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Article of the Month: February 2016

Miech R, Johnston L, O’Malley PM, Keyes KM, Heard K. Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics. 2015 Nov;136(5):e1169-77.

Main Points

  • Increased opioid misuse in adults has been linked to a history of legitimate prescription opioid use.
  • Legitimate prescription opioid use prior to 12th grade is independently associated with 33% increase in the risk of future opioid misuse after high school
  • This association was concentrated in 12th grade students who have little to no history of drug use and strong disapproval of marijuana use.
  • However, this association does not predict frequent future opioid misuse.  Opioid misuse in this lower stratum was limited to 5 or fewer occasions of misuse in the 12 months.
  • The very lowest risk stratum in the study did not predict misuse prescription opioids.  This was attributed to this stratum having a higher composition of minority youth compared to other risk stratum.

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FOAM Party: January 2016

As part of our revamp, we’re pleased to bring you a new monthly blog series, FOAM party. Drs. Tal Berkowitz and Maneesha Agarwal will scour the FOAM universe to bring you the very best from the past month for you to review. Want to know why your EM resident wants to use an alcohol pad to treat his patient’s vomiting? You’ve come to the right place…

downloadA recent post on ALiEM discusses the use of inhalation of isopropyl alcohol pads for nausea and vomiting.  It is readily available and they recommend 3 inhalations within 15 minutes up to 2 times.

The FOAM piece states that there is one pediatric article that found it to be “too noxious,” despite being effective. This was an anesthesia article from 1999 looking at post-op nausea and vomiting in children and reported that while there was effect above placebo from the inhaled isopropyl, there were high rates of recurrent nausea and vomiting requiring further medications. The study included children above 6 years old so there are no studies looking at younger populations.
The lesson we have taken from this is that it may be an effective, immediately available intervention for the actively vomiting patient while awaiting alternatives such as ondansetron to arrive or kick in.
  1. Wang SM, Hofstadter MB, Kain ZN. An alternative method to alleviate postoperative nausea and vomiting in children. J Clin Anesth. 1999; 11(3): 231-4. PMID: 10434220

Screen Shot 2016-01-13 at 3.45.50 PMLife In The FastLane (LITFL) has some updates to their critical care compendium with a nice overview of preoxygenation prior to intubation. There is a lot of discussion in the adult FOAM/literature regarding optimal ways to intubate critically ill patients. Many blogs (LITFL, ALiEM, and EMCrit) have some great summaries regarding how some of them tackle these difficult situations, including intubating DKA patients. Not all of these recommendations are evidence based, as for many of these scenarios there is no evidence, but they represent experienced thought processes for tackling these stressful scenarios.

The main lessons to be learned from the preoxygenation discussion are the limitations to various devices (BVM, NRB), troubleshooting some devices, and ways to consider improving preoxygentation and apneic oxygenation considering even using a standard nasal cannula at 15L/min under a NRB or NPPV device and leaving it in place during intubation. As children have even less capacity for maintaining oxygen sats during apnea, some of these methods may be even more relevant for us to try. You can also read about our own Dr. Wendy Little’s take on the subject.

cannulation-1-copy Ever challenged with finding an IV on one of your patients? Song or Stories, a relatively new blog from the perspective of a pediatric anesthesiologist, has some great tips and tricks for IV placement to consider. Consider giving it a whirl when waiting for the IV team, NICU team, flight team, or whatever other IV expert you’ve called on. Bonus points if you consider ultrasound!

If we’re talking about poking kids with a needle, we also have to talk about lumbar punctures. The folks over at Don’t forget the bubbles have a great post on some simple tricks to improve your likelihood of getting that champagne tap. Do you know where to find Tuffer’s line?

While perhaps to basic for PEM/UC faculty, ALiEM also recently published pearls on pediatric causes of chest pain. It’s not a bad quick read/review, and given that this is a popular blog with EM residents around the country (including our own fabulous Emory EM residents), it’s worth perusing so you know what that resident is talking about when they quote that pediatric chest pain is cardiac in only 6% of cases.

Caduceus-Cookie2.pngPeds EM Morsels has a nice review of indications for discharge after successful enemareduction of intussusception. In summary, discharge may be appropriate for a child with successful reduction by air-contrast enema who does not have signs of perforation or peritonitis, is able to tolerate PO, is afebrile and pain free, has undergone a brief post-enema observation period in the ER, and has the capability to easily return if symptoms recur or if they become ill.

A few articles are referenced, including one by one of our pediatric surgeons,  Dr. Mehul Raval, in which nearly half of patients who were reduced in radiology were successfully discharged home with only one patient returning for recurrence. They reported improved cost-effectiveness with this approach.
Raval MV1, Minneci PC2, Deans KJ2, Kurtovic KJ3, Dietrich A4, Bates DG5, Rangel SJ6, Moss RL2, Kenney BD2. Improving Quality and Efficiency for Intussusception Management After Successful Enema Reduction. Pediatrics. 2015 Nov;136(5):e1345-52. PMID: 26459654.

mandible-dislocation-300x212The folks over at ALIEM have also recently posted a neat trick for reducing a mandible dislocation extra-orally – without putting your fingers in the patient’s mouth! They have a fabulous video and claim that this approach works without sedation too. Might be worth a whirl next time one of these patients lands in our ED…

greenwaldFinally, from our very own Dr. Mike Greenwald, chair-elect for the ACEP Section of Pediatrics, poses a great question as we face the second half of the winter volume surge: is teaching and clinical productivity truly mutually exclusive? Dr. Greenwald argues (and exemplifies) why it isn’t. 

Seen another fabulous piece of FOAM not covered in this month’s FOAM party? Send it our way for inclusion in next month’s FOAM party.

Keep FOAMing,

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Bonus Post: Highlights & Pearls from ACEP 2015

By Mike Greenwald MD

Too many excellent lectures to attend. The conference was run so professionally. Lots of help for everything you needed. Plenty of parties and meetings to network with other docs. The exhibit hall was packed with too much to see in 1 day. Included a special area with cutting edge high-tech products and featured some live simulations with actors that was remarkable. The conference even featured mid-day yoga and meditation sessions.

Below are pearls from some of my favorite talks. These presentations are recorded for anyone interested.

Pediatric Neurology: Nothing or Nightmare


  • AEIOTIPS for differential
  • TICLS for Developmental Screen
  • Pediatric Assessment Triangle: Appearance, WOB, Circulation

Case: Weakness with URI – late presentation of Inborn Error of Metabolism

Key Labs: Glu, Lactate, Ketones and Ammonia

Case: 4 y/o altered. No suspected ingestion…until someone noticed the clonidine patch she thought was a bandaid!

Most Lethal Animals

Marine Envenomations

  • Most cause sx by blocking Na channels
  • Some antivenoms exist
  • Australia most dangerous waters
  • Jellyfish toxin causes anaphylaxis as well as curare effect
  • Tx: cut tentacles, scrape site with card, vinegar, hot water
  • Hot water treats many envenomations as they feature heat labile toxins
  • Urine doesn’t work

Snake bites in US

  • 25% are dry
  • deaths are rare in US, common in tropical areas
  • Tx: immobilize with compression – NOT cut/suck nor tourniquet


Black widow spiders venom lacks cytotoxin – so no necrosis like the brown recluse

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Bonus Post: Pearls from the 2015 AAP National Convention & Exhibition

By Sofia Chaudhary MD

IMG_3041The national annual AAP conference covers a wide range of topics from general pediatric care to subspecialty pediatric care.  Each of the subspecialties have separate sessions that are being given at the same time as the main sessions- so lots to pick from including global health.  The pediatric ER section and general surgery section start with the pre conference program on Friday and ends Sunday while the conference typically continues till Tuesday.

This year for the ED section we had abstract presentations, poster presentations, general pediatric ER talks on physician burnout, state of pediatric emergency medicine and quality, etc.  In addition there are especially fun sessions to attend such as Emergiquiz presentations where PEM fellows give a case and have another fellow from a different program to try to work through the diagnosis. There’s also the PEM Pix presentation where 13 interesting case photos are presented and the audience has to guess the diagnosis. Continue reading

PEM Relevant Articles

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PEM Relevant Articles: January 2016

Pardon our dust as we slightly revamp PEM education update for 2016. While we don’t have a formal lit review team for this month, please enjoy some abstracts selected by the academic administrator…


Mata DA, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015 Dec 8;314(22):2373-83.

Conclusions and Relevance: In this systematic review, the summary estimate of the prevalence of depression or depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2% depending on the instrument used, and increased with calendar year. Further research is needed to identify effective strategies for preventing and treating depression among physicians in training.

Editor comment: consider this as a possibility when a trainee seems to be underperforming.

Florin TA, et al. Emergency Department Use of Computed Tomography for Children with Ventricular Shunts. J Pediatr. 2015 Dec;167(6):1382-1388.e2.

Conclusions: A CT scan was obtained in half of ED visits for children with a ventricular shunt, with wide variability in utilization by hospitals. Strategies are needed to identify children at risk of shunt malfunction to reduce variability in CT utilization and radiation exposure in the ED.

EC: Don’t forget – we can consider the 8-second rapid brain MRI protocol during normal business hours to spare these patients radiation.

Lion KC, et al. Effect of Telephone vs Video Interpretation on Parent Comprehension, Communication, and Utilization in the Pediatric Emergency Department: A Randomized Clinical Trial. JAMA Pediatr. 2015 Dec 1; 169(12):1117-25.

Conclusions and Relevance: Families with limited English proficiency who received video interpretation were more likely to correctly name the child’s diagnosis and had fewer lapses in interpreter use. Use of video interpretation shows promise for improving communication and patient care in this population. Continue reading

Landmark Article

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Landmark Article: Medical Malpractice Experience of Physicians. Predictable or Haphazard?

Sloan FA, et al. Medical Malpractice Experience of Physicians. Predictable or Haphazard? JAMA. 1989 Dec 15;262(23):3291-7

We should not practice medicine, overwhelmed by the fear of malpractice litigation. Defensive medicine is costly not only to society and the patient, but also to us as physicians. It diminishes our love of medicine and our satisfaction with a job well done. My belief is that instead of testing and treating, we can do more to reduce our litigation risk, by showing empathy, listening, and allowing questions.

This landmark article published in JAMA in 1989 remains one of the most thorough reviews published on the subject of risk of litigation and the market and regulatory factors that may contribute to litigation risk.

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PEM Relevant Articles: December 2015

Schilling S, et al. Testing and Treatment After Adolescent Sexual Assault in Pediatric Emergency Departments. Pediatrics. 2015 Dec;136(6):e1495-503.

National guidelines recommend testing and prophylaxis for chlamydia, gonorrhea and pregnancy for sexual assault victims. This study reports adherence to the recommended guidelines in 38 pediatric ED’s in the PHIS (Pediatric Hospital Information System) database between 2004 and 2013. It also compares adherence to guidelines in ED’s that have a specialized sexual assault pathway. This data was collected using a survey sent directly to the physicians of the 38 hospitals.  The study concluded that there is significant variation in testing and prophylaxis at the 1st visit in Pediatric ED’s, and while the rates of testing remain the same, patients were more likely to receive the recommended prophylaxis in hospitals with a specialized pathway. The presence of a sexual assault team did not affect testing or prophylaxis.

Data is as follows:

  • Large cohort of patients: 12,687, 93% female, 79% <16 years old, 34% non-Hispanic white, 38% non-Hispanic black. 74% presented within 72 and 79% within 120 hours of assault.
  • 30% of the patients presented to an institution that had a specialized pathway
  • 64% presented to an institution with a specialized sexual assault evaluation team
  • Based on survey results, 76% reported testing adolescents, regardless of time of assault; 1/3rd used 72-hour cutoff for chlamydia and gonorrhea prophylaxis, 42% used 120 hours as a cutoff for emergency contraception, 68%-71% reported that they provided the prophylaxis in the ED, rather than writing a prescription
  • PHIS data analysis showed:
    • 44% (6%-89%) received the recommended testing. This was regardless of whether a pathway or a sexual assault team was used.
    •  35% (0%-57%) received prophylaxis. Hospitals with pathways were 50% more likely to give prophylaxis, however the presence of a sexual assault team made no difference
  • Limitations
    • ED setting, so testing and prophylaxis could have occurred at a non-ED facility, specifically if a sexual assault team/ child advocacy center was involved


Bacharier LB, et al. Early Administration of Azithromycin and Prevention of Severe Lower Respiratory Tract Illnesses in Preschool Children With a History of Such Illnesses: A Randomized Clinical Trial. JAMA. 2015 Nov 17;314(19):2034-44.

For preschool-aged children with recurrent wheezing, systemic corticosteroids may be less effective than in older children. There is some evidence that azithromycin can improve asthma and lower respiratory tract symptoms (i.e. bronchospasm). In this double-blind, randomized, placebo-controlled trial, investigators evaluated if a course of azithromycin given early in a lower respiratory tract illness in patients with known history of wheezing not on a daily controller medication could prevent progression to a severe lower respiratory tract disease. Severe disease was defined as:

  • symptoms considered more than mild after 3 albuterol treatments in an hour
  • requiring albuterol more than every 4 hours
  • requiring more than 6 albuterol treatments in 24 hours
  • having moderate to severe cough or wheeze for 5 or more days since the study medication was started.

There was a statistically significant decrease in the hazards ratio of 0.64 (95% CI, 0.41-0.98), with an absolute risk reduction of 0.03 (95% CI, 0.00-0.06); the NNT was 33. Interestingly, the NNT decreased as the number of antibiotic courses for subsequent wheezing episodes increased (from 33 for one respiratory tract infection down to 7 for four respiratory tract infections). This may indicate that there is a select subgroup of those who would respond to such a therapy, though this doesn’t appear to be associated with a tested IL-8 genotype. [PG]

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