Skin and Soft Tissue Guideline

By Preeti Jaggi

Most antibiotics are prescribed in the outpatient setting and there are many opportunities for optimizing antimicrobial prescribing in this setting. Skin and soft tissue infections (SSTIs) are common presenting complaints in emergency department.  Infectious Disease Society of America guidelines recommend 5 days of initial treatment for non-purulent SSTI. In addition, randomized controlled trials have shown that cephalexin vs. both trimethoprim/sulfamethoxazole and cephalexin (to treat for presumed methicillin resistant Staphylococcus aureus as well as Group A streptococcus) are equally effective for non-purulent SSTI. This implies that cephalexin alone can be used for patients without abscesses. For patients presenting with purulent SSTIs, recent studies have shown comparable cure rates when trimethoprim/sulfamethoxazole or clindamycin are used for 7 instead of 10 days following I&D. 

In our system, we have found a wide range of variation in the outpatient management of SSTIs for both antibiotic choice and duration of treatment. For both purulent and non-purulent SSTIs, clindamycin or trimethoprim/sulfamethoxazole were generally being prescribed for 10 days, a longer duration than recommended. In a recent quality improvement project, we were able to improve antibiotic prescribing for both purulent and non-purulent SSTIs. Exclusion criteria were patients with impetigo, paronychia, preseptal and orbital cellulitis, cephalosporin allergy, and inpatient admission. 

Submersion Injury Guidelines

By Sarah Lazarus

Every summer, there are many articles and news reports of drownings. Some of these reports use terms that are outdated, such as delayed drowning, “dry” drowning, and near-drowning. The World Health Organization (WHO) defines drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid.

  Any submersion or immersion incident without evidence of respiratory impairment should be considered a water rescue and not a drowning. Drowning remains a large cause of morbidity and mortality in children. Drowning is the leading cause in ages 1-4.  At least 10 people die from drowning daily. 

CHOA Constipation Guideline

By Beesan Agha, MD








Constipation is a common problem throughout childhood and affects up to 30 percent of children and accounts for an estimated 3 to 5 percent of all visits to pediatricians.1 Early intervention is key to avoid complications such as anal fissures, stool withholding, fecal incontinence (encopresis), and psychosocial consequences. This guideline represents a collaboration of several specialties including pediatric emergency medicine, urgent care, and gastroenterology with the goals of:

  • Understanding the diagnostic criteria for functional constipation
  • Being aware of red flags that may indicate organic causes of constipation
  • Establishing a uniform process for the evaluation and management of constipation
  • Decreasing utilization of abdominal x-rays to diagnose constipation

Patients >1 month of age who meet the diagnostic criteria for functional constipation are included in the guideline.

Diagnostic criteria for functional constipation must include TWO or more of the following:

  1. Two or fewer defecations per week
  2. At least one episode per week of incontinence after the acquisition of toileting skills
  3. History of retentive posturing or excessive stool retention
  4. History of painful or hard bowel movements
  5. Presence of a large fecal mass in the rectum
  6. History of large diameter stools which may obstruct the toilet

Functional constipation is responsible for more than 95% of cases of constipation in healthy children one year and older.2 Although constipation is common, it is still important to evaluate children and be diligent to identify the few that have organic causes of constipation. Some red flags that should raise your suspicion to a possible organic cause include:

  • Midline dimple; Tuft of hair over lower back
  • New onset lower limb weakness/motor delay
  • Signs of systemic illness: fevers, mouth sores, joint pain, rash
  • Weight loss
  • First passage of meconium after 48 hours of life
  • Persistent abdominal distension/vomiting
  • Bloody diarrhea
  • Bilious emesis
  • Failure to thrive, Malabsorption
  • Tight rectum gripping finger; explosive stool/air from rectum upon withdrawal of examining finger
  • Family history of Hirschsprung’s disease

The treatment of functional constipation begins with determining whether the patient has fecal impaction. If fecal impaction is determined by a digital rectal exam it recommended the patient receive a glycerin suppository for children <1 year of age and a soap suds enema for children >1 year of age. Enema dosing can be found in the guideline.

Upon discharge the patient will receive education on appropriate dose and home use of miralax to continue the treatment of constipation as an outpatient. These recommendations are included below:

1-3 years old

Cleanout: Take 1 capful (17 grams) Miralax every day for 3 days in 8 oz. of juice

Maintenance: On day 4 take ¼ capful (4.25 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/8 capful but do not stop taking  

4-5 years old

Cleanout: Take 2 capfuls (34 grams) Miralax every day for 3 days in 16 oz. of juice Maintenance: On day 4 take ¼ capful (4.25 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/8 capful but do not stop taking

6-11 years old

Cleanout: Take 7 capfuls (119 grams) Miralax for 1 day in 32 oz. Gatorade

Maintenance: On day 2 take ½ capful (8.5 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/4 capful but do not stop taking

12 years and older

Cleanout: Take 14 capfuls (238 grams) Miralax for 1 day in 64 oz. Gatorade

Maintenance: On day 2 take 1 capful (17 grams) Miralax daily in at least 8 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/2 capful but do not stop taking

  • Encourage fluid intake (especially during cleanout)
  • Referral to PCP in 2 weeks. Continue maintenance dosing until seen by PCP

The constipation guideline can be accessed on CHOA Physician Portal:

Under clinical excellence clinical practice guidelines

  1. Epidemiology of childhood constipation: a systematic review.

Van den Berg MM, Benninga MA, Di Lorenzo C

Am J Gastroenterol. 2006;101(10):2401.

  1. Prevalence, symptoms and outcome of constipation in infants and toddlers.

Loening-Baucke V

J Pediatr. 2005;146(3):359


ED Guidelines on Child Sex Trafficking and Exploitation

Greenbaum 2014

by Jordan Greenbaum, MD

The number of cases of suspected sex trafficking seen in Children’s emergency departments (ED) is steadily rising.  This is largely due to improved recognition by law enforcement and the implementation of a community protocol that directs authorities to bring newly identified victims to a Children’s emergency department for immediate medical evaluation.  Between 2014 and 2015, 92 medical exams were completed in the 3 EDs.  In response to the increased awareness of this vulnerable group of youth, Children’s has implemented guidelines for recognizing and responding to suspected cases of child sex trafficking and exploitation.  The guidelines are the product of a multidisciplinary collaboration between providers at the Stephanie Blank Center for Safe and Healthy Children (SVB), and staff from a variety of Children’s departments, including the multiple EDs. Along with a comprehensive overview of sex trafficking, including definitions, potential indicators and detailed instructions on making reports to authorities, the guidelines provide flow diagrams for recognizing and responding to suspected cases.

In the Emergency Departments, providers are asked to consider the possibility of sex trafficking if a child > 11 years old presents with chief complaints of:

  • Vaginal or penile discharge
  • Requests for STI or pregnancy testing
  • Intoxication or ingestion
  • Suicide attempt
  • Clearance exam for the Division of Family and Children’s Services (DFCS)
  • Acute sexual assault

OR, child has

  • History of running away from home
  • An injury that is suspicious for being inflicted

If these or other concerns are noted, staff should request a social work consult.  The social worker will use the Short Screen for Child Sex Trafficking (also included in guidelines) to further assess for possible victimization.  If staff continues to have concerns, they should contact the Child Protection team by calling the Transfer Center.  A trained nurse practitioner from the SVB Center is available anytime of day to come to the ED to conduct a medical evaluation.  Social work will contact law enforcement, DFCS and Georgia Cares.  The latter is an organization that serves as the entry point for services for child trafficking victims.  Upon notification, staff from Georgia Cares will begin an evaluation and work with authorities to determine post-discharge housing, and further referrals.

Should a child protection on-call nurse practitioner not be available, the guidelines include detailed discussions related to issues of confidentiality and assent, obtaining a medical history and prepping interpreters.  The medical exam protocol is also included, as are STI prophylaxis and HIV PEP guidelines. In addition, the on-call child protection team physician is available for phone consultation at anytime at 404-785-DOCS.



Simple Abscess Clinical Practice Guideline



By Rebecca Burger (

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

Community Acquired Pneumonia Guidelines

By Sam Spizman


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: to review this and other CHOA Guidelines