1. The Best of the PEM
literature in the last year
Terry P Klassen, MD, MSc, FRCPC
CEO and Scientific Director, Manitoba Institute of
Child Health
Associate Dean, Academic, Faculty of
Medicine, University of Manitoba
PEM Review Course
Edmonton CPS meeting
June 18, 2013

2. 2
A initiative to mobilize knowledge on best pediatric
emergency care
Brought to you by:

4. Approach
 Mainly used 2012 as the last year
 Journals searched:
◦ Pediatrics
◦ Journal of Pediatrics
◦ Archives Disease Childhood
◦ JAMA Pediatrics
◦ Annals of Emergency Medicine
◦ Academic Emergency Medicine
◦ Pediatric Emergency Care
◦ JAMA

5. Approach continued
Pubmed, used term
“Pediatric Emergency
Medicine”
So some articles are from
2013
Criteria: interesting,
relevant, quality

6. Constipation #1 (or is it number
2)
 Seldom in these update talks
 Few gravitate to it as their research
domain
 ? Poop phobia
 Yet our younger patients love to talk
about it and important part of their
humour

7. Yet we know
 It is common “Constipation is the most
common diagnosis in children
presenting with abdominal pain”
 20% of patients
 Pediatrics 2013;131:1098-1106.
 Most have acute symptoms and get
better
 Female, recurrent pain, duration (>2
days) and medical visit (Arch Pediatr
Adolesc Med 2000;154:1204-8)

8. RCT of PEG 3350 vs Enema for
fecal disimpaction in PED
 Intervention: Milk and molasses
enema (1:1, 10 mL/kg, max 500 mL)
in the ED or PEG 3350 (1.5
g/kg/d, max 100g/day) for 3 days
 Maintenance: PEG 3350 (0.8
g/kg/day) for both groups
 Telephone follow up days 1,3 and 5
days
 Primary outcome: Symptom
improvement
Ped Emerg Care 2012;28:115

9. Results
 79 patients (39 PEG; 40 enema)
 Day 1, PEG patients less likely to
have improved symptoms
 Half enema group upset in ED with
treatment vs none in PEG group
 At Day 5, no differences between
groups
 Most treatment failures in PEG group
(83%, p = 0.08)

10. Bottom line
 Either approach has advantages and
disadvantages
 Discussion with child/family for
preferences
 More research needed in constipation
presenting to the ED

11. Appendicitis #2
 We know from previously quoted
study, that 1 to 5% of children
presenting with abdominal pain will
have appendicitis
 Who has not been burnt with this
diagnosis?
 So what about the use of diagnostic
imaging adjuncts?
 What about radiation from CT of
abdomen?

12. Temporal trends in radiographic testing among pediatric patients presenting to the ED with
abdominal pain.
Fahimi J et al. Pediatrics 2012;130:e1069-e1075
©2012 by American Academy of Pediatrics

13. Figure?2 Rates of CT and US in children with appendicitis at 40 pediatric EDs in the United States, 2005-2009.
Richard G. Bachur , Kara Hennelly , Michael J. Callahan , Michael C. Monuteaux
Advanced Radiologic Imaging for Pediatric Appendicitis, 2005-2009: Trends and Outcomes
The Journal of Pediatrics Volume 160, Issue 6 2012 1034 - 1038
http://dx.doi.org/10.1016/j.jpeds.2011.11.037

14. Figure?3 Association between the rate of advanced imaging (<ce:italic> x</ce:italic> -axis) and the rate of negative appendectomy
(<ce:italic> y</ce:italic> -axis) (weighted by the number of appendectomy procedures per hospital) in pediatric ED patients un...
Richard G. Bachur , Kara Hennelly , Michael J. Callahan , Michael C. Monuteaux
Advanced Radiologic Imaging for Pediatric Appendicitis, 2005-2009: Trends and Outcomes
The Journal of Pediatrics Volume 160, Issue 6 2012 1034 - 1038
http://dx.doi.org/10.1016/j.jpeds.2011.11.037

15. Appendicitis #2
 Clinical practice guideline to help
stratify into low, medium and high risk
 Low: WBC < 10,000 and polys <
67%, bands < 5%, absence of
guarding in RLQ or periumbilical
areas.
 High: WBC > 10,000, > 67% presence
of guarding and/or focal tenderness in
RLQ or periumbilical area
 Greater than 13 hours of pain
Acad Emerg Med 2012;19:886

16. Appendicitis #2
 Low risk: home and follow up in 6 to
12 hours
 Medium: Attending discretion but
imaging with ultrasound +/- CT scan
 High risk: Refer to surgery
 58% managed without CT, 37% went
to OR with no imaging
 Rate of missed appendicitis, 2% and
negative appendectomy 1%
Acad Emerg Med 2012;19:886

17. Intussusception #3
 Of course for the little ones, one
always worries about this possibility
 308 patients with 12.3% with
intussusception
 Factors lethargy at home and bloody
stools
Ped Emerg Care 2012;

18. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2
FIGURE 2
Ability of Pediatric Physicians to Judge the Likelihood of
Intussusception.
Weihmiller, Sarah; Monuteaux, Michael; Bachur, Richard
Pediatric Emergency Care. 28(2):136-140, February 2012.
DOI: 10.1097/PEC.0b013e3182442db1
FIGURE 2 . Ability of physicians to predict a diagnosis of
intussusception based on history and clinical
examination. *Numbers in the bars represent actual
patient numbers.

19. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2
FIGURE 1
Accuracy of Plain Radiographs to Exclude the Diagnosis
of Intussusception.
Roskind, Cindy; Kamdar, Gunjan; Ruzal-Shapiro, Carrie;
Bennett, Jonathan; Dayan, Peter; MD, MSc
Pediatric Emergency Care. 28(9):855-858, September
2012.
DOI: 10.1097/PEC.0b013e318267ea38
FIGURE 1 . Patient flow.

20. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2
TABLE 3
Accuracy of Plain Radiographs to Exclude the Diagnosis
of Intussusception.
Roskind, Cindy; Kamdar, Gunjan; Ruzal-Shapiro, Carrie;
Bennett, Jonathan; Dayan, Peter; MD, MSc
Pediatric Emergency Care. 28(9):855-858, September
2012.
DOI: 10.1097/PEC.0b013e318267ea38
TABLE 3 Test Characteristics of 3-View Abdominal
Radiography in the Diagnosis of Intussusception When 2
or More of the 3 Views Have Air in the Ascending Colon

21. 2
SPEAKING ABOUT
PAIN…

22. 2
Pain management in the PED
#4
 Vulnerable population in both
diagnosis and treatment of pain
 More likely to be inadequately treated
 Communication barriers
 Pain exposure may be harmful
Ped Emerg Care 2012;28:524-528

23. Approach
 Baseline data – identify areas of
deficiency and room for improvement
 Multidisciplinary Committee
 Intervention – next slide
 Collection of post-intervention data
Ped Emerg Care 2012;28:28:524

24. Intervention
 Proper pain scales
 Pain as 5th vital sign
 Treatment with pharmacologic and
nonpharmacologic methods
 Triage pathway for those with moderate
or severe pain to receive analgesics
immediately
 Topical anesthetics and oral sucrose
 Reassessment of pain
 Discharge pain action plans
Ped Emerg Care 2012;28:28:524

25. Results
 Before (102) – after (109)
 Increase in patients in pain receiving
analgesic 34 to 50%
 Median time 97 minutes to 57 minutes
 Reassessment of pain 6 to 76%
Ped Emerg Care 2012;28:28:524

26. Inferences
 A structured intervention, tailored to
pain management shortcomings, may
lead to improvements
Ped Emerg Care 2012;28:28:524

27. Concussion #5
 Burgeoning research area –
professional athletes
 Trickle down to the ED
 Roger Zemek is our man in PERC

28. Rest does matter
 49 young athletes
 Prescribed 1 week of cognitive and
physical rest
 Main outcome Concussion Symptoms
Scale ratings, Immediate Post-
Concussion Assessment and
Cognitive Testing
J Pediatr 2012;161:922-926

29. Outcome
 Regardless of time post injury (weeks
to months)
 Participants showed improved
performance on Immediate Post-
Concussion Assessment measure

30. It may be the cerebral blood flow
 12 children with sports-related
concussion matched controls
 No structural, metabolic, neuronal or
axonal injury.
 Reduction in CBF that improved over
time
Pediatrics 2012;129:28-37

31. Critical procedures #6
 25% of community EDs felt
uncomfortable performing potentially
life saving procedures on children
 In survey of pediatric ED medical
directors 62% judged number of
intubation opportunities as inadequate
for providers to maintain competency
 In one pediatric ED, survey of 114
children undergoing RSI, 48% failed
first intubation attempt
Ann Emerg Med 2013; 61:263-270

32. Critical procedures in the PED
 261 procedures during 194
resuscitations, which represented 0.22%
of all ED patient evaluations
 61% of PEM faculty did not perform a
single critical procedure
 Orotracheal intubation occurred 147
times (56%)
 63% of PEM faculty did not perform a
single intubation
 PEM fellows median of 3 critical
procedures
Ann Emerg Med 2013; 61:263-270

33. Critical procedures – 12
months Oratracheal intubation (147)
 Intraosseous line placement (41)
 Pharmacologic cardioversion (23)
 Tube thoracotomy (18)
 Central line (15)
 Needle thoracostomy (9)
 Electrocardioversion (6)
 Defibrillation (1)
 Pericardiocentesis (1)
Ann Emerg Med 2013; 61:263-270

34. RSI from video review
 114 children undergoing RSI in ED in
the 12 months
 52% of children were tracheally
intubated on first attempt
 61% of subjects had 1 or more
adverse events during RSI
Ann Emerg Med 2013; 61:251-259

35. Figure 3 First-attempt success by physician type (n=subjects per type). “Attending” is comprised of both attending physicians from
Pediatric Emergency Medicine and providers from Anesthesiology. First attempt success was 88% (6 of 7 subjects) for PEM atten...
Benjamin T. Kerrey , Andrea S. Rinderknecht , Gary L. Geis , Lise E. Nigrovic , Matthew R. Mittiga
Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects
Found by Video Review
Annals of Emergency Medicine Volume 60, Issue 3 2012 251 - 259

36. Procalcitonin #7
 Is it time to add this to your diagnostic
tool set?
 Need to re-evaluate criteria to identify
infants at high risk of SPI with this as
criteria?

37. Diagnostic value in well-
appearing young febrile infants
 Study performed in Spain (an
important part of REPEM and PERN)
 1112 infants who had PCT measured
and blood culture performed
 IBI diagnosed in 23 (2.1%)
 PCT was only independent risk factor
for IBI (OR = 21.69 (7.63 to 59.28)
Pediatrics 2012;130:815-822

38. Receiver operating characteristic (ROC) curves to detect definite (A) SBIs and (B) IBIs.
Gomez B et al. Pediatrics 2012;130:815-822
©2012 by American Academy of Pediatrics

39. SR of topic
 8 studies – 1,883 for procalcitonin
analysis
Ann Emerg Med 2012:60:591-600

40. Figure 3 Forest plot of diagnostic odds ratio for studies using PCT ( A ), C-reactive protein ( B ), or leukocyte count ( C ) to detect
SBI among children with fever without source.
Annals of Emergency Medicine Volume 60, Issue 5 2012 591 - 600

41. Asthma #8
 Very common presenting problem
 The more we can get children to stay
away from ED or get them out faster
with their acute asthma the better

42. Dex at the door
 A time-series controlled trial
 Physician initiated compared to nurse
initiated (4 months each)
 N = 644
Pediatrics 2012;129:671-680

43. Dex at the door
 Median time to improvement 24
minutes (1 to 50, P= 0.04)
 Admission rate OR = 0.56, 0.36-0.8
 Time to steroid decreased by 44
minutes , 17 to 68
 Conclusion: Triage nurse initiated
steroid treatment reduced times to
clinical improvement and discharge
and reduced rate of admissions
Pediatrics 2012;129:671-680

44. Supportive evidence
 406 children, similar outcomes
 Annals of Emerg Med 2012;60:84 to
91
Pediatrics 2012;129:671-680

45. Shaken baby syndrome # 9
 Very challenging to identify suspected
abusive head trauma
 So having a set of variables to look for
would be helpful
Pediatrics 2012;130:315-323

46. Systematic review
 To determine clinical and radiographic
characteristics associated with
abusive head trauma (AHT) and
nonabusive head trauma (nAHT) in
children
 24 studies included
 No meta-analysis due to heterogeneity
of studies
 19 variables identified
Pediatrics 2012;130:315-323

47. Variables associated with
AHT
 Subdural
hemorrhage
 Cerebral ischemia
 Cerebral edema*
 Retinal
hemorrhage
 Skull # occurring
with ICI
 Metaphyseal
fractures
 Long bone
 Rib fractures
 Any bruises*
 Seizure within 24
hours
 Apnea at
presentation
 No adequate
history
Pediatrics 2012;130:315-323

48. Variables associated with nAHT
 Epidural hemorrhage
 Isolated skull fracture
 Scalp swelling
 Head and neck bruising (? Not when
high quality studies excluded)
Pediatrics 2012;130:315-323

49. To pack or not to pack? #10
 After incision and drainage in the
PED, should a wound be packed?
Ped Emerg Care 2012;28:514

50. RCT on the question
 RCT, single blind study
 Randomized to packing vs not after
drainage
 Treatment failure at 48 hours (masked
observer)
Ped Emerg Care 2012;28:514

51. Results
 57 randomized over 15 month period
 Failure rate 70% in packed group vs
59% in nonpacked group (11%, -15%
to 36%)
 Bottom line: no evidence for packing
but small study
 But key question for the future
Ped Emerg Care 2012;28:514

52. Concluding thoughts
 Advances in knowledge incremental
but significant
 Each study adds something
 There was clustering in certain areas
of concussion, appendicitis, pain and
asthma