ED Rounds – Oral Rehydration in Children

Pediatric Dehydration and Oral Rehydration

ED Rounds Presentation by: Dr Paul Page


 

  • Volume Depletion (hypovolemia): refers to any condition in which the effective circulating volume is reduced. It can be produced by salt and water loss (as with vomiting, diarrhea, diuretics, bleeding, or third space sequestration) or by water loss alone (as with insensible water losses or diabetes insipidus).
  • Dehydration -refers to water loss alone. The clinical manifestation of dehydration is often hypernatremia. The elevation in serum sodium concentration, and therefore serum osmolality, pulls water out of the cells into the extracellular fluid.

American Family Physician article (2009) – Diagnosis and Management of Dehydration in Children


 


SJRHEM Guideline

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

 


View/Download Full Presentation below:

Download (PDF, 817KB)

Continue Reading

EM Reflections – March 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:

 


Vertebral Artery Dissection – a tricky diagnosis and potentially catastrophic if missed…

 

Consider dissection in vertigo patients even without history of significant or mild trauma.

Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Dizziness, vertigo, double vision, ataxia, and dysarthria are common clinical features. Lateral medullary (Wallenberg syndrome) and cerebellar infarctions are the most common types of strokes.

Diagnosis – CT Angiography

Treatment – Antiplatelet or Anticoagulation (unless contraindications – see article below)

Cervical Artery Dissection in Stroke Study (CADISS) trial, RCT – antiplatelets versus anticoagulants in the treatment of extracranial carotid and vertebral artery dissections (VADs) = no difference found in outcomes between groups receiving antiplatelets vs anticoagulants. CADISS

Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations – (full text)

Rounds Presentation by Dr Kavish Chandra (R2 iFMEM)

Download (PDF, 755KB)


 

Limping Kids – inability to weight bear is always significant…

Need for thorough investigation of non traumatic hip pain in child unable to weight bear. Don’t get biased with previous diagnosis even if by specialists.

Don’t miss – Septic Arthritis or SCFE


From – Orthobullets.com – Hip Septic Arthritis – Pediatric – Author:

See this SJRHEM ED Rounds on Limping Kids

Take home pearls:

  • A limping/NWB child that can crawl is likely to have pathology below the knee
  • Examine least likely source of symptoms first.
  • Flex, Adduct and Int Rot hip most likely manoeuvre to elicit pain in hip pathology
  • Children >8yrs – X-ray hip first
  • If fever (>38°) or > 24hrs then bloods (incl CRP)
  • CRP < 12 is very reassuring (and a high CRP mandates further Ix to rule out septic arthritis)
  • Positive ultrasound is most likely to be irritable hip
  • Negative ultrasound – X-ray leg

 

 

Continue Reading

RCP – To syringe or not to syringe, that is the question

To syringe or not to syringe, that is the question

Resident Clinical Pearl (RCP) – March 2017

Kalen Leech-Porter, PGY2 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis and Dr. Brian Ramrattan

 

Snapshot Summary:

Problem:

  • Parents often give their children the wrong dose of medications.

Solution:

  • Provide parents a syringe to draw up medications
  • Describe the amount of medication in mL, not teaspoons or cc’s
  • Make sure to give simple instructions

 


 

Preamble:

It is well known amongst health practitioners that accurate dosing in pediatrics is extremely important; even a small miscalculation can have catastrophic results, potentially even death. We double check and triple check our calculations to make sure we prescribe the correct weight based dose. This is an excellent practice, and one we should continue to be diligent with, but if we don’t give proper instructions to parents, our calculations will be in vain: in a recent study of parents observed preparing prescriptions for their children, 84% of them made a measurement error!

The Study:

Yin HS, Parker RM, Sanders LM, et al. Liquid medication errors and dosing tools: a randomized controlled experiment. Pediatrics 2016;138(4):e20160357.

In this randomized control study, 2110 parents were assigned to 5 different groups in an outpatient office setting.  All groups got the same prescription for amoxicillin, and the parents were observed preparing the medication for their children (three times).  The groups differed in the tools provided (measuring cup, syringe, or both) and how the units were described (mls, teaspoons or both).  (See below).

 


Results:

Across all groups, 84.4% of parents made at least one measurement error (at least a 20% under/over dose).  21% of parents more than doubled the prescribed dose. The group with the fewest errors was group I: when prescriptions were only written in mLs, and only a syringe was provided.  Using the measuring cup, 43% of parents made a dosing error compared to 16% with the syringes (p<0.001).

Parents with lower health literacy and from lower socioeconomic backgrounds were more likely to make mistakes, but like those with better literacy made fewer mistakes in the syringe only group versus the groups that included cups.

 

Conclusion:

When writing out pediatric liquid prescriptions, describe the medications in terms of mL and specify that the meds should be distributed with a syringe, or provide a syringe from the hospital.  This study did not demonstrate whether having practice draw up medications reduced errors, however it seems prudent to have health care workers observe parents give a first dose in the ED if time permits.

 

 


See the SJRHEM Tylenol and Advil dosing sheets on our Patient Information Leaflet page

 


 

Reference:

Abstract/FREE Full Text

Continue Reading

ED Rounds – February 2015

An enjoyable and informative set of presentations by Dr Ramrattan, Dr Talbot and Dr Greer
The presentations can be downloaded and reviewed from the CPD File Store (Rounds)

Dr Brian Ramrattan – Alphabet Soup

TREKK –  Translating Emergency Knowledge for Kids
To create a national network that is a trusted source for easy access to the latest evidence, best practices, user-friendly resources and discussions in pediatric emergency care. It will be created and used by health professionals and the families they care for and its work will drive the highest quality of health care for children and families seeking emergency care in Canada.
Their mission is to deliver the highest standard of care to every child, whether they choose to seek treatment in a pediatric or general emergency department
More topics on their website
The following were presented:
Bronchiolitis, Croup, Gastroenteritis
Bronchiolitis
  • Routine CXR not supported by evidence however need to take each case on its merits. If suspect pneumonia – CXR
  • NPA or CBC does not alter management
  • High risk groups – Prems, <3/12
  • Most can be discharged
  • Steroids do not reduce LOS
  • Epinephrine may reduce admissions on day 1 but there is no long term benefit
  • Bronchodilators are not effective in bronchiolitis
  • Steroids plus Epinephrine may reduce admission rates for up to 7 days, but not recommended routinely
  • Recommended- Oxygen and Hydration
  • Admission criteria – include unable to maintain sats > 90% without O2, Not feeding, increase WOB, Resp rate > 70
Croup
  • Worse at night
  • Usually improve on way to hospital
  • Clinical diagnosis
  • Febrile, bark, tachypnea
  • Westley Croup Score – may be useful for RT to do while observing child pending discharge
  • Lateral Neck X-ray may be helpful for retropharyngeal abscess, epiglotitis
  • Recommended – Steroids +/- Epinephrine (if need rapid Rx)
Gastroenteritis
  • ORT as good as IV Rehydration
  • Anti emetics lower need for admission and IVRT
  • Not enough evidence for probiotics
  • Consider weight in kg as ORT mL per 5 mins e.g. 10kg = 10mls per 5 mins
  • Ondansetron 8-15kg – 2mg 15-30kg – 4mg
Alberta – Vomiting and Diarrhoea Pathway

 

Dr Jo-Ann Talbot – Do We Choose CPD Wisely?

We are not very good at deciding what to focus on?
Continuum from competence to expertise
Scope of Practice will impact on how we choose our CPD
Why should we have-  Practice Assessment
  • Role in Feedback in identifying areas where our competency can be improved
  • Flaws in self assessment
  • Increasing expectation of the profession
Revalidation is comming…
  • Association of Canadian Regional Colleges have guidelines
  • ACEP – Exam, PAR, Lifelong learning, Patient Feedback etc
  • UK GMC –  system
How can we Improve – Where is the Gap?
  • Perhaps chart reviews
  • Review M&Ms and complaints
  • Are there common things that we do that say if we are a safe doctor?
Needs Assessment Triangulation
  • Synthesis and integration of data from multiple sources
  • Narrow down to the most important problems
  • Assessment
    • Knowledge – e.g self assessment
    • Performance assessments – Sim, Audit, 360, Teaching
  • “How do we know if we are providing excellent care?” – Group discussion – suggested ways below
    • Informal follow up
    • CQI chart audits
    • Bounce backs
    • Procedural audits
    • External chart review
    • M&M’s
    • Trauma Charts
    • Should we get the discharge summary
    • Letters from clinics
    • But what is excellence?
      • Combination of knowledge, skill, implementation, communication
      • We are the experts in Emergency Care – we should set the standards.

 

Download (PDF, 5.91MB)

Dr Matt Greer – Turn it up to 11. LP in the Diagnosis of SAH

  • 1% Headaches = SAH
  • 14% of ED Headaches get CT (US Stats)
  • Unenhanced CT is 100% sensitive < 6hrs
  • Xantho is only useful >12hrs  but < 2weeks (this is now debated – see presentation for details)
  • Type and Location of pain has no predictability for cause
  • Do we still need to LP after CT – ( answered in the presentation)
  • No Gold standard
  • But CT plus LP had been considered standard for early studies
  • LP’s are hard to interpret
  • Unenhanced CT performed < 6hrs – 100% sensitivity
  • Need 3rd generation CT Scanner
  • Need Radiologist – who is routinely reading Head CTs
  • LP – most sensitive >12hrs  and < 2 weeks
  • Xanthochromia determined the positive result
  • But Xanthochromia may not be such a good gold standard?
  • Why  not just do CTA
  • But 2-5% have aneurysm in population
  • So which ones do you treat?
Continue Reading

DEM Rounds – October 14th 2014

A big welcome to our nursing / nurse practitioner colleagues at todays rounds. Recent attendance at m&m’s and rounds has been increasing significantly, and a larger venue may soon be required! Just a reminder that ALL (Students, Residents, Physicians, Nurses, NPs, etc) are invited to these CPD (continuous professional development) events.

Dr Chris Vaillancourt  presented the recent update in Food Allergies

We were remind that we are frequently faced with patients and their parents requiring advice on the hot topic of food allergies and especially ‘prevention’ of food allergies

Notes from rounds:

If one parent with a food allergy the child has 30% chance of developing Atopy (atopic dermatitis, childhood Asthma, food allergy, allergic rhinitis) in that order – allergic march – developed over childhood in this order
If two parents  with food allergy = child risk = 70%

Allergen exposure in early infancy is good if its via the gut, bad if its via the skin (especially if atopic via atopic skin rash)
Due to activation of T-Helper Cells – TH1 vs TH2 = less allergies if TH1 activated via gut than TH2 vis skin

Current Strategies  – debunked
Maternal hypoallergenic food eating – false
No cat in house – false – in fact a cat in the house with new infant may be protective

Mechanism
Most kids are getting sensitised via ‘broken skin’ in first year life
Via T-Helper 2 system
Getting exposed via gut stims TH1 system  – reduced risk of allergy

Window of opportunity
For kids at risk
4-6 months window for oral sensitisation – may reduce risk of later food allergy

Other Recommendations
No evidence for using soy milk to prevent food allergy

Breast feed until 4-6months then feed them what you want

Wait fro LEAP study – big RCT looking at food allergies and due to present results in next 2 months

 

 

Dr Peter Ross  presented on Ebola. An extremely stimulating review of the current situation and state of preparedness of own own system. Much discussion was had both during and after the presentation.

It was noted that there is a Provincial plan for managing patient with suspected Ebola. This can be accessed via the Horizon Intranet (Skyline Homepage) This is updated regularly. SJRHEM has printed copies of the plan in accessible areas of the department. These should be accessed and read by all. We have already completed an in-situ simulation for a ‘potential’ ebola case this month. The report for this can be accessed in the Simulation Files  – InSitu Sessions – Oct 3rd.

PPE Training is ongoing

Dr Howlett will be posting an update to this website in the next week

Video: here

Full presentation here : 

Download (PDF, 796KB)

 

Dr David Lewis presented on limping kids

Take home pearls:

  • A limping/NWB child that can crawl is likely to have pathology below the knee
  • Examine least likely source of symptoms first.
  • Flex, Adduct and Int Rot hip most likely manoeuvre to elicit pain in hip pathology
  • Children >8yrs – X-ray hip first
  • If fever (>38°) or > 24hrs then bloods (incl CRP)
  • CRP < 12 is very reassuring
  • Positive ultrasound is most likely to be irritable hip
  • Negative ultrasound – X-ray leg

Full presentation here: 

Download (PDF, 2.08MB)

 

Continue Reading