Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine June 10-12, 2011

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1 LTC Jeremiah Johnson, MD Pediatric Emergency Medicine Brooke Army Medical Center Christus Santa Rosa Children s Hospital I have no financial interest in any products I discuss today Practical applications for primary care Develop office emergency preparedness plan Personal experience tricks of the trade Recent literature tricks of the trade Splinting lab Discussion-share your tricks

2 18 m/o with trouble breathing ER follow up Racemic epinephrine earlier He is stridorous and sleepy (and you are scared) Lets review your emergency preparedness plan Practice mock code using this scenario Personnel training Phone triage Receptionist is the triage nurse Emergency preparedness plan Role assignments Provider IV, drugs, oxygen 911 caller, Recorder CPR training for all staff Practice a mock code Familiarity with equipment and procedures

3 ESSENTIAL OPTIONAL OR SUGGESTED Albuterol for inhalation Epinephrine (1 : 1,000) Activated charcoal Antibiotics Anticonvulsants (diazepam/lorazepam) Corticosteroids (parenteral/oral) Dextrose (25%) Diphenhydramine (parenteral) Epinephrine (1 : 10,000) Atropine sulfate (0.1 mg/ml) Naloxone (0.4 mg/ml) Sodium bicarbonate (4.2%) Normal saline (NS) or lactated Ringer's (500-mL bags) 5% dextrose, 0.45 NS (500-mL bags) ESSENTIAL Oxygen and delivery system Bag-valve-mask (450 ml and 1,000 ml) Clear oxygen masks, breather and non-rebreather, with reservoirs Suction device, tonsil tip, bulb syringe Peak flow meter Nebulizer (or metered-dose inhaler with spacer/mask) Oral airways (sizes 00 5) OPTIONAL Nasal airways (sizes 12 30F) Magill forceps (pediatric, adult) Suction catheters (sizes 5 14F) Nasogastric tubes (sizes 6 14F) Pulse oximeter Laryngoscope handle (pediatric, adult) with extra batteries, bulbs Laryngoscope blades (straight 0 4; curved 2 3) Endotracheal tubes (uncuffed ; cuffed ) Stylets (pediatric, adult) Butterfly needles (19 25 gauge) S Catheter-over-needle device (14 24 gauge) S Arm boards, tape, tourniquet S Intraosseous needles (16,18 gauge) S Intravenous tubing, microdrip S

4 ESSENTIAL OPTIONAL Color-coded tape or preprinted drug doses Cardiac arrest board/backboard Sphygmomanometer (infant, child, adult, thigh cuffs) Splints, sterile dressings Spot glucose test Stiff neck collars (small/large) CAB, not ABC emphasizing compressions Check responsiveness, call for help, AED Limit pulse check to 10 seconds 30:2, hard and fast No look, listen, feel Cricoid pressure removed You CAN use an AED for all ages <8 y/o attenuator preferred Calcium not routinely recommended Titrate oxygen as required Croup, laryngomalacia, epiglotitis, upper airway obstruction Oxygen, calming maneuvers Racemic epinephrine 2.25% racemic mixture 0.5ml diluted with saline by neb

5 How much epinephrine in 2.25% solution? 1% = 10 mg/ml (I remember lidocaine) 2.25% = 22.5 mg/ml; or mg/0.5ml But we only want the L isomer 5ml of 1:1000 Epi nebulized is the appropriate dose (5 mg) Parenteral form of dexamethasone tastes better (0.6 mg/kg) Parenteral form better tasting 0.6 mg/kg 2 days of dexamethasone equivalent to 5 days of prelone Axial traction injury Toddler age Usual reduction technique Supination Flexion Lots of tears, parenteral gasps

6 66 patients randomized a traditional reduction hyperpronation maneuver initial attempt failure, a second attempt performed 2 nd failure--alternate method performed Hyperpronation was 94% first attempt supination-flexion at 69% Three patients failed supination-flexion (first and second attempt) successfully reduced with hyperpronation Hyperpronation was also subjectively rated as significantly easier then supination-flexion by the practitioner Bek D et al. Pronation versus supination maneuvers for the reduction of pulled elbow : a randomized clinical trial European Journal of Emergency Medicine. 2009, 16(3), Increasing incidense of MRSA Time constraints in a busy practice Equipment Proceedural sedation LMX 4 relieves pain, may cause spontaneous drainage Retrospective chart review of children presented with skin abscess to an urban ED Excluded pilonidal abscess, paronychia or GU abscess 300 patients selected from 3 sites *Treating MD assigned anesthetic cream*

7 LMX applied for min, occlusive dressing Of 300,169 children required treatment in the ED. 110 received topical anesthetic (younger, more MRSA, less surrounding cellulitis) and 59 did not. Spontaneous drainage 26/110 (24%) topical anesthetic spontaneously drained 0/59 (0%) without a topical anesthetic. Proceedural Sedation Anesthetic applied: 26/110 (24%) No anesthetic: 24/59 (41%) (OR 0.45) Return visits topical anesthetic group 22% returned to the ED 2% needed intervention No anesthesia 34% returned to ED None needed intervention Consider in all abscesses, even if referring to ED

8 2 y/o bead in the nose earlier / % Cold sx for 2 days Dad blew in mouth to clear bead Breathing funny Seems like his stomach is bigger PMH: Term, no NICU, UTD SOC: Lives with mom and dad Daycare Meds/Allergies none GEN: Alert, non toxic HEENT: runny nose CHEST: Clear, RR 28 CV: Tachy, no m, well perfused ABD: Tender, non guarding, decreased BS, tender to percussion LABS/Xrays?

9 Roberts: Clinical Procedures in Emergency Medicine, 4th ed.

10 Oxymetazolone (Afrin) in affected nare Lidocaine anesthesia Headlight ($15) Alligator forcepts are great Ear curette Generally not emergent Amoxacillin an refer to ENT Button battery Magnets Cerumen impaction Debrx Colace Irrigation Curette (lighted is best) $80 vs $50 a box Insects: kill with lidocaine or Auralgan Irrigation direct stream superiorly

11 Cyanoacrylate on q-tip Non porous Smooth or round Gel or Dermabond Cooperative patient Referral to ENT What is different between these fractures Which one can be managed without a cast? Also called Buckle Metaphaseal, not involving physis Not diaphysis (greenstick) Treatment goals Pain relief Protection from injury Removeable splint

12 Splint or cast No change in re-fracture rate Earlier return to activity with removable splint Less disability with splint vs cast Ace wrap maybe just as effective Kliegman: Nelson Textbook of Pediatrics, 18th ed.; Chapter 62 - Emergency Medical Services for Children Field JM, Hazinski et al AHA guidelines for CPR and emergency cardiovascular care science. Circulation. 2020; 122:S639-S933. Qureshi F, Zaritsky A, Poirier MP. Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr. 2001;139(1):20 Bek D et al. Pronation versus supination maneuvers for the reduction of pulled elbow : a randomized clinical trial European Journal of Emergency Medicine. 2009, 16(3), Hogan ME, Vandervaart S, Perampaladas K, Machado M, Einarson TR, Taddio A. Systematic Review and Meta-analysis of the Effect of Warming Local Anesthetics on Injection Pain. Ann Emerg Med Roberts: Clinical Procedures in Emergency Medicine, 4th ed accessed 5/10/2011 Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117(3):691. Abraham A, Handoll HH, Khan T. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev. 2008