C.L.A.P.P.E.D. Practice Changes 11/16/2015. No conflict of interest to declare. CLinically Applied Pearls from the Pediatric Emergency Department

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1 C.L.A.P.P.E.D. CLinically Applied Pearls from the Pediatric Emergency Department Stephen Noseworthy, MD No conflict of interest to declare Practice Changes 1. Obtaining Urine Samples 2. Role of Probenecid in Soft tissue infections 3. Using Allerject over Epipen until recently 4. Using more online resources to assess and manage concussion 5. Using more Ventolin MDI with a spacer over nebulizer for acute asthma management 1

2 By the end of our talk today you should be able to: 1. use a new technique for obtaining a clean urine sample in a child < 90 days of age. 2. recognize and know where to find the new BCCH treatment algorithm for diagnosing and treating febrile UTI s in children 3. assess and manage pediatric concussions 4. access online and community resources for concussion Objectives Arch Dis Child 2013;98: Steps 2

3 Accuracy of a new clean-catch technique for diagnosis of urinary tract infection in infants younger than 90 days of age María Luisa Herreros MD PhD1,2, Alfredo Tagarro MD PhD1,2, Araceli García-Pose MD1, Aida Sánchez MD3, Alfonso Cañete MD PhD1,2, Pablo Gili MD PhD2 Pediatrics & Child Health 2015, 20(6);e30-3 New Research Cultures obtained from both clean catch and catheterization Culture result clean catch Culture result Catheterization Positive Negative Total Positive Negative Total Sensitivity 97% (CI 82% to 100%) Specificity 89% (CI 65% to 98%) Collection technique; culture result Leukocyte Esterase Positive (n) Catheter; positive (n=34) 30 8 Catheter; negative (n=21) 0 1 Clean-catch; positive (n=37) 32 9 Clean-catch; negative (n=20) 4 0 Nitrite Positive (n) Urinalysis Results 3

4 1. Catheter gold standard vs. Suprapubic aspiration 2. More males than females 3. Small sample size 4. Included only infants with high likelihood of having a SBI Study Limitations It appears that this new technique for clean catch urine is as sensitive and specific as catheter collection in this particular study, but more research is needed In the meantime: This is not a harmful procedure Is as good as other clean catch techniques (ie waiting for baby to void) May be faster than just waiting and even catheterization Can easily be carried out by parents and an office staff member Conclusion BC Children s Hospital Emergency Department Guidelines Urinary Tract Infections Febrile UTI 4

5 Movie Trailer - Concussion 5

Second Impact syndrome Post-concussion syndrome Post-traumatic epilepsy Post-traumatic vertigo Cranial nerve injuries Chronic Traumatic Encephalopathy Complications Headache Amnesia Dizziness Nausea

6 Second Impact syndrome Post-concussion syndrome Post-traumatic epilepsy Post-traumatic vertigo Cranial nerve injuries Chronic Traumatic Encephalopathy Complications Headache Amnesia Dizziness Nausea Vomiting Confusion Loss of Consciousness is not required, and often absent Symptoms Identify Patients with worrisome Features 1. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury Martin Osmond, et al. for the Pediatric Emergency Research Group of Canada, Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective cohort study Nathan Kuppermann, et al, for the Pediatric Emergency Care Applied Research Network (PECARN),

7 CATCH Study PECARN study Diagnostic Tool 7

8 Treatment Strategies UIDELINES_for_Diagnosing_and_Managing_Pediatri c_concussion_recommendations_for_hcps v1.1. pdf 8

http://www.injuryresearch.bc.ca/wpcontent/uploads/2014/09/return-to-play.

10 Online: ChildHealth BC CPS Position Statement Sport Related Concussion: Evaluation and Management, 2014 Other Resources Community: BC Centre for Ability (0-19yrs) Fraser Health Concussion Clinic (16 and older) GF Strong Early Response Concussion Service for Adolescents (12-15 yrs) Sports Medicine Clinics acute symptoms Pediatricians with special interest Role of School counselling, IEP s, adjustment of academic expectations Other Resources 10

11 1. Obtaining a urine sample from an infant is often a necessary and time consuming investigation. 2. With just 3 easy steps - feeding, tapping the abdomen, and rubbing the lumbar spine you can have your very own sample in less than a minute! 3. This technique does not require more manpower than catheterization and can be done in your office. 4. More research and dissemination will make this an everyday practice Summary 1. The complications of concussions can be fatal (Second Impact Syndrome), or can be long and drawn out affecting a person socially, emotionally, intellectually, and physically. 2. There are more resources available to us now than ever before for evaluating and treating concussions - SCAT3 and Parachutecanada.org and injuryresearch.bc.ca - excellent online resources for physicians, parents, patients and coaches 3. Return to Learn should take priority over Return to Play in all pediatric concussions Summary Useful Websites 11

1. Herreros Fernandez ML, Gonzalez Merino N, Tagarro Garcia A, et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child 2013;98:27-9 2.

Pediatrics & Child Health 2015, 20(6);e30-3 3. Kuppermann N, Holmes JF, Dayan PS et al.

12 1. Herreros Fernandez ML, Gonzalez Merino N, Tagarro Garcia A, et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child 2013;98: Herreros Fernandez ML, Tagarro Garcia A, Garcia-Pose A, et al. Accuracy of a new clean-catch technique for diagnosis of urinary tract infection in infants younger than 90 days of age. Pediatrics & Child Health 2015, 20(6);e Kuppermann N, Holmes JF, Dayan PS et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 374 (9696): (2009). 4. McCrory P, Meeuwisse WH, Aubrey M et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November Br J Sports Med. 47 (5): (2013). 5. Osmond Martin H, Klassen Terry P, Wells George A, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ March 9, (4), First published February 8, Purcell, Laura K, Canadian Pediatric Society Healthy Active Living and Sports Medicine. Sport-related Concussion:evaluationand management March Paediatr Child Health 2014;19(3); Zemek R, Duval S, DeMatteo C et al. Guidelines for Diagnosing and Managing Pediatric Concussion [Internet]. Toronto, ON: Ontario neurotrauma Foundation; 2014 June [accessed 2014 Nov 28]. Available from: References Thank-you Brain101.orcasinc.com 12

Use of CT in minor traumatic brain injury. Lisa Ayoub-Rodriguez, MD Bert Johansson, MD Michael Lee, MD

Use of CT in minor traumatic brain injury Lisa Ayoub-Rodriguez, MD Bert Johansson, MD Michael Lee, MD No financial or other conflicts of interest Epidemiology of traumatic brain injury (TBI) Risks associated