Updates on HIV non-occupational post-exposure prophylaxis (nPEP)

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By Atsuko Koyama, MD, MPH and Lauren Middlebrooks, MD

According to the 2017 Youth Risk Behavior Survey (YRBS), almost 30% of 9th to 12th graders reported being “currently sexually active,” and only 54% used a condom at their last sexual encounter [1]. Despite improved antiretroviral regimens and HIV pre- and post-exposure prophylaxis (PrEP and PEP), adolescents and young adults continue to make up a quarter of new HIV diagnoses (21%, n=8,090), with the majority of these cases being secondary to male-to-male (MSM) sexual contact [2]. Given the prevalence of sexual activity amongst adolescents who present under a variety of circumstances disclosing past sexual activity, knowledge about non-occupational HIV PEP (nPEP) is relevant and important for all pediatricians.

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Beat the Heat

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By Thuy Bui, MD

thuy.bui@pemaweb.com

CASE – Part 1:

You are volunteering at the SuperHero Sprint – CHOA’s summertime 5K race.  A 12-year-old male running in his first race is brought to the medical tent by his mother.  He is diaphoretic and vomiting.  What are you concerned about?

BACKGROUND:

All heat-related deaths and illnesses are preventable.  However, despite this fact, each year an average of 658 people die from extreme heat per the CDC’s Morbidity and Mortality Weekly Report.

In the United States alone, there were 8,081 heat-related deaths from 1999-2010 according to the Centers for Disease Control.  And more recently, according to the National Safety Council’s Injury Facts, 87 people died in the U.S. in 2017 from exposure to excessive heat.

Children, because of multiple factors including their lower sweat rate and higher metabolic heat production, account for approximately 4% of heat-related deaths.  In fact, heat stroke is the 3rdmost common cause of exercise-related mortality for U.S. high school athletes; and since 1998, 619 children have died in vehicles from heat-related issues in the U.S. Continue reading

Fever Clinical Practice Guideline Update-What’s new in managing fever in children under age 2?

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by Becky Burger, beckyburger@emory.edu

The Children’s Healthcare of Atlanta Clinical Practice Guideline (CPG) on fever in infants and young children was updated in November 2018. The updated guidelines are available on Careforce:  https://choa.careforceconnection.org/docs/DOC-19464

Here are the changes based on age:

For children 0-28 days:

  • The recommended empiric antibiotics are Ampicillin and Gentamicin IV (If there is no IV access, ok to give first dose of both IM)
  • If there is concern for meningitis, give Ampicillin and Ceftazidime (this is for CHOA Emergency Departments only, Urgent Cares do not have Ceftazidime in their pharmacies)
  • If there is suspicion for HSV, it is recommended that HSV PCR be sent from blood, CSF and any suspicious skin lesion. Also nee d to swab eyes, nose & rectum for HSV
  • If patient has diarrhea, send GI PCR panel (GI PCR panel replaces stool culture)

For children 29-60 days:

  • If CRP is obtained, there was consensus on CRP>2 mg/dl as the new cut off for abnormal
  • Urine WBC cut off for abnormal is >9 WBC hpf or Nitrite positive or LES ³2+
  • Preferred antibiotic is still Ceftriaxone, but if there is suspicion for bacterial meningitis add Vancomycin (this is for CHOA Emergency Departments only, Urgent Cares do not have Vancomycin in their pharmacies)

For children 2-6 months:

  • Urine WBC cut off for abnormal is >9 WBC hpf or nitrite positive or LES ³2+; if any one of these abnormal values are present, urinalysis will reflex to urine culture automatically
  • The recommended empiric antibiotic for UTI is Cephalexin 25mg/kg/dose TID x10 days (alternative regimen if concern for compliance with TID dosing is Cefprozil 15mg/kg/dose BID)
  • If there is suspicion for UTI and plan to treat for UTI, ensure that urine culture is ordered (if urinalysis has not already reflexed to culture). As always, urine culture should be from an acceptable specimen (bag specimens not adequate for urine culture)

For children 6-24 months:

  • Same updates as 2-6 months as listed above

If there are any further questions about the Fever CPG 2018 updates, feel free to contact Dr. Becky Burger (beckyburger@emory.edu) or Shabnam Jain (sjain@emory.edu).

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Non-Accidental Trauma Tips

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By Erin Wade
erin.wade @choa.org

 

 

 

 

 

 

Child physical abuse is a serious health problem that affects many children in Georgia and the United States. Along with the potentially devastating trauma of physical abuse, we now know that adverse childhood experiences can cause other issues that can affect a child’s health and well being throughout their lives. Appropriate identification of non-accidental trauma is of paramount importance for all pediatric healthcare providers. Thus, as April is National Child Abuse Prevention month this article gives you a few tips to utilize.

Research has shown that a large number of infants who present with severe injuries secondary to abuse had recently been evaluated by a healthcare provider and had demonstrated subtle injuries during those initial evaluations[i]. These subtle injuries, or sentinel injuries, when detected, give healthcare providers an opportunity to intervene and prevent more serious harm from befalling the child, and should warrant a trip to the Emergency Room for further evaluation.

The Ten-4 rule is a great guide when evaluating small children for possible non accidental trauma[ii].

  • Any bruising to the Torso, Ears, or Neck is highly concerning for abuse and requires further evaluation
  • Bruising anywhere on a child 4-months of age or younger is highly concerning for abuse and requires further evaluation. This is true of any child that is not yet cruising, regardless of their age.

In addition to the TEN-4 rule, other highly concerning physical exam findings include[iii]:

  • Fractures with a high specificity for abuse[iv]
    • Classic metaphyseal lesions (bucket handle fractures, corner fractures)
    • Rib fractures, especially posterior
    • Scapula fractures
    • Spinous process fractures
    • Sternal fractures
  • Multiple fractures at various stages of healing
  • Patterned injuries (burns, bruises, healed skin injuries, etc.)
  • Loop marks
  • Bite marks
  • Immersion burns
  • Significant injury without a plausible reported history to account for the injury

The identification of sentinel injuries in children of any age requires further evaluation for non-accidental trauma. A thorough history, physical exam, and photographic documentation, along with appropriate radiographic and laboratory analysis are of utmost importance. If a provider is unable to complete such a work up, the child should be evaluated in the Emergency Room as soon as possible in order to complete the necessary non-accidental trauma work-up.

For further non-emergent questions contact us at 404-785-3820; for emergent questions call the Children’s Transfer center at 404-785-7778

[i]Sheets, L. K., et al. “Sentinel Injuries in Infants Evaluated for Child Physical Abuse.” Pediatrics, vol. 131, no. 4, 2013, pp. 701–707., doi:10.1542/peds.2012-2780.

[ii]Pierce, M. C., et al. “Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma.” Pediatrics, vol. 125, no. 1, 2009, pp. 67–74., doi:10.1542/peds.2008-3632.

[iii]Christian, C. W. “The Evaluation of Suspected Child Physical Abuse.” Pediatrics, vol. 135, no. 5, 2015, doi:10.1542/peds.2015-0356.

[iv]Kleinman PK ed. Diagnostic imaging of child abuse 2nd ed Mosby 1998

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Heavy Menstrual Bleeding Guideline

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by Mona Kulkarni

mona.kulkarni@pemaweb.com

 

Case: 15-year-old otherwise healthy adolescent presents to your office complaining of a menstrual cycle lasting longer than 10 days. She has been changing her sanitary pads hourly at times and passing heavy clots.  Now she’s feeling a bit dizzy.

What is the work up that we need to do?  The Heavy Menstrual Bleeding guideline was created by our team to help guide us in the evaluation.

Heavy Menstrual Bleeding (HMB) is one of the most common adolescent gynecology complaints we see in the ED.  The differential diagnosis is broad including anovulatory cycles, hypothyroidism and underlying bleeding disorders (up to 20% of cases). The importance of early recognition and determination of the underlying cause can positively impact the teen’s quality of life, school attendance and sports participation.

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Behavioral Health ED Visit: Expectations and Limitations

 

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By: Kristin Weinschenk, MD and Michael Lowley, MD

Kristin.Weinschenk@choa.org

The primary goal of the psychiatric evaluation in an ED setting is to assess the safety of the individual, and to connect them with resources at the appropriate level of care. This begins at triage with a screening tool called the ASQ (Ask Suicide-Screening Questions to Everyone in Medical Setting), a five-item questionnaire which flags patients for risk of recent or current thoughts of self-harm. A positive screen will then trigger referral for amore detailed evaluation by either the psychiatric social worker in the ED, or by a member of the Psychiatry Consult Liaison service. The MH professional will conduct a psychosocial assessment, and complete a more detailed suicide risk assessment tool called the BSSA. Once level of risk is established, the treatment plan will reflect the need for appropriate safety and monitoring, whether at an inpatient psychiatric hospital or in a less restrictive care setting.

 

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Head Injury Update 2018

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By Micheal Greenwald

mgreenw@emory.edu

Research continues on a number of fronts regarding head injury evaluation and management.  Below are highlights from 2 of these articles and a summary of a recently published set of guidelines from the CDC.  The articles were exceptionally large studies that pertain to important factors in deciding when to use CT in evaluation of head injury in children. The CDC guidelines explain levels of evidence for a variety of issues regarding diagnosis, prognosis management and treatment of concussion.

Vomiting as a predictor of intracranial injury1

This large sampling (19, 920) of pediatric head injury patients in Australia and New Zealand (2011-14) looked at association of clinically important TBI (ciTBI) and vomiting.  This study supports previous research showing that vomiting is common following head injury, especially under 2 years of age; however, vomiting is rarely an independent predictor of ciTBI.

Patients with skull fractures, altered mental status, and headaches more likely to have ciTBI with vomiting (OR 80.1; 95% CI 43.4–148.0; OR 2.4; 95% CI 1.0–5.5; and OR 2.3; 95% CI 1.3–4.1, respectively).

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Fever and Limp-Review of Children’s Musculoskeletal Guidelines

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BY Mike Mallory

michael.mallory@pemaweb.com

 

A 3-year-old comes to your office with a fever and a limp.  Parents noticed a little discomfort yesterday, but it’s worse today and now the child doesn’t want to bear weight.  What is the work up that we need to do?  That is the question that the recently finalized Musculoskeletal (MSK) Infection clinical practice guideline attempts to answer.

The first question that the guideline asks us is to determine our level of suspicion for risk of MSK infection.  The following historical and exam features should raise suspicion of MSK infection.

History:

Pain, fever, inability to bear weight, gait disturbance/limp, limited use of extremity, immobility of extremity, travel to area with endemic Lyme disease.

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Asking Saves Kids

Kiesha Fraser Doh, MD
kiesha.fraser @emory.edu

 

As of June 14th there have been 23 school shootings this year!  A total of 1,392 children have been killed or injured by firearms. In comparison during the influenza season from October 2017 to May 2018 a total of 172 children died. [1]This year of 2018 has been especially deadly for children, with 547 firearm deaths this year. [2]Thus more children died from firearm injuries this year compared to influenza deaths despite frequent media reports about influenza death compared to firearm injuries.

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Opioid Policies and Pediatrics: When the Pendulum Swings Children Will Get Hurt

Mike Greenwald, MD
mgreenw @emory.edu

 

 

 

 

 

 

Even if you have turned off all news sources over the past 2 years it would be hard to escape the urgent alarms regarding opioid misuse in the US. The statistics are remarkable.

  • Since 1999, overdose deaths involving opioids quadrupled.1
  • 2000-2015:greater than half a million people died from drug overdoses.
  • 91 Americans die every day from an opioid overdose.
  • 1999 to 2010: number of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled.2,3

This is compelling evidence that we have a problem – perhaps some more than others.  Opioid addiction is a frequent challenge for those caring for adults in the Emergency Department with some centers (e.g. rural) seeing more of this than others. Those who care for injured and ill children are left with 2 important questions: (1) What is the evidence regarding opioid addiction in children? (2) To what extent is the management of acute pain in children contributing to an increase in opioid related morbidity and mortality?

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