Monthly Archives: March 2017

ED Usage Tips

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(ways to make things easier for your patients when referring them)

 

* Utilize CHOA App for ED/urgent care wait times

* Encourage patients to utilize MyChart to see labs

* If sending patient for a procedure, for ex: abscess drainage, fracture reduction keep them NPO

* ALWAYS call transfer center before referring a patient

* Hughes Spalding is different: no access to surgeons, no ICU, no 24 hour ultrasound, no MRI, minimal subspecialists-Hematology and the O’s (Opthalmology, Non-surgical Orthopedics, Oral Surgery)

* When referring a patient leave a cell phone number to contact you and update your colleagues on patients being referred to the ED

* Labs and X-rays can be done at the hospital as outpatients with an order from you – the patient doesn’t have to come via the ED unless you also want them seen by an ED physician.

* Respiratory viral panel testing is generally not indicated for previously healthy children in whom treatment for influenza is not necessary (or can be done on clinical grounds)

To Tamiflu or Not to Tamiflu?

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shpic

Sherita Holmes, MD sherita.holmes@emory.edu

Every year we expect a flu epidemic which usually starts in the fall and lasts until spring (as early as October and last until late May).  According to the most recent CDC Weekly U.S. Influenza Surveillance Report (week 8 – February 25th), flu activity remains elevated in the United States; although it appears to be downtrending.1
We know that in a majority of patients; the flu manifests as a nuisance that causes our patients to have high fevers with self-limited respiratory symptoms, fatigue, and myalgias. However, we also know that in the very young (age < 2 years) or very old (age > 65 years) as well as those with underlying medical conditions (i.e. asthma, immunosuppression, diabetes, heart disease) [see Table 1]; the flu can be fatal. This flu season there have been 40 pediatric deaths reported thus far [Figure 1].1 This underscores the importance of prevention and why it is critical that we encourage flu vaccination, especially in these high risk groups.

 

While vaccination is important in preventing influenza, we can use antiviral medications to shorten the length of illness (by 1-2 days), reduce complications such as pneumonia, and lessen severity.2 Antiviral medications should be started as soon as possible – ideally within the first 48 hours of illness – for any patient with suspected or confirmed influenza who: has severe, complicated, or progressive illness; is in a high risk group; or is hospitalized.3 Consider chemoprophylaxis in patients in high risk groups with known exposure to influenza.

 

There are two classes of antivirals for influenza: neuraminidase inhibitors (oseltamivir, zanamivir) and adamantanes (amantadine, rimantadine). The adamantanes are not effective against influenza B and there are high levels of resistance against the current influenza A viruses. For 2016-2017 flu season, the CDC only recommends using the neuraminidase class of antivirals. Oseltamivir (Tamiflu) is available in pill or liquid form, while zanamivir (Relenza) only available in inhaled form. Please refer to Tables 2 and 3 for further information regarding antiviral medication age designations, contraindications, adverse effects, and dosages.3,4

 

In the battle against influenza, we must do our best to not only identify the appropriate patients that would benefit from antiviral medications, but most importantly to encourage all patients and their loved ones to get vaccinated.

 

 

 

 

CDC https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm

Table 3 Harper et al. https://doi.org/10.1086/598513

 

 

 

 

 

References:

 

  1. CDC Weekly U.S. Influenza Surveillance Report

https://gis.cdc.gov/grasp/fluview/flu_by_age_virus.html

 

  1. Campbell, Angela. CDC Expert Commentary 2016-2017 Influenza Antiviral Recommendations

http://www.medscape.com/partners/cdc/public/cdc-commentary

 

  1. Centers for Disease Control (CDC) and Prevention 2016-2017 Flu Season

https://www.cdc.gov/flu/about/season/current.htm

 

  1. Harper, S.A., Bradley, J.S., Englund, J.A., et al. Seasonal Influenza in Adults and Children—Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America

https://doi.org/10.1086/598513

Pediatric Appendicitis Practice Guidelines

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Reena Blanco, MD
rnarwan@emory.edu

Alesia Fleming, MD, MPH
aflemi2@emory.edu

 

Acute appendicitis is the most common, non-traumatic surgical emergency encountered in children. Early identification can lead to timely removal preventing perforation and its complications.  Abdominal pain is a common symptom in the emergency department.  To help differentiate the surgical from medical emergencies, CHOA emergency medicine, surgery and radiology teams collaborated to develop the suspected appendicitis clinical guideline.

The broad goals of the team were to:

  • Identify children with the highest risk of appendicitis
  • decrease utilization of abdominal CT to diagnose appendicitis
  • Increase utilization of the Pediatric Appendicitis Score (PAS).
  • Streamline and standardize clinical evaluation
  • Decrease time to diagnosis and definitive care

 

The guideline was implemented in 2013 using the PAS as a common language tool to better communicate across services.  Patients 5 years and older with abdominal pain for less than 72 hours** suspected of having appendicitis are evaluated according to the pathway with screening labs, given an initial IV fluid bolus and pain medication.  After this, the PAS score is calculated and used to further guide care and communicate across services for next steps.

Patients with a PAS of 0-4 have a low suspicion for appendicitis. The physician should consider other diagnoses. There is always a risk that the patient may develop further symptoms as disease progresses therefore if discharged home, these patients need to be seen by their PCP within 24 hours for re-evaluation.

A PAS of 5-7 is equivocal for appendicitis and diagnostic imaging or surgical consult is warranted.  The guideline promotes US as the exam of choice for initial evaluation.  Ultrasound has a sensitivity is 98% and specificity is 92% in identifying appendicitis in those where the appendix was clearly seen. In addition to eliminating exposure to ionizing radiation ultrasound can evaluate female patients for ovarian torsion which is part of the differential of appendicitis.  The exact correlations between radiation exposure and cancer in children is not known, and utilizing alternative imaging modalities such as ultrasound limit exposure to ionizing radiation.

If the patient has a PAS >8 there is a high suspicion for appendicitis, imaging is not required, and surgery should be immediately consulted.

The guideline does not represent a professional care standard and physicians will need to be prudent in determining most appropriate care, but it does offer an approach to abdominal pain that should help with efficiency of care and ultimate outcome of our patients.

 

**exclusions outlined in clinical practice guidelines on md.choa.org under

clinical excellence->clinical practice guidelines