The story of Pediatric Emergency Medicine at Emory University and Children’s Healthcare of Atlanta at Egleston and Hughes Spalding

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by Wendy Little (wendalyn.little@emory.edu)

Children’s Healthcare of Atlanta is one of the largest and busiest pediatric healthcare systems in the United States. The three CHOA emergency departments collectively encounter over 200,000 visits per year and the hospitals, with their full complement of pediatric subspecialty providers, care for some of the sickest and most medically complex patients in the state and the region. While specialized pediatric healthcare in Atlanta dates back to the early 1900s, there were no pediatric emergency departments and no pediatric emergency specialists in Atlanta until the mid 1980’s The growth of emergency medical care for children in Atlanta over the past 30 years has been phenomenal! Continue reading →

Simple Abscess Clinical Practice Guideline

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By Rebecca Burger (beckyburger@emory.edu)

In the emergency department we implemented a simple abscess Clinical Practice Guideline (CPG) almost one year ago. Here is some key information about the CPG and about loops.

Which patients require I&D in the ED?

Abscess ≥ 1cm in diameter. Smaller abscesses may be lanced with a scapel after LMX is applied.

Continue reading →

CHOA Diversion Policy-Reminder and Updates

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I hope that the winter season is going well for you.  We all know this is our busiest season of the year.  I just wanted to update you all about winter related changes.

Due to the high volume of patients we are currently seeing in our Children’s Healthcare of Atlanta Hospitals we are currently on a diversion for patients aged 15 and older who have not previously established care with one of our clinics. If your patient presents to the ED without a referral and they are over 15 they will be evaluated.  We have an agreement with Dekalb Medical Center who has agreed to accept patients of this age for admission.

As always if you have a patient who is under the age of 15 and you would like to send them to CHOA to be seen please call the transfer center at 404-785-7778 and update them on your concerns and evaluation recommendations. Please always take the time to call the transfer center if you are referring a patient this helps us to identify your concerns and alleviates the confusion when families say my pediatrician sent me but are unclear of the reason why. If you are a pediatrician and would like to speak with an pediatric emergency medicine physician you can also upon request be transferred to one of us. If you would like a call back please specifically indicate that to the transfer center and give a number that is reliably answered such as a cell phone number or backline number.

Updates:

  • Our PEMCONNECT newsletter will be published quarterly from this point on.
  • We will send email updates via our ED outreach listserve
  • In an effort to obtain important information about community pediatric practices please look out for an email survey via the listserve in the new year-2016!

Have a blessed holiday season and Happy New Year.  We hope to visit more of your practices and Emergency Departments next year.

Baby it’s cold outside!” – A look at Winter Safety and Injury Prevention

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By Sofia Chaudhary

SCHAUD3@emory.edu

As the temperature drops and winter sets in, let’s remind families to keep their children safe.
Carbon monoxide-The invisible gas that kills
According to the CDC, there are around 15,000 ED visits and 500 deaths annually due to unintentional, non-fire related carbon monoxide (CO) poisoning.  There is a steep rise of these incidents during the months of November to February every year. These CO poisonings can be easily prevented with proper vehicle, appliance, and heating system maintenance along with education on correct usage of heating and cooking devices.  The National Poison Data System shows that the home is the primary site for carbon monoxide exposure with the second most common site being the workplace. Children in comparison to adults can develop carbon monoxide poisoning more rapidly due to faster respiratory rates and increased oxygen utilization.
So what happens when one inhales this odorless, tasteless gas? In brief, CO rapidly crosses our body’s capillary membrane and displaces one oxygen molecule from hemoglobin, binding more than 200 times as strong to the hemoglobin and reducing the ability of the remaining oxygen molecules to be released.  Oxygen delivery to peripheral tissues is reduced. In addition, CO can disrupt cellular respiration, worsening oxygen utilization and displaces nitrous oxide from proteins causing vasodilation.  The CDC reports that an elevated carboxyhemoglobin (COHb) level of 2% in a nonsmoker and 10% in a smoker suggests CO poisoning.  The clinical status of a patient, however, is a more accurate depiction of the severity of illness after CO exposure.  The most common symptoms of carbon monoxide poisoning include headaches, dizziness, nausea, or vomiting and can often be misdiagnosed as a viral illness.  Infants may present with fussiness or irritability.  More severe poisoning and prolonged exposures can cause confusion, ataxia, altered mental status, coma, arrhythmias, myocardial ischemia or infarction, lactic acidosis, metabolic acidosis, acute renal failure, or non-cardiogenic pulmonary edema.
Prevention strategies for CO poisoning:
• Install carbon monoxide detectors with a back up battery on every level in your home, at least 15 feet away from fuel burning appliances.  Be sure to have one near all separate sleeping areas.
• Check your CO detectors twice a year, when you change your clocks in the spring and fall.  Remember these detectors do not take the place of your smoke alarms- you can often find dual detectors.
• If the CO alarm goes off exit the home immediately and call for help.
• Do not use charcoal grills, generators, camping stove, gasoline powered tools or pressure washers inside the house, the garage, or near the windows. Generators should be outside and 20 feet away from all windows, doors, and vents.
• Have water heater, gas clothes dryer, and gas stove serviced by a technician once a year or as recommended by manufacturer.  All vents for these appliances should be kept clear and free from debris.
• Have heating system/furnace checked annually and make sure the pilot light is working properly.  Have the chimney for fireplaces cleared and checked annually to prevent debris buildup with subsequent CO retention.
•Do not keep your car running inside the garage, even if the garage door is open.  Have your car’s vehicle emission system checked annually.
•Do not use your gas stove to warm the house.
Treatment of CO poisoning starts with removal from source of CO.  Supportive care is given in the ER with 100% oxygen non-rebreather mask until the patient is symptom free, usually after 4 to 5 hours.   Contact poison control to report incident and receive additional support. Labs are drawn to check COHb level and lactate level (for closed house fires), and EKG for severe poisonings. Elevated lactic acid levels > 10 mmol/L correlates with elevated cyanide levels and cyanide antidotes should be given. Patients with altered mental status or presenting in a coma are intubated and given 100% oxygen.  Hyperbaric oxygen is reserved for severe CO poisonings, those presenting with altered mental status, loss of consciousness, COHb levels of 25-30%, showing signs of cardiac disease, or with acidosis.  Of note, discharged patients are given instructions to be aware of delayed neurological presentations up to 48 hours after initial exposure and are asked to follow up with PCP 2 weeks after initial exposure for repeat physical and neurologic exam. (Figure 1)

How much is too much?

Bundling kids this winter while riding and resting, we all have worn those “poofy” winter jackets growing up or my ultimate favorite, the bunny suit! Unfortunately, most parents are not aware that what may keep their child warm may also cause injury when worn while sitting in a car seat or booster seat.  The issue lies with the ability of these coats and jackets to be compressed when there is an impact and thus creating space between the child and seat belt harness.  This additional space can propel the child forward causing additional external and internal injury in addition to some children falling out of the harness itself.   Coats and jackets should be removed upon placing a child in a car or booster seat.  It is safe to wear sweatshirts and sweaters that children would wear while playing indoors or place a blanket or jacket on child’s lap away from face and over seatbelt.  To make sure that the car seat straps are not too loose over the child’s body, parents should do the pinch test.  With the harness pulled tight and the chest clip at the level of the armpit pinch the strap with the thumb and index finger at the level of the collarbone (see below-Figure 2).  If the strap webs in between the thumb and index then the straps are too loose, if no webbing then the straps are tight enough.  If parents want to do the pinch test with thin jackets or to check the safety of their child’s outer layers they should tighten the harness with the outer layer on then remove outer layer and buckle the child again doing the pinch test to see if any extra space was created by this outer layer.
Parents of newborns and infants may want to bundle their little ones in thick blankets or wraps to stay warm.  Unfortunately as we know this can increase the risk for suffocation by direct obstruction or by reducing air flow in the space around child’s mouth and nose. A newborn has a tidal volume of approximately one ounce-leaving very little reserve. Parents should be reminded to place their child on their backs on a firm crib mattress with a tight fitted sheet without any additional items in the crib including stuffed animals or bumpers.  Sleep sacks are a snug fitting and safe option for babies to keep warm.  We also see a rise of suffocation or SIDS during these cold months from co-sleeping.  Parents may not realize that it is not only rolling over their child that can cause suffocation but even if something as simple as their arm falling onto the babies face.  One option may be to have the crib in the same room as parent if they want to stay close or to use a pack and play in the room with a newborn top mattress section so that it is easy access for mother to reach over to pick up her child.  Enjoy the holiday and winter season we hope these few reminders can help you keep your patients and families safe!

 

 

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(Figure 1-Source CDC)

Seatcheck

(Figure-2 Pinch Test-SAFEKIDS.ORG)

Antibiotic Stewardship

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By Lekha Shah

lashah@emory.edu

Jenna Wade, a feisty 17-month-old toddler, presents the ER because her mom found a swollen, red, tender area on her right buttock today after she spiked a fever. On clinical exam, she has a soft tissue abscess. She will require Incision & Drainage (I&D) under procedural sedation. Her distraught mother asks, “How did this happen?” and “What can I do to prevent this next time?”

We are largely to blame for the current epidemic increase in MRSA. Abscesses and cellulitis from CA-MRSA (community acquired MRSA) are routine, rather than rare. Many pediatric providers have memorized the dose and concentration of Bactrim and Clindamycin suspensions. CA-MRSA is so widely prevalent in the US that the CDC’s Choosing Wisely campaign now recommends against the routine use of wound culture; instead soft tissue infection should be presumed be due to MRSA or S. pyogenes. Many CHOA PEM physicians sedate for I&D approximately once (or more) per shift per provider and treat MRSA-associated cellulitis on a daily basis.

What is the scope of the antibiotic overuse problem? The antibiotic prescribing rate for children under age 2 years exceeds that of elderly adults over 65 years! Acute viral respiratory infections (e.g., sinusitis, acute bronchitis, viral pharyngitis, and otitis media) account for 75% of antibiotic prescriptions written for children, mostly under 2 years of age. According to a large UK database analysis of 3.4 million respiratory infections (excluding pneumonia) treated with antibiotics, the number need to treat (NNT) to prevent 1 complication was > 4000 (Peterson).

Regarding more serious adverse events, a recent CDC analysis found 944 pediatric Clostridium difficile infections in the US in 2010-11. Of the community acquired C. difficile isolates, 71% occurred in infants. Horton, et als’ study in the May issue of Pediatrics, found a dose-dependent association between antibiotic exposure and onset of Juvenile Idiopathic Arthritis compared to age-matched controls.

From the ER perspective, adverse events attributable to antibiotics account for >142,000 ER visits/per year in the US. Allergic reactions account for four-fifths of these ER visits; the most common culprit drugs are penicillins and cephalosporins. These are bread-and-butter drugs in any pediatric practice.

Many of our patients, and perhaps some of us, believe that antibiotics are benign, but consider this statement in an opinion piece by Linder regarding antibiotics in acute URI treatment: “For your infection, there is ~1 in 4000 chance that an antibiotic will prevent a serious complications, a 5-25% chance that it will cause diarrhea, and an ~1 in 1000 chance that you will require a visit to the emergency department because of a bad reaction to the antibiotic.”

For further information, please visit the CDC Get Smart: Know When Antibiotics Work website at http://www.cdc.gov/getsmart/week/partners/partners.html.

Community Acquired Pneumonia Guidelines

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By Sam Spizman

samuel.spizman@emory.edu

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Recently, CHOA put together a task force to review the evaluation and treatment of pneumonia. Members included representatives from both inpatient and outpatient care areas. The goal was to provide a more consistent and evidence-based approach to treatment. Based on their review, CHOA implemented a guideline for simple pneumonia in December 2014. The guidelines are available on the new MD portal. The key points are discussed below:

There are some exclusion criteria. The guideline excludes neonates and complex patients with comorbidities. Examples include:

  • Infants <2 Months Of Age
  • Immunocompromised
  • Cystic Fibrosis
  • Nosocomially Acquired Pneumonia (>48 Hrs)
  • Moderate To Severe Effusion, Empyema/Abscess, Necrosis
  • Multilobar Pneumonia · Suspected Aspiration Pneumonia
  • Medically Complex Patients

This last criterion is clinically subjective.

The admission criteria are listed as the following:

  • Signs and Symptoms Of Respiratory Distress (note: pulse ox of 90% acceptable for outpatient management)
  • Vomiting/poor PO/dehydration
  • Inability To Manage Patient At Home
  • Failed Outpatient Therapy
  • Consider If ≤ 6 Months With Lobar Consolidation

These are not all inclusive and we welcome any phone conversation to better take care of your patient.

One of the main goals for the taskforce was to recommend antibiotic therapy for both outpatient and inpatient treatment. Literature reviews still show that the most common etiologic bacterial organism is pneumococcus (for simple lobar pneumonias without effusion or empyema). Staph aureus and Strep pyogenes are considerations, but are less prevalent.

Strep pneumoniae continues to show susceptibility to penicillins. Because of this, Amoxicillin is the recommended first-line antibiotic of choice. The recommended daily dosing is that of high-dose Amoxicillin (90-100mg/kg/day) as in the treatment of otitis media. It is recommended to divide this into 3 doses, not 2. The literature to support this says that the required MIC (mean inhibitory concentration) for pneumococcus is 2mcg/ml. While both bid and tid dosing achieve adequate peaks, bid dosing achieves only a 65% cure rate while tid dosing achieves a 90% cure rate. The implication is that bid dosing results in the MIC falling below 2mcg/ml in some patients, resulting in treatment failures.

For inpatients, recommended IV therapy is Ampicillin until the patient meets discharge criteria.

In the case of true penicillin allergy, the recommended treatment is clindamycin for outpatients and ceftriaxone or levofloxacin for inpatients.

Lastly, treatment to cover atypical pneumonia (Mycoplasma) is not recommended unless the patient is failing outpatient therapy.

Take- home points:

– Amoxicillin and Ampicillin are the first-line recommendations for simple CAP

– High-dose Amoxicillin should be divided into tid dosing

– We all probably utilize too much Rocephin and Augmentin for CAP

Please refer to CHOA MD portal: md.choa.org to review this and other CHOA Guidelines

Bronchiolitis Update 2015

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By Maggie Kilgore and Javier Tejedor-Sojo

Margaret.Killgore@choa.org

javier.tejedor-sojo@choa.org

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As we move into bronchiolitis season, we wanted to remind you all of the new recommendations for inpatient and outpatient bronchiolitis treatment published by the AAP in 2014. These new recommendations were incorporated into Children’s Healthcare of Atlanta’s updated guidelines in the fall of 2014. Bronchiolitis is one of the top three admission diagnoses at Children’s. The 2014 Children’s guideline fosters patient-centered, value-based outcomes, more closely supports evidence-based therapies and interventions, and recommends that care providers deliver a consistent message to families.

Some of the key elements of the 2014 AAP guideline are that:

  • Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Chest X-Rays or laboratory studies should not be obtained routinely
  • Clinicians should not routinely administer albuterol or epinephrine to patients with a diagnosis of bronchiolitis
  • Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one
  • In infants with bronchiolitis, clinicians may choose not to administer supplemental oxygen if the O2 saturation exceeds 90%

It can be difficult to explain to families that the best treatment for their child is supportive care. The evidence and the new recommendations support that supportive care is what patients benefit from the most. In regards to albuterol, current recommendations discouraging its use in bronchiolitis are derived from the 2010 Cochrane review which included 10 inpatient and 10 outpatient trials. There was no statistical difference in the rate of hospitalization, length of hospitalization, oximetry nor time to resolution of illness at home between albuterol and placebo treated children. Some brief improvement in clinical respiratory scores was noted among outpatient and hospitalized patients but the standard mean difference was very small and no impact on clinical care would be expected.

There may be a sub-group of children with an underlying predisposition to asthma who may exhibit a response to albuterol. These children are generally older (>12 months) and have either a previous history of wheezing or atopy or a strong family history of asthma in first degree relatives. In the bronchiolitis guideline, these children may receive a single trial of albuterol without other concurrent interventions to determine whether they exhibit a positive clinical response to it. If they indeed have a positive documented response to albuterol these children would be managed under the ED/Inpatient asthma pathway.

Families should be educated that bronchiolitis is a disease that may last for two to three weeks. Many parents present for care because they are concerned their child is not feeding as usual. During the acute illness it is common and expected that children will feed less than their baseline. We need to help parents understand that if their child can sustain their basic fluid needs (even if they take sometimes half of what they typically drink), they are not likely to get dehydrated. Patients who maintain saturations >90% on room air, are able to handle secretions, and can maintain acceptable hydration and activity can generally be treated at home with supportive therapy.

On October 1, 2014 Children’s implemented the guidelines in the ED, Urgent Care, and Inpatient Settings. During the Sept 2014—April 2015 season, we decreased albuterol usage in 1-12 month olds with bronchiolitis from 45% to 25% in the ED and from 40% to 11% for patients who were admitted. We were able to achieve these results without negatively impacting our length of stay or 7 day readmission rate. Reducing the use of therapies that have not demonstrated benefit to our patients and helping them return home sooner if medically stable, is an example of delivering value to them and their families.

If there are any questions about the guideline, feel free to contact :

Dr Shabnam Jain sjain@emory.edu

Dr Tejedor-Sojo  javier.tejedor-sojo@choa.org

Please see the link below to the clinical guideline page on the physician portal for access to our guidelines, link to the AAP 2014 recommendations, and see Children’s full evidence summary that is posted on the physician portal:

https://md.choa.org/clinical-excellence/clinical-practice-guidelines/bronchiolitis