalhome/primarycareprovider.
Thischildfallsintoagroupthatmaybeatelevatedriskforcomplicationsfrominfluenza.Recommendthattheybeevaluatedforpossibletreatment.Recommendthatthechild’scaregivercontactthechild’smedicalhome/pri-marycareproviderthatday.
YES
YES
YES
YES
NO
NO
NO
NO
2009-2010 Influenza Season Triage Algorithm for Children (≤ 18 years) With Influenza-Like Illness
†Thesesymptomsarepurposelybroadtominimizethepossibilityofmisclassifyingpeoplewhotrulyhaveseveresymptoms.Thepersonattemptingtotriagethepatientshouldtakeintoaccounttheseverityanddurationofthesymptomswhendecidingwhetherornotpatientsshouldbeadvisedtoseekevaluationimmediately‡Suggestedrespiratoryratesindicativeof“fastbreathing”includedinBox
Box 1: Definition of “Fast Breathing”Age Respiratoryrate
Birthupto3months >60/min3monthsupto1year >50/min1to<3years >40/min3to<6years >35/min6to<12years >30/min12to18years >20/min
Adaptedfromhttp://www.cdc.gov/h1n1flu/clinicians/pdf/childalgorithm.pdf
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For all patients triaged using this algorithm, the following should also be assessed:
Doestheillchildhaveanyofthefollowingconditions?Neurologicaldisorderssuchas:1. Epilepsy,cerebralpalsy,brainorspinalcordinjuries,andneuromusculardisorders(eg,
musculardystrophy)2. Chronicrespiratorydiseasessuchasthoseassociatedwithimpairedpulmonaryfunction
and/ordifficultyhandlingsecretions;thoserequiringoxygen,tracheostomy,oraventila-tor;andthosewithasthma.
3. Moderatetoprofoundintellectualdisability(mentalretardation)ordevelopmentaldelay4. Deficienciesinimmunefunctionorconditionsthatrequiremedicationsortreatments(eg,
certaincancertreatments,HIVinfection)thatresultinsignificantimmunedeficiencies5. Cardiovasculardiseaseincludingcongenitalheartdisease6. Significantmetabolic(eg,mitochondrial)orendocrinedisorders7. Renal,hepatic,hematological(includingsicklecelldisease)disorders8. Receivingchronicaspirintherapy9. Pregnancy
Isthechildatleast2yearsoldbutlessthan5yearsold?
Thischildappearstobeatlowerriskforcomplicationsfrominfluenzaandmaynotrequiretestingortreatmentiftheirsymptomsaremild.Inordertohelppreventspreadofinfluenzatoothers,thesepatientsshouldbeadvisedto:• Keepawayfromotherstotheextentpossible,particularlythoseathigherriskforcompli-
cationsfrominfluenza(seeboxbelow).Thismayincludestayinginaseparateroomwiththedoorclosed.
• Covertheircoughsandsneezes• Avoidsharingutensils• Washtheirhandsfrequentlywithsoapandwateroralcohol-basedhandrubs• Stayhome(eg,noschool,childcare,groupactivities)until24hoursaftertheirfever
resolveswithouttheuseofantipyretics(ie,acetaminophen,ibuprofen)
Moreinformationisavailableat:http://www.cdc.gov/flu/homecare/index.htm.Inaddition,rememberthatvaccinationforseasonalinfluenzaandpandemic(H1N1)influenzaisrecom-mendedforallchildren6monthsthrough18yearsoldandhouseholdcontactsandout-of-homecaregiversofchildrenlessthan6monthsold.
Doespatientlivewithapersonathigherriskforcomplicationsofinfluenzaincludingsomeonewhois:• Age<2orage≥65,or• PregnantOrsomeonewithanyofthefollowingcomorbidconditions:• Chronicpulmonarydisease(includingasthma),cardiovasculardisease(exceptisolated
hypertension),renaldisease,hepaticdisease,hematologicaldisorders(includingsicklecelldisease),ormetabolicdisorders(includingdiabetesmellitus)
• Disordersthatthatcancompromiserespiratoryfunctionorthehandlingofrespiratorysecretionsorthatcanincreasetheriskforaspiration(eg,cognitivedysfunction,spinalcordinjuries,seizuredisorders,orotherneuromusculardisorders)
• Immunosuppression,includingthatcausedbymedicationsorbyHIV• Child(<18)onchronicaspirintherapy
Inaddition,vaccinationforseasonalinfluenzaandpandemic(H1N1)influenzashouldberecommendedforallchildren6monthsthrough18yearsoldandhouseholdcontactsandout-of-homecaregiversofchildrenlessthan6monthsold.
Thischildfallsintoagroupthatmaybeatelevatedriskforcomplicationsfrominfluenza.Recommendthattheybeevaluatedforpossibletreatment.Recommendthatthechild’scaregivercontactthechild’smedicalhome/pri-marycareproviderthatday.
Thischildfallsintoagroupthatmaybeatelevatedriskforcomplicationsfrominfluenza.Recommendthatthechild’scaregivercontactthechild’smedicalhome/primarycareproviderthatdaytodiscusstheneedforfurtherevaluationandtreatment.
Shouldsymptomsworsen(eg,short-nessofbreath,unresolvingfever)orshouldthechild’scaregiverhavefurtherquestionsorconcernsaboutthechild’shealth,recommendthecaregivercon-tactthechild’shealthcareprovider.
Thehigherriskcontactsofthesepa-tientsshouldbeadvisedtocontacttheirmedicalhome/primarycareproviderthatdayforadviceonstepstheymightneedtotaketopreventinfection.
YES
YES
YES
NO
NO
2009-2010 Influenza Season Triage Algorithm for Children (≤ 18 years) With Influenza-Like Illness (continued)
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Clinical Pathway For The Management Of Pediatric Seizures
*Highriskcondition(indicatesCTbrainrecommended):Recenttraveltoendemiccystercercosisregion,headinjury,VPshunt,focalseizurelessthan33monthsofage,malig-nancy,HIV,suspicionforincreasedICpressure,neurocutaneousdisorder,persistentseizure,sicklecelldiagnosis,malignancy1
Neuro-surgeryconsult,admittoPICU
Admittoappropriateunitwithpediatricneurology47
Dischargehomewithappropriatefollowupandseizureprecuations3,47
YES
AEDs3,8,13
1.phenobarbital2.phenytoin3.benzodiazepineConsiderpyridoxineandotherAEDsuntilseizureiscontrolled;maintainairway
NO
Isneonatestillseizing?
CBC,bloodcultures,AEDmedicationlevelifappropriate,calcium,magnesiumlevel,BMP3
Ifmeningitisissuspected,giveIVantibiotics;ifherpesissuspected,giveantivirals.Per-formLPifnotcontraindicated.
Neonatalneuroimaging3
1.BrainCT2.Possiblecranialultrasound3.ConsiderinpatientMRI
Admitortransfertoappropri-atelevelofcare(ie,NICU),orderpediatricneurologyconsult,andcontinueairwayandseizuremanagement
PediatricseizurepatientpresentstotheED
ABC’s,IV,monitor,pulseoximetry,bedsideglucose,stabilizecervi-calspineiftrauma
Determinetypeofseizurefromdirectobservationorhistory
Ispatientaneonate?
Giveanti-pyretic
Ifthepatientisstillseizing,giveAEDsasappropriateuntilseizurestops;maintainairway
ConsiderbrainCTifhighriskcriteriaofrecenttraveltoendemicareaforcystercercosis,suspectedincreasedintracranialpressure,etc1,3
Simplefebrileseizure
Workupforfeverwithorwithoutsource:CBC,bloodculture,cathUA,viralswabs,stoolcultures,treatinfectionasappropriate.
**Meningitishigh-riskcriteria1.RecentMDvisit/antibiotics2.Focalseizure3.Lessthan12monthsofage4.12to18monthsofagewithsymptomssuggestiveofmeningi-tis(ie,increasedICP,petechiae,Kernig’s,Brudzinski’s)
Ifthepatientisstillseiz-ing,giveAEDs1.phenobarbital2.phenytoin3.benzodiazepineConsiderpyridoxineandotherAEDsuntilseizureiscontrolled;maintainairway3,8,13
Laboratorytests:testelectrolytesifpatientisaninfant,hasatemperaturelessthan36.5°C,orisactivelyseizingintheED36
BrainCTifhigh-riskorpredisposingcondition*
AbnormalCT?
NO
YES
PerformLP
IVantibioticsifmeningitisissuspectedYES
YES
NO
NO
YES
Anymeningitishighriskcriteria**?13,16,17,19
NO
Doeschildlooksick?(Abnormallabsoranysignsofmeningitis)
Wasseizurecomplex?
Istherefever>100.4°Frectalplusaseizure?
NO
LPcontraindicated?
NegativeLP?
Doesthechildappearwellandhavefollow-uparranged?
YES
NO
YES
NO
NO
NO
YES
YES
YES
16
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Clinical Pathway: Patient With ANC < 500 Or Chemotherapy-Induced Neutropenia
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2009EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
Evaluateairway,breathing,andcirculation.
Obtainbloodculture.(Class I)
PerformurinalysisandCXRifclinicallyindicatedaswellasfurtherculturesbasedonhistoryandphysicalexamination.(Class II)
Startcefepime50mg/kg/doseormeropenem20mg/kg/dosewithorwithoutvancomycin15mg/kg/dose.*¥(Class I)
Admittohospital.
*Thepractitionershouldchooseantibioticsbasedonhospitalpolicyandlocalbacterialresistancepatterns.¥Maximumdosesofmedicationsarenotlistedhere.Pleaserefertoadatabaseforcompletedosingrecommendations.
YESNO
Doesthepatienthavehypotensionorsignsofshock?
Obtainbloodcultureandinitiatebroadspectrumantibioticswithmeropenem20mg/kg/doseandvancomycin15mg/kg/dose.*(Class I)
PerformurinalysisandCXRaswellasfurtherculturesbasedonhistoryandphysicalexamination.(Class II)
TreathypotensionwithisotonicIVFboluses.Reassessaftereach20mL/kgbolus.(Class I)
Hashypotensionresolvedwithisotonicboluses?
YESNO
Initiateinotropes.(Class I)AdmittoPICU.
Admittohospital.
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Evaluateairway,breathing,andcirculation.
NO YES
Clinical Pathway: Patient With Mild To Moderate Neutropenia*
Isthepatientunstable?
IstheWBCtheonlycelllinethatisabnormal? ProceedtoPathway1.
Doesthepatienthavesignsofsystemicbacterialinfection?
Consultahematologisttoruleoutotheretiologiessuchasaleukemicprocessor
aplasticanemia.
Sendbloodculture.(Class I)
PerformurinalysisandCXRaswellasfur-therculturesbasedonhistoryandphysicalexamination.(Class II)
Startcefepime50mg/kg/doseormeropenem20mg/kg/dose.(Class I)
Admittohospital.
Doespatienthavesignsoflocalizedinfection?
Doespatienthavesignsofviralinfection?
Ifthepatientiswellappearingwithmildtomoderateneutropeniaunrelatedtocancerorprimaryimmunodeficiency,considerdischargetohomewithappropriateoralantibioticcoverage.Closefollow-upmustbeensured.Admissiontothehospitalwillberequiredifinfectiondoesnotimprovewithoralantibiotics.
Ifthepatientiswellappearing,withoutsourceofinfection,consider
bloodcultureandceftriaxone50mg/kgwithfollow-upthenextday.
Providesupportiveoutpatientcarewithclosefollow-up.
*Anypatientwhoisill-appearingshouldhavebroad-spectrumantibioticsinitiatedandshouldbeadmittedtothehospitalregardlessoftheANCvalue.Thepractitionershouldalsoriskstratifybasedonsuspectedunderlyingcauseandexpecteddurationofneutropenia.
NO YES
NO YES
NO YES
NO YES
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Clinical Pathway For Evaluation And Treatment Of Cerebral Edema
• Astaffmemberisconcernedaboutanacuteneurologicchangeinthepatient.
• Considermannitol0.25-1.0g/kgIVover20minutes.Repeatforcon-tinuingsymptoms.(Class II)OR
• Consider3%normalsaline5-10mL/kgIVover30minutes.Repeatforcontinuingsymptoms.(Class III)
• Continuecurrentmanagement.
• Consider criteria-based assessment for cerebral edema. (Indeterminate)
lDoesthepatienthaveatleast1ofthefollowing:abnor-malmotororverbalresponsetopain,posturing,cranialnervepalsy,orneurologicrespiratorypattern?OR
lDoesthepatienthaveany2ofthefollowing:alteredorfluctuatingconsciousness,sustainedheartratedecel-erations,orage-inappropriateincontinence?OR
lDoesthepatienthave1criteriafromthesecondgroupplusatleast2ofthefollowing:emesis,headache,leth-argyordecreasedarousability,diastolicbloodpressure>90mmHg,orage<5years?
YES NO
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Clinical Pathway: Migraine Headache Neuroimaging
YES
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2010EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
Doesthepatienthaveamigraineheadache?
Isthepatient’sneurologicalexamnormal?
NO
NO
NO
YES
YES
Isthereseizureassociatedwiththehead-ache?
Obtainneuroimaging(Class II)
Obtainneuroimaging(Class II)
Noneuroimagingrequired(Class II)
NO
Evaluateothercausesofheadache
Obtainneuroimaging(Class II)
Isthisheadachesimilartopatient’spriorheadaches?
YES
20
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Clinical Pathway: Pediatric Migraine Clinical Treatment Pathway
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2010EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
Utilizeoutpatient/oralmedications(Class I)
Intravenousfluids(Class II)Decreaseenvironmentalstimuli(Class II)
Istheheadacheduration<4hours?
Prochlorperazine(Class II)
“Triptans”SumatriptanSQ/PO/INZolmatritanPO/INRizatriptanPOAlmotriptanPO
(Class II)
Istheheadacheimprovedafter1to2hours?
Consider2ndmedication:ValproicAcid(Class III)
Dihydroergotamine(Class III)
Dischargepatient
Istheheadacheimprovedafter1to2hours? Dischargepatient
Inpatientadmission(Class I)
NO
NO
NO
YES
YES
YES
YES
FPS-Rpainscale>3?
NO
21
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Monitorfordevelopmentofcentralnervoussystemdepressionandseizures.Ifchildremainsasymptomaticfor4hourspostingestion,thendischargetohome.
Ingestionofcamphor,eucalyptusoil,oranimidazoline
Clinical Pathway: Oil Of Wintergreen, Pennyroyal Oil, Camphor, Eucalyptus, Imidazoline Decongestant
NO
NO
YES
Shortstayadmission;consideradministrationofactivatedcharcoal;administerN-acetylcysteine;monitorforhypoglycemiaand
liverdysfunction.
Obtainsalicylatelevel.Ifchilddevelopsalteredmentalstatusorhasasalicylatelevelgreaterthan100mg/dL,thenconsiderdialysis.Ifchild
remainsasymptomaticfor4hoursandsalicylatelevelsarenottoxicandaredeclining,thenthechildmaybedischargedtohome.
Anysymptomaticchildshouldbeadmittedtoamonitoredsetting.
NO
NO
YESChildasymptomatic
Consideradministrationofactivatedcharcoal.Monitorthechildforatleast12hourspostingestionfordevelopmentofananticholinergicsyn-dromeduetoatropineand/orforopioidsyndromeduetothediphenoxyl-
ate.
YESCentralnervoussystemand/orrespiratorydepression
Administernaloxoneuntilopioideffectsarereversed.Admittoamoni-toredsetting.
YES
YES
Ingestionofpennyroyaloil
Ingestionofoilofwintergreen
Clinical Pathway: Diphenoxylate–Atropine
YES
Ingestionofoilofwintergreen,pennyroyaloil,eucalyptusoil,camphor,oranimidazoline
YES
Ingestionofdiphenoxylate–atropine
22
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Consideroctreotide;admittomonitoredsetting.
NO
NO
YES
HypoglycemiaIfthechilddevelopsnohypoglycemiaforatleast8hours
followingtheingestion,thenthechildmaybedischargedbacktounmonitoredsetting.
YESHypoglycemiaresolvesfollowingoralorparenteralglucose
Admitandmonitorforreoccurrenceofhypoglycemia.
Anysymptomaticchildexposedtoanorgano-phosphateshouldbemonitoreduntilcomplete
resolutionofsymptoms.
Seizure
Ingestionofanorganophosphate-containingproduct
NO
NO
YES
YESChildasymptomatic
YES
Monitorforatleast4hours.Ifthechilddemonstratesnosignsorsymptoms,thechildmaybedischargedtohome
YESWheezingorairwaysecretions
Administeratropinebytheintravenous,intramuscular,orendotra-chealrouteatadoseof0.02mg/kg(minimumof0.1mg)every5minutesuntilresolution.Considerpralidoximeadministration.
Administerbenzodiazepinesuntilresolutionofseizureactivity.Inaddition,consideradministrationofatropine.Contactneurology
andconsiderelectroencephalogrammonitoring.Considerpralidoximeadministration.
NO
Clinical Pathway: Organophosphates
Clinical Pathway: Sulfonylureas
YES
Ingestionofsulfonylureabyachild
23
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Clinical Pathway For The Treatment Of Pediatric Burns
1.Earlyintubation(Class II)2.Oxygensupplementation3.ChestX-ray(Class III)4.EvaluateforCOpoisoning
1.20to40mL/kgbolusnormalsalineorlactatedRinger’s(Class II)2.Cardiacpressuresifneeded3.Evaluateforactivebleeding
1.Cervicalspineprecautions(Class II)2.HeadCT(Class II)3.Radiographstolookforfractures(Class II)4.Bloodfortypeandcrossmatch
1.Identify%TBSAburned(LundandBrowder,ruleofninesorpalmrule(Class II)
2.UsetheParklandformula:4mL/kg/%TBSA(Class II)3.PlaceaFoleytomonitorurineoutput(Class II)
1.Considertransfertoaburncenterspecializinginpediat-rics(Class II)
1.Washburnwithmildsoapandwater2.Debridetheburn.(Class II)3.Applyantimicrobialointmentorcream(ClassII)4.Applyasyntheticskinsubstituteorocclusivedressing.
(optional)(Class II)5.Providetetanustoxoidinjection+/-tetanusimmune
globulin(TIG)
1.Notifytheappropriateauthoritiestoensurethechild’ssafety
Theevidence for recommendationsisgradedusingthefollowingscale.Class I:Definitelyrecommended.Definitive,excellentevidenceprovidessupport.Class II:Acceptableanduseful.Goodevidenceprovidessupport.Class III:Maybeacceptable,possiblyuseful.Fair-to-goodevidenceprovidessupport.Inde-terminate: Continuingareaofresearch.
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2008EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.
YES
YES
YES
YES
YES
YES
YES
PrimarySurvey:AirwayandBreathingl Aretheresignsofairwaycompromise,stridor,significant
facialinjury,orinhalationinjury?
PrimarySurvey:Circulationl Aretheresignsofhypotensionorshock?
PrimarySurvey:Disabilityl Removeclothing,jewelry,andharmfulforeignbodies.
SecondarySurvey:l Multisystemtrauma?
SecondarySurvey:BurnEvaluationl Largeburn(>20%TBSA)
BurnEvaluation:l Istheburninaconcerninglocation(hand,feet,face
genitalia,overajoint)l Doestheburnrequireadmission?
Istheburnpartialorfull-thickness?
Isthereconcernthisinjurywasinflicted?
NO
NO
NO
NO
NO
NO
24
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Clinical Pathway For The Treatment Of Mammalian Bites
YES NO
High risk injury?(includingthosewithdelayedpresenta-tion,bitestothehand,andimmuno-compromisedpatients)
Lower risk injury?(includingthosetoyoung,otherwisehealthypatientswhowerenotbittenontheirhand)
Perform physical examination.• Notethelocationofwound.• Notethedepthandtypeofwound(eg,avulsion,puncture,crush).• Assessfunctionifanextremityisinvolved.• Performaneurovascularexamination.• Assesspatientforsignsofinfectionifdelayedpresentation.
Consideraconsultationandprescribingantibiotics.
Order diagnostic studies.• Orderradiographsifbonyinjury,violationofjoint,orforeignbodyissuspected.• OrderawoundcultureandGramstainforinfectedwounds.• Orderadditionalstudiesifbacteremia/sepsisispresentincludingacompletebloodcell
count,bloodculture,coagulationstudies,andliverpanel.
Isitalaceration?
Iftheinjuryisuncomplicated,ask:If the injury is complicated:(involvestendons,joints,bones,and/ornerves,orsepsisisevident)
Isitapuncturewound?
Cleanseanddressthewound.Considerantibiotics.
Consideraconsultandpossibleadmission.
Considersuturingthewoundifneeded.Suturethelaceration.
Perform wound care.• Irrigate.• Debrideifindicated.• Performincisionanddrainageifanabscessispresent.• Considerwoundclosureincosmeticallyimportantareas.• Elevateandimmobilizeifwoundisonextremity.
Isthelacerationofcosmeticconcern?
NO
YES YES
Gather the history of the injury.• Obtainpatientinformationincludingpastmedicalhistory,medica-
tions,drugallergies,tetanusimmunizationstatus,andsocialfactors.
• Obtainanimalinformationincludingrabiesimmunizationstatus,animal’shealth,andlocationofanimal.
• Obtaininformationregardingtheinjuryincludingprovokedvsun-provokedinjuries,timing,anddelayinseekingmedicaltreatment.
25
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Clinical Pathway For Treatment Of Traumatic Dental Injuries
Typeofinjury
AnalgesicsSoftdiet
AnalgesicsSoftdiet
NOYES
AnalgesicsSoftdiet
Splint,ifsevereAnalgesicsSoftdiet
NOYES
Allowtore-eruptIfnore-eruptionafter2
months:extract
Allowtore-eruptIfnore-eruptionafter3to6weeks:extract,splint,rootcanal
NOYES
RepositionSplint
RepositionSplint
NOYES
Donotre-implant Re-implantimmediatelyNOYES
Pulpectomyorpulpotomy
Enamelonly:analgesics
Enamelanddentin:cap,restoration
NOYES
Ifapical:restorationIfcoronalormiddle:
extract
Concussion—istoothprimary?
Subluxation—istoothprimary?
Intrusion—istoothprimary?
Extrusion,lateralluxation—istoothprimary?
Avulsion—istoothprimary?
Fractureofthecrown(primaryandperma-nent)--Isthefracturecomplicated(ie,in-
volvesenamel,dentin,andpulp)?
Fractureoftheroot,primaryandpermanent
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2010EBPractice,LLCd.b.a.EBMedicine.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLCd.b.a.EBMedicine.
26
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Clinical Pathway For Treating Pediatric Wounds
Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.
Copyright©2010EBPractice,LLCd.b.a.EBMedicine.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLCd.b.a.EBMedicine.
Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness
LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)
•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling
Class II•Safe,acceptable•Probablyuseful
LevelofEvidence:•Generallyhigherlevelsofevidence
•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies
•LessrobustRCTs•Resultsconsistentlypositive
Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments
LevelofEvidence:•Generallylowerorintermediatelevelsofevidence
•Caseseries,animalstudies,consensuspanels
•Occasionallypositiveresults
Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch
LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory
•Resultsnotcompelling
Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-
tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.
Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.
YES
YES
NO
NO
NO
Woundriskfactors:• Infected?(Class I)• Obviouscontamination?(Class I)• Sustained>18hrago?(Class II)
Closurebysecondaryintentionor
Delayedprimaryclosure
Wound<6hrold?(Class I)
Closurebysecondaryintentionor
Delayedprimaryclosure
• Anesthesia—topicalorinjectable(Class I)• Cleanse:chlorhexidine–alcoholpreparation(Class II)• Irrigation:tapwaterorsaline(Class II)• Chooseclosuremethod:suture,cyanoacrylate,staples
Referto“ClinicalPathway:PediatricPainAndAnxietyInTheED”
• Imaging,ifindicated,forforeignbodies• Consultspecialist,ifindicated
Primaryclosurepreparation
Sedationneeded?
• Clean,viabletissue?• Well-vascularizedarea?• Nocomorbiditiesthatmightleadtopoorwoundhealing?(Class II)
NO
YES
YES
27
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