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Pediatric Emergencies John D. Rowlett, MD, FAAP Associate Lecturer Fitzgerald Health Education Associates, Inc. No. Andover MA Georgia Emergency Associates Savannah, GA Disclosure: Baxter Pharmaceuticals

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Pediatric emergencies l.jpg

Pediatric Emergencies

John D. Rowlett, MD, FAAP

Associate Lecturer

Fitzgerald Health Education Associates, Inc.

No. Andover MA

Georgia Emergency Associates

Savannah, GA


Disclosure baxter pharmaceuticals l.jpg
Disclosure: Baxter Pharmaceuticals

  • Since signing the disclosure agreement, I have signed an agreement to be an investigator and occasional speaker for Hylenex©,, manufactured by Baxter. I own no individual stock in this company. This product will be mentioned briefly in this talk

 2009 Fitzgerald Health Education Associates, Inc.


Goals for this talk l.jpg
Goals for this Talk

  • Overview of Pediatric Assessment

  • Evaluation of the Acutely Ill Child

  • Review of fever, approach to the febrile child

  • Gastrointestinal Emergencies

  • Neurologic Emergencies

  • Respiratory Emergencies

  • Sudden Death/Cardiac Emergencies

 2009 Fitzgerald Health Education Associates, Inc.


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Lecture Plan

  • 12:30-1:45 Lecture

  • 1:45-2:00 Break

  • 2:00-3:15 Lecture

  • 3:15-3:30 Break

  • 3:30-4:30 Lecture

 2009 Fitzgerald Health Education Associates, Inc.


Emergency medicine rules l.jpg

Rule # 1: The goal of emergency medicine is to ensure oxygen and glucose delivery to the brain.

Rule #2: Everything else is subordinate to Rule #1.

Rule #3: When in doubt, refer to Rule #1

Emergency Medicine Rules

 2009 Fitzgerald Health Education Associates, Inc.


The pediatric assessment triangle l.jpg
The Pediatric oxygen and glucose delivery to the brain.Assessment Triangle*

*Pediatric Education for Prehospital Professionals.

Developed by the American Academy of Pediatrics

 2009 Fitzgerald Health Education Associates, Inc.


The pediatric assessment triangle pat l.jpg
The Pediatric Assessment Triangle (PAT)* oxygen and glucose delivery to the brain.

Observational assessment

Formalizes the “general impression”

Establishes severity of illness or injury

Determines urgency of intervention

Identifies general category of physiologic abnormality

*Pediatric Education for Prehospital Professionals.

Developed by the American Academy of Pediatrics

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.


Pat appearance l.jpg
PAT: Appearance oxygen and glucose delivery to the brain.

  • Does the child look sick or does the child look well?

    • May change with fever control

  • How is the child

    • Interacting with parent(s)

    • Interacting with provider

    • Interacting with environment

 2009 Fitzgerald Health Education Associates, Inc.


Pat breathing l.jpg
PAT: Breathing oxygen and glucose delivery to the brain.

  • Is the respiratory rate

    • Low, normal, or increased?

    • Is there accessory muscle use?

    • Are breath sounds normal or are there wheezes, rales, and/or ronchi?

  • Pulse oximetry? Capnography?

  • Nothing better than a loud cry

 2009 Fitzgerald Health Education Associates, Inc.


Pat circulation skin color l.jpg
PAT: Circulation/Skin Color oxygen and glucose delivery to the brain.

  • What is the capillary refill time?

    • Under 2 seconds

    • Under 1 second

    • Instant

    • I routinely discuss this with parents

  • Urine output?

  • Mental status?

 2009 Fitzgerald Health Education Associates, Inc.


Vital signs by age l.jpg
Vital signs by Age oxygen and glucose delivery to the brain.

 2009 Fitzgerald Health Education Associates, Inc.


A word about blood pressures l.jpg
A word about blood pressures oxygen and glucose delivery to the brain.

  • Notoriously innaccurate

  • Minimum (mm Hg) should probably be 80 + twice age in years

  • Due to compensatory mechanisms in children (predominantly increased HR), may be “normal” in dire circumstances (until collapse)

 2009 Fitzgerald Health Education Associates, Inc.


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The triage nurse sends you a phone call from the mother of a 6 week old infant. The mother states that the child “felt warm” so she took her temperature under the arm and it was 104.1o F. What should she do now?

 2009 Fitzgerald Health Education Associates, Inc.


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Illness is caused by an imbalance in the four humors (blood, phlegm, yellow bile, and black bile. The purpose of fever is to “cook” the excess humor and bring the body back to normal homeostasis.

Hippocrates

 2009 Fitzgerald Health Education Associates, Inc.


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“Fever is a mighty engine which Nature brings into the world for conquest of her enemies.”

Thomas Sydenham, 1600

 2009 Fitzgerald Health Education Associates, Inc.


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“Humanity has but 3 great enemies: fever, famine, and war; of these, by far the greatest, by far the most terrible, is fever.

William Osler, 1896

The study of fevers of the South. JAMA 1896;26:999-1000

 2009 Fitzgerald Health Education Associates, Inc.


Control of body temperature l.jpg
Control of body temperature war; of these, by far the greatest, by far the most terrible, is fever.

  • Hypothalamus

    • Body’s “Thermostat”

    • Maintenance of “set point”

      • Autonomic

      • Endocrine

      • Behavioral

 2009 Fitzgerald Health Education Associates, Inc.


Fever the good and the bad l.jpg
Fever: The Good and the Bad war; of these, by far the greatest, by far the most terrible, is fever.

Benefits

Adverse effects

Hypermetabolism

Increased insensible fluid losses

Generalized malaise

You simply feel crummy when you have a temperature

Remember the last time YOU had a fever?

  • Increased leukocyte mobility and activity

  • Activation of T lymphocytes

  • Increased production of interferon

 2009 Fitzgerald Health Education Associates, Inc.


Fever metabolic effects l.jpg
Fever: Metabolic Effects war; of these, by far the greatest, by far the most terrible, is fever.

  • For each degree (C) increase over basal body temperature

    • Heart rate increases 10 to 15 beats per minute

    • Respiratory rate increase 3 to 5 breaths per minute

 2009 Fitzgerald Health Education Associates, Inc.


Carl wunderlich l.jpg
Carl Wunderlich war; of these, by far the greatest, by far the most terrible, is fever.

  • 1868

    • Reported the mean adult temperature was 98.6oF

    • Data was more than 1 million readings on 25,000 patients

      • Axillary temp, 1 foot long thermometer

 2009 Fitzgerald Health Education Associates, Inc.


Sites for measuring temperature l.jpg
Sites for Measuring Temperature war; of these, by far the greatest, by far the most terrible, is fever.

Central

Pulmonary artery, lower esophagus

Most accurate, difficult to access

Axillary

Inaccurate

Slow to change, affected by sweating, cooling

No role in modern pediatrics

 2009 Fitzgerald Health Education Associates, Inc.


Sites for measuring temperature22 l.jpg
Sites for Measuring Temperature war; of these, by far the greatest, by far the most terrible, is fever.

Oral

Less lag time

Reasonably accurate for age 5 years +

Affected by oral fluid intake and mouth breathing

Rectal

Gold standard

Nobody likes a rectal temperature

 2009 Fitzgerald Health Education Associates, Inc.


Sites for measuring temperature23 l.jpg
Sites for Measuring Temperature war; of these, by far the greatest, by far the most terrible, is fever.

Tympanic membrane

In theory, should be close to that of brain

Studies have shown wide variability (Cerumen, technique, acute otitis media)

Temporal artery

Well tolerated, just innaccurate, especially in sick infants < 3 months of age

 2009 Fitzgerald Health Education Associates, Inc.


The mometer l.jpg
The MOMeter war; of these, by far the greatest, by far the most terrible, is fever.

  • “He just felt warm to me”

    • Subjective, varies by site of the infant touched by the examiner

    • Sensitivity range 71 to 89%

    • Specificity and positive predictive value < 50%

 2009 Fitzgerald Health Education Associates, Inc.


Normal variation in body temperature l.jpg
Normal Variation in Body Temperature war; of these, by far the greatest, by far the most terrible, is fever.

El-Radhi AS, Barry W. Thermometry in paediatric practice. Arch Dis Child 2006;91:351-6.

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

25


Fever defined as a rectal temperature greater than or equal to 100 4 0 fahrenheit 38 o c l.jpg
Fever: war; of these, by far the greatest, by far the most terrible, is fever.defined as a rectal temperature greater than or equal to 100.40 Fahrenheit (38o C)

 2009 Fitzgerald Health Education Associates, Inc.


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Antipyretic pharmacology war; of these, by far the greatest, by far the most terrible, is fever.

 2009 Fitzgerald Health Education Associates, Inc.


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Ibuprofen or Acetaminophen war; of these, by far the greatest, by far the most terrible, is fever.

  • Both are effective

  • Both can have dosing errors

  • I prefer ibuprofen because:

    • Tastes better, works faster

      • Hay et al. BMJ 2008;337:a1302

  • APAP is safer in dehydrated children

    • ? increased asthma risk in children <1yr

      • Beasley R et al Lancet 2008;372:1039.

  •  2009 Fitzgerald Health Education Associates, Inc.


    Slide29 l.jpg

    Avner PIR war; of these, by far the greatest, by far the most terrible, is fever.


    What do i do in the er l.jpg
    What do I do in the ER war; of these, by far the greatest, by far the most terrible, is fever.

    • It’s nice to get the temperature down

    • While there is significant difference between the response of serious vs. minor illness fever to antipyresis, the APPEARANCE may change

    • Seriously ill children still look sick when the temperature is normal

     2009 Fitzgerald Health Education Associates, Inc.


    What about alternating ibuprofen and acetaminophen l.jpg
    What about alternating ibuprofen and acetaminophen war; of these, by far the greatest, by far the most terrible, is fever.

    • Widely practiced

      • 67% of parents

      • 50% of practitioners

    • No conclusive data to suggest that it is either safe or more effective

    • Potential risks include dosing error and theoretic renal & hepatic toxicity

     2009 Fitzgerald Health Education Associates, Inc.


    Rectal acetaminophen l.jpg
    Rectal Acetaminophen war; of these, by far the greatest, by far the most terrible, is fever.

    • Historically ineffective, likely secondary to improper dosing

    • New recommendation range from 25 to 45 mg/kg first dose with about ½ this for q six hour subsequent doses

      • Based on serum levels, most of the data are from anesthesia studies

     2009 Fitzgerald Health Education Associates, Inc.


    Fever phobia l.jpg
    “Fever Phobia” war; of these, by far the greatest, by far the most terrible, is fever.

    • Described by Schmidt in 1980

    • Parents view fever not as a symptom, but as a disease

      • About 30% of acute care pediatric visits are for fever

      • May lead to unnecessary testing and overuse of antibiotics

    • Parental education is key

     2009 Fitzgerald Health Education Associates, Inc.


    Selected references for fever l.jpg
    Selected References for Fever war; of these, by far the greatest, by far the most terrible, is fever.

    Acute Fever

    Avner J. Pediatrics in Review. 2009;30:5-12

    Entire issue of Clinical Pediatric Emergency Medicine, December 2008

    multiple articles on fever in children

     2009 Fitzgerald Health Education Associates, Inc.


    Slide35 l.jpg

    Back to our case: The mother arrives with her infant, now asleep in the carrier. She states that he took a bottle (3 ounces) and has been sleeping quietly; he has had one wet diaper and one unusually loose and malodorous stool. His temperature is 101.6o (rectal)

     2009 Fitzgerald Health Education Associates, Inc.


    Chart review and physical examination l.jpg
    Chart Review and asleep in the carrier. She states that he took a bottle (3 ounces) and has been sleeping quietly; he has had one wet diaper and one unusually loose and malodorous stool. His temperature is 101.6Physical Examination

    • Prenatal history

      • Negative

    • Birth

      • SVD at term

      • Apgars 9, 10

      • No problems in nursery

    • Mom healthy

    • No sick visits

    • HR 180, RR 30

    • Appears well

    • CRT 1 second

    • Vigorous cry

    • No focal findings on exam

     2009 Fitzgerald Health Education Associates, Inc.


    The febrile infant work up l.jpg
    The Febrile Infant: Work-up asleep in the carrier. She states that he took a bottle (3 ounces) and has been sleeping quietly; he has had one wet diaper and one unusually loose and malodorous stool. His temperature is 101.6

    • CBC

      • Part of all screening protocols, though independently not that useful

    • Urinalysis and culture

      • Catheterized specimen if at all possible

      • All specimens should be cultured

      • Most likely source of bacterial infection

     2009 Fitzgerald Health Education Associates, Inc.


    The febrile infant work up38 l.jpg
    The Febrile Infant: Work-up asleep in the carrier. She states that he took a bottle (3 ounces) and has been sleeping quietly; he has had one wet diaper and one unusually loose and malodorous stool. His temperature is 101.6

    • CXR

      • Routine, though in the absence of physical findings rarely helpful

        • Indicated if patient is tachypneic, has rales, ronchi, grunting, retractions, wheezing, grunting, stridor, cough, nasal flaring

  • Other tests

    • Clinically suggested (RSV, Rotavirus, Flu)

  • Clinically helpful?

    • C-reactive protein, serum procalcitonin

  •  2009 Fitzgerald Health Education Associates, Inc.


    To tap or not to tap that is the question whether tis nobler to l.jpg
    To Tap or Not to Tap, THAT is the question. Whether tis nobler to …

    Given that:

    • Prevalence of bacterial meningitis is low

    • Marked decreased since advent of H. influenzae and S. Pneumonia vaccines

    • Best estimates (2 studies) = .5%

      Should we tap every child < 60 days who has a documented fever?

     2009 Fitzgerald Health Education Associates, Inc.


    For now the answer is yes l.jpg
    For now, the answer is YES nobler to …

    • Some (including some well-respected clinicians) would disagree

    • The single most accurate and reliable test for meningitis is the lumbar puncture; any management strategy which omits this is inherently riskier than I choose to be

     2009 Fitzgerald Health Education Associates, Inc.


    Common strategies for management of febrile infants l.jpg
    Common Strategies for management of febrile infants nobler to …

    Modified from Baker MD, Avner JR. The Febrile infant: What’s new?

    Clin Ped Emerg Med 2008;9:213-20.

     2009 Fitzgerald Health Education Associates, Inc.


    Common strategies for management of febrile infants42 l.jpg
    Common Strategies for management of febrile infants nobler to …

    Modified from Baker MD, Avner JR. The Febrile infant: What’s new? Clin Ped Emerg Med2008;9:213-20.


    Common strategies for management of febrile infants43 l.jpg
    Common Strategies for management of febrile infants nobler to …

    Modified from Baker MD, Avner JR. The Febrile infant: What’s new? Clin Ped Emerg Med 2008;9:213-20.

     2009 Fitzgerald Health Education Associates, Inc.


    What about the child 30 days old l.jpg
    What about the nobler to … child < 30 days old?

    • Incidence of serious infection much higher in this age group (compared to infants 30-60 days old

    • No strategy for risk stratification has been successful other than “they all get worked up, admitted, and place on antibiotics”

     2009 Fitzgerald Health Education Associates, Inc.


    Philadelphia and boston criteria and the febrile infant 30 days l.jpg
    Philadelphia and Boston Criteria and the febrile infant < 30 days

    372 infants; SBI/ meningitis = 45 (12%)

    • Of these, misclassification as low risk

      • Philadelphia criteria = 13.3%

      • Boston criteria 17.8%

        • Kadish et al. Applying outpatient protocols in febrile infants 1-28 days of age. Clin Pediatr 2000;39:81-8.

          254 similar infants (in Philadelphia)

      • inappropriately classified 15% of the infants with SBI/meningitis

        • Baker MD et al. Unpredictability of SBI in febrile infants from birth to 1 month of age. Arch Pediatr Adolesc Med 1999;153:508-11.

     2009 Fitzgerald Health Education Associates, Inc.


    What about the child 90 days of age with documented fever l.jpg
    What about the child > 90 days of age with documented fever days

    • The older the child, the more discerning the physical examination

    • In fully immunized children, incidence of SBI/meningitis continues to decline

      • H. influenzae almost extinct, though recent outbreak (5 cases) in Minnesota

        • All were un/incompletely vaccinated

      • S. Pneumonia cases continues to decline

     2009 Fitzgerald Health Education Associates, Inc.


    Potential sources of infection l.jpg
    Potential Sources of Infection days

    • Occult Bacteremia

    • Occult Pneumonia

    • Occult Urinary Tract Infection

    • Viral infection

    • Meningitis

    • Otitis media

    • Pharyngitis

    • Sinusitis

     2009 Fitzgerald Health Education Associates, Inc.


    Workup for the well appearing fully immunized child 90 days of age l.jpg
    Workup for the well- appearing, fully immunized child > 90 days of age

    • Disease specific testing

      • Influenza, RSV, Rotavirus, GAHBS

    • Urinalysis

      • Occult UTI most common source of SBI fever in this group; has not changed secondary to immunizations

     2009 Fitzgerald Health Education Associates, Inc.


    Urinalysis source is key l.jpg
    Urinalysis: Source is Key days of age

    • Urine bag

      • High false positive rate; Only use if time permits the collection of second (cath) specimen if bag +

    • Urine Culture = Gold standard

    • Supapubic tap: Haven’t done one in 15 years

    • Clean-catch: if done right, it’s fine

     2009 Fitzgerald Health Education Associates, Inc.



    Utis treatment l.jpg
    UTIs: Treatment days of age

    • Simple cystitis

      • 5-10 days

      • Antibiotic choice depends on age of patient, local resistance patterns, other complicating factors

        • Amoxicillin, tmp/smx, amox + clavulanate, cephalosporins

      • Oral therapy is fine, even if a little sick

     2009 Fitzgerald Health Education Associates, Inc.


    Utis treatment52 l.jpg
    UTIs: Treatment days of age

    • Febrile UTIs

      • New data suggest oral therapy okay, even for younger infants (if tolerating po therapy)

      • 10-14 days of therapy

      • Quinolones

        • Not approved, though safety data promising

     2009 Fitzgerald Health Education Associates, Inc.


    Utis follow up l.jpg
    UTIs: Follow-up days of age

    • For decades, recommendation was VCUR (voiding cysto-urethrogram) on all children < 2 years of age with febrile UTI (after recovery)

      Renal ultrasound recommended by AAP in 1999; recent study suggests that if normal prenatal u/s at post conceptual age >=30 weeks, additional study unnecessary

     2009 Fitzgerald Health Education Associates, Inc.


    Utis follow up54 l.jpg
    UTIs: Follow-up days of age

    • The efficacy of long-term prophylactic antibiotics for children (especially girls) is unclear

      • Recent study reported antibiotic prophylaxis in children younger than 30 months with VUR (vesiculoureteral reflux) and pyelonephritis was ineffective at preventing recurrent pyelonephritis or renal scarring

        • Pennesi M. Pediatrics 2008;121:1289-94

     2009 Fitzgerald Health Education Associates, Inc.


    Slide55 l.jpg

    Meanwhile, back to our case days of age

     2009 Fitzgerald Health Education Associates, Inc.


    Slide56 l.jpg

    The child is sent to the emergency room for further evaluation. His work-up is completely normal and according to the Philadelphia criteria, he is discharged home and instructed to follow-up the next day. Fortunately, you office is open, in the words of the Beatles, “Eight days a week.”


    Slide57 l.jpg

    The next day, the child is dutifully brought in by mother. He has been doing well except for the now frequent watery, malodorous, slightly green stools. His fever has been under 101.00 F (rectal). Mom notes that she stopped checking the temperature because “every time I do he boo boos all over everything!”


    Slide58 l.jpg

    Physical examination reveals a happy, child with a HR of 140, RR 30, and temperature of 100.10 F (rectal). Capillary refill is about 1.5 seconds and the remainder of the examination is remarkable only for some redness of the perineum and yet another foul-smelling diaper.


    Dehydration in children definition and etiology l.jpg
    Dehydration in Children 140, RR 30, and temperature of 100.1Definition and etiology

    • Loss of fluids and electrolytes due to:

      • Increased fluid output

        • Gastroenteritis (#1 cause)

        • Fever

        • Heat/exertion

        • Trauma (bleeding/burns)

      • Decreased fluid intake

        • Anorexia

        • Sore throat

        • Respiratory distress

          • Fleisher GR et al, eds. Textbook of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2006;234.

     2009 Fitzgerald Health Education Associates, Inc.


    Dehydration in children epidemiology of gastroenteritis l.jpg
    Dehydration in Children: 140, RR 30, and temperature of 100.1Epidemiology of Gastroenteritis

    • Diarrhea is one of the leading causes of illness and death in young children

      • 1954-79 ~4.6 million children died/year1

      • 1980s: 3.3 million children died/year1

      • 1990s: 2.5 million deaths/year in children <5 years1

      • 2003: ~1.87 million children under 5 years died2

    • 1. Parasher UD et al. Bull World Health Organ. 2003;81:236 2. World Health Organization. The treatment of diarrhea: A manual for physicians and other senior health workers. 4th rev. Geneva, Switzerland: WHO Presss; 2005.

     2009 Fitzgerald Health Education Associates, Inc.


    Dehydration in children epidemiology of gastroenteritis62 l.jpg
    Dehydration in Children: 140, RR 30, and temperature of 100.1Epidemiology of Gastroenteritis

    • In the U.S., acute gastroenteritis in children annually accounts for

      • More than 1.5 million outpatient visits

      • 200,000 hospitalizations

      • ~300 deaths/year1

    • 1. King CK et al. Managing acute gastroenteritis among children. MMWR. 2003;52:1-16. www.cdc.gov.mmwr/preview/mmwrhtml/rr5216al.html

     2009 Fitzgerald Health Education Associates, Inc.


    Dehydration in children assessment l.jpg
    Dehydration in Children: 140, RR 30, and temperature of 100.1Assessment

    WHO Signs

    Dry mucus membranes

    Sunken eyes

    Abnormal radial pulse

    Tachycardia

    HR > 150 bpm

    Decreased urine output

    • Decreased skin elasticity

    • Capillary refill > 2 seconds

    • General appearance

    • Absent tears

    • Abnormal respirations

    1-2 findings indicate deficit <5%; 3-5 findings indicate deficit 5-9%

    6 or more findings indicate deficit of >=10%

    Gorelick MH et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99;e6.

     2009 Fitzgerald Health Education Associates, Inc.


    Dehydration in children assessment64 l.jpg
    Dehydration in Children: Assessment 140, RR 30, and temperature of 100.1

    Gorelick MH et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99;e6.

     2009 Fitzgerald Health Education Associates, Inc.


    Dehydration in children assessment65 l.jpg
    Dehydration in Children: 140, RR 30, and temperature of 100.1Assessment

    Gorelick MH et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99;e6.

     2009 Fitzgerald Health Education Associates, Inc.


    Gastroenteritis epidemiology l.jpg
    Gastroenteritis: Epidemiology 140, RR 30, and temperature of 100.1

    Severe Diarrheal Disease Requiring Hospitalization: Infants & Young Children

    Developing Countries

    Industrialized Countries

    Unknown

    Unknown

    Rotavirus

    Rotavirus

    Parasites

    Otherbacteria

    ToxigenicEscherichia coli

    Bacteria

    Adenovirus

    Adenovirus

    Astrovirus

    Calicivirus

    Astrovirus

    Calicivirus

    From Kapikian AZ, Hoshino Y, Chanock RM. In: Knipe DM, Howley PM, Griffin DE, et al. Fields Virology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001:1787–1825. Reprinted with permission.

    Merckmedicus.com


    Rotavirus l.jpg
    Rotavirus 140, RR 30, and temperature of 100.1

     2009 Fitzgerald Health Education Associates, Inc.


    Rotavirus gastroenteritis burden of disease in us children under 5 yr l.jpg

    20–60 140, RR 30, and temperature of 100.1

    1:200,000

    55,000–70,000

    1:70

    205,000–272,000

    1:7

    410,000

    4:5

    2.7 M

    Rotavirus Gastroenteritis: Burden of Disease in US Children Under 5 yr

    Cumulative Risk by Age 5

    Annual Events

    Centers for Disease Control and Prevention. MMWR. 2006;55:(RR-12):1–13.

    2008 Fitzgerald Health Education Associates, Inc.

    Centers for Disease Control and Prevention. MMWR. 2006;55:(RR-12):1–13.

    Merckmedicus.com


    Rotavirus infection cumulative probability by 24 months of age l.jpg
    Rotavirus Infection: Cumulative Probability by 24 Months of Age

    1.0

    1st infection

    0.9

    0.8

    0.7

    2ndinfection

    0.6

    Probability of

    Rotavirus Infection

    0.5

    3rdinfection

    0.4

    0.3

    4th infection

    0.2

    5th infection

    0.1

    0

    2

    4

    6

    8

    10

    12

    14

    16

    18

    20

    22

    24

    Age, months

    From Velázquez FR, Matson DO, Calva JJ, et al. N Engl J Med. 1996;335:1022–1028. Reproduced with permission by Massachusetts Medical Society.

    © 1996 Massachusetts Medical Society. All rights reserved.

     2009 Fitzgerald Health Education Associates, Inc.

    Merckmedicus.com


    Slide70 l.jpg

    Image 114_02. Rotavirus Infections. Rotavirus, typical epidemiologic curve. Rotavirus disease is the leading cause of deaths from diarrhea in the world.

    Red Book Online Visual Library, 2006. Image 114_02. Available at: http://aapredbook.aappublications.org/visual. Accessed December 10, 2007

    Copyright ©2006 American Academy of Pediatrics

     2009 Fitzgerald Health Education Associates, Inc.


    Seasonal variation of rotavirus cdc l.jpg
    Seasonal variation of Rotavirus (CDC) epidemiologic curve. Rotavirus disease is the leading cause of deaths from diarrhea in the world.

     2009 Fitzgerald Health Education Associates, Inc.


    Slide72 l.jpg

    Rotavirus Gastroenteritis: Seasonality Burdens Healthcare Infrastructure

    Influenza

    Respiratory Syncytial Virus

    Rotavirus

    Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun

    *Peak seasons may vary

    1. Centers for Disease Control and Prevention. Influenza Fact Sheet. October 17, 2006. Available at: http://www.cdc.gov/flu/protect/keyfacts.htm.

    Accessed November 29, 2006. 2. Centers for Disease Control and Prevention. MMWR. 2004;53:1159–1160. 3. Centers for Disease Control and

    Prevention. MMWR. 2006;55( RR-12):1–13.

    Merckmedicus.com


    Rotavirus gastroenteritis presenting symptoms among outpatients 36 months of age l.jpg
    Rotavirus Gastroenteritis: Presenting Symptoms Among Outpatients <36 Months of Age

    Merckmedicus.com


    Rotavirus gastroenteritis presenting symptoms in hospitalized children l.jpg
    Rotavirus Gastroenteritis: Presenting Symptoms in Hospitalized Children

     2009 Fitzgerald Health Education Associates, Inc.


    Summary l.jpg
    Summary Hospitalized Children

    • Rotavirus gastroenteritis

      • In US children <5 years, associated with1:

        • ~2.7 million symptomatic episodes/year ~410,000 outpatient visits/year ~205,000–272,000 ED visits/year ~55,000–70,000 hospitalizations/year

      • An unpredictable disease that can lead to serious consequences, including hospitalization1

      • Affects parents and providers in terms of time, expense, and anxiety2

    Merckmedicus.com

    1. Centers for Disease Control and Prevention. MMWR. 2006;52(RR-12):1–13. 2. Coffin SE, et al. Pediatr Infect Dis J. 2006;25:584.

     2009 Fitzgerald Health Education Associates, Inc.


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    RotaTeq Hospitalized Children

    • Liquid Vaccine

      • Contains multiple serotypes

        • G1 (76) (1% of disease)

        • G2 (11)

        • G3 (2.6)

        • G4 (1)

      • Other serotypes can cause disease

    • 3 dose series between 6 and 32 weeks of age; can be completed by as early as 4 months of age

     2009 Fitzgerald Health Education Associates, Inc.


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    Rotateq Hospitalized Children

    • Efficacy

      • 98% effective presenting severe rotavirus infection

      • 74% effective preventing mild, moderate rotavirus infection

    • Among vaccinated children, Hospitalizations/ ED visits from serogroups G1,G2,G3, and G4 reduced

      • 95% in United States

      • 90% in Latin America

      • 95% in Europe

     2009 Fitzgerald Health Education Associates, Inc.


    Rotarix glaxosmithkline l.jpg
    Rotarix (GlaxoSmithKline) Hospitalized Children

    • Monavalent vaccine derived from the most common human rotavirus strain (G1P)

    • Provides cross-protection to most human strains

     2009 Fitzgerald Health Education Associates, Inc.


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    Rotarix Hospitalized Children

    • 90% protection following 1st dose

    • Significant reduction in hospitalizations

    • Significant protection sustained for two years

     2009 Fitzgerald Health Education Associates, Inc.


    The big picture with rotavirus vaccines the third world l.jpg
    The Big Picture with Rotavirus Vaccines: The Third World Hospitalized Children

    • Will they be effective among the poorest children?

    • Will they be safe

    • Can they be made affordable

     2009 Fitzgerald Health Education Associates, Inc.


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    Current Treatment Options: Hospitalized ChildrenOral Rehydration Therapy (ORT)

    • The American Academy of Pediatrics recommends ORT as the preferred treatment for fluid and electrolyte loss caused by diarrhea in children with mild-to-moderate dehydration

      • Less expensive than intravenous fluid therapy (IVT)

      • Can be administered in various settings

      • Fewer complications compared with IVFT

      • Requires ongoing attention from the caregiver

        Practice Parameter Committee. Pediatrics 1996;97:424-35.

     2009 Fitzgerald Health Education Associates, Inc.


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    Current Treatment Options: Hospitalized ChildrenOral Rehydration Therapy (ORT)

    • Of 60 PEM fellowship directors surveyed on rehydration preferences, only 4 used ORT in all circumstances recommended by the AAP. Cited barriers to ORT include:

      • Disagreement with AAP recommendations

      • Moderate dehydration status

      • Belief that ORT is too time consuming

      • Expectation of parents

      • Expectation of referring physicians

      • Previous trial of ORT

        Conner GP et al. Pediatr Emerg Care. 2000;16;335-8.

     2009 Fitzgerald Health Education Associates, Inc.


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    ORT: Types of Fluid Hospitalized Children

    • WHO fluid

      • Sodium 75 mmol/L

      • Potassium 20 mmol/L

      • Chloride 65 mmol/L

      • Citrate 10 mmol/L

      • Glucose 75 mmol/L

        • Prepared has osmolality of 245 mOsm/L

     2009 Fitzgerald Health Education Associates, Inc.



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    Oral Ondansetron (Zofran Hospitalized Children®)

    • 106 patients aged 1-10 years

      • Moderate dehydration, failed oral hydration

      • Randomized to receive ODT ondansetron or placebo

      • Fluids/popsicles introduced in 30 minutes

    • IV therapy eventually required by

      • 21.6% of ondansetron group

      • 54.5% of placebo group

      • Number needed to treat = about 3

        • Roslund G et al. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy; a randomized controlled trial. Ann Emerg Med 2008;52:22-9.

     2009 Fitzgerald Health Education Associates, Inc.


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    ORT: The Basics Hospitalized Children

    • Use an appropriate fluid

    • Estimate fluid deficit

      • Ex: 5% dehydration in 15 kg child = estimated deficit of .05*15 = 750 cc

    • Begin at about 5 cc every 5 minutes; add 5 cc/feed as tolerated

    • Goal: Replace 10 cc/kg in first hour and entire deficit in 4 hours

     2009 Fitzgerald Health Education Associates, Inc.


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    NG therapy Hospitalized Children

    • Effective

    • Cheaper

      • Less supplies, nursing time

      • Estimated about 20% less than IV

      • Labs largely unnecessary

        • Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 2002;109:566-72.

  • Despite this, it really hasn’t entered mainstream PEM practice

  •  2009 Fitzgerald Health Education Associates, Inc.


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    Key Points for Managing Vomiting and Diarrhea in Children Hospitalized Children

    • Most children are not clinically dehydrated and do not require a PO challenge prior to discharge

    • ORT with appropriate fluid is preferred initial therapy

    • Rehydration should be performed rapidly (over < 4 hours)

    Modified from Hostetler MA. Gastroenteritis: An evidence-based approach to typical vomiting diarrhea and dehydration. Pediatric Emergency Medicine Practice. 2004;5:1-20.

     2009 Fitzgerald Health Education Associates, Inc.


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    Key Points for Managing Vomiting and Diarrhea in Children Hospitalized Children

    • Once started, rehydration is continued in the ED and then continued at home by the parents

    • Successful ORT involves

      Rehydration

      Maintenance and prevention of dehydration

      Realimentation

    Modified from Hostetler MA. Gastroenteritis: An evidence-based approach to typical vomiting diarrhea and dehydration. Pediatric Emergency Medicine Practice. 2004;5:1-20.

     2009 Fitzgerald Health Education Associates, Inc.


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    Key Points for Managing Vomiting and Diarrhea in Children Hospitalized Children

    • Laboratory testing seldom necessary

    • Medications usually not necessary

    • Following rehydration, rapid realimentation with age-appropriate unrestricted diet

      • Dilution of formula and milk restriction is not necessary

    Modified from Hostetler MA. Gastroenteritis: An evidence-based approach to typical vomiting diarrhea and dehydration. Pediatric Emergency Medicine Practice. 2004;5:1-20.

     2009 Fitzgerald Health Education Associates, Inc.


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    Pop Quiz Hospitalized Children

    • What is the easiest way for me to get the nurse mad at me (for at least the rest of the shift, maybe longer?

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


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    Answer Hospitalized Children

    • Ask for an IV to be placed on a sick child.

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Barriers to iv access l.jpg
    Barriers to IV Access Hospitalized Children

    Experience

    Not all that common, even in busy ER

    Technically difficult

    Anxious parents

    Staff

    Need additional help, frequently not available

    Host

    Tired

    Small

    Cranky

    Dehydrated

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


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    Traditional IV Access in Children Hospitalized Children

    • Average time for nurse (and staff) is 20 minutes

    • Average attempts ranges from two to four per STAFF, frequently abandoned because of lack of access (for equivocal sticks)

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


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    Some New (and not so new) toys Hospitalized Children

    • Vein illumination

    • Vein location

      • Ultrasound

      • Intravenous device

    • Intra-osseous

    • Subcutaneous hydration

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Vein illumination l.jpg
    Vein Illumination Hospitalized Children

     2009 Fitzgerald Health Education Associates, Inc.


    The vein viewer l.jpg
    The Vein Viewer Hospitalized Children

     2009 Fitzgerald Health Education Associates, Inc.


    In development at georgia tech l.jpg
    In Development at Georgia Tech Hospitalized Children

     2009 Fitzgerald Health Education Associates, Inc.


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    Ultrasound View of Vein, Artery Hospitalized Children

     2009 Fitzgerald Health Education Associates, Inc.


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    Ultrasound Machines Hospitalized Children

     2009 Fitzgerald Health Education Associates, Inc.


    Vein entry indicator device veid l.jpg
    Vein Entry Indicator Device (VEID) Hospitalized Children

    • Attaches to the female end of standard catheter; Emits a “beep” when the vein is entered; Anesthesiologist study

      • No difference for easy veins

      • Intermediate veins (barely visible or palpable)

        • 6.4 vs 46.1 seconds, (VEID vs No VEID)

      • Difficult veins (neither visible nor palpable)

        • 22.2 vs. 97.1 seconds (VEID vs No VEID)

      • 1st attempt success (intermediate + difficult)

        • 89.7 (VEID) vs. 23.3 (no VEID)

      • `

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.

    101




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    Note that the 5 mm mark is Hospitalized ChildrenNOT visible above the skin

    Size matters!

    Note that the 5 mm mark is NOT visible above the skin

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


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    The Right Site Hospitalized Children

    Site selection is dependent upon:

    Absence of contraindications

    Accessibility of the site

    Ability to monitor and secure the site

    Desired flow rates

    Policy/Protocol specifications

     2009 Fitzgerald Health Education Associates, Inc.


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    EZ-IO PD 15 mm Needle Set Hospitalized Children

    5 mm mark

    15 gauge

    EZ-IO AD 25 mm Needle Set

    EZ-IO LD 45 mm Needle Set

    Length and color are the only differences between Needle Sets

     2009 Fitzgerald Health Education Associates, Inc.

    T430 RevA


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    Intraosseous usage and pain Hospitalized Children

    Insertion pain is specific,

    local and of short duration

    Infusion pain is general,

    diffuse and protracted

     2009 Fitzgerald Health Education Associates, Inc.


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    Prepare Equipment Hospitalized Children

    Inspect needle cartridge or packaging for damage and sterility (verify seal)

    Open cartridge and attach driver to needle set (leave cap on needle until ready to insert)

    Open EZ-Connect and prime w/saline (or lidocaine for conscious patients)

    Leave syringe attached to EZ-Connect

     2009 Fitzgerald Health Education Associates, Inc.

    T430 RevA


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    DO NOT USE EXCESSIVE FORCE Hospitalized Children

    Simply RELEASE the triggerwhen you feel the “POP” or “GIVE” to avoid possible recoil on 3-39 Kg patients

     2009 Fitzgerald Health Education Associates, Inc.

    T430 RevA


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    Any medication approved for peripheral IV injection Hospitalized Children

    IO and IV doses are the same

    Follow each med administration with 3-5ml fluid flush

    Lab Testing:

    > Draw 3-10ml for waste

    > Aspirate IO blood for standardized labs

    > May use heparinized syringe

     2009 Fitzgerald Health Education Associates, Inc.


    Slide111 l.jpg

     2008 Fitzgerald Health Education Associates, Inc. Hospitalized Children

     2009 Fitzgerald Health Education Associates, Inc.


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    Contraindications for EZ-IO Access Hospitalized Children

    Fracture (targeted bone)Previous orthopedic procedures near insertion site

    Prosthetic Limb or joint

    IO within past 24 hours (targeted bone)

    Infection at the insertion site

    Inability to locate landmarks or excessive tissue

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.

    T430 RevA


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    Subcutaneous Hydration Hospitalized Children

    • Old concept from the 1940s

    • Augmented with hyaluronidase

      • Previously animal product

      • Human recombinant product now available

        • Hylenex (Baxter, remember I have an affiliation with them)

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


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    Current Treatment Options: Hospitalized ChildrenIntravenous Fluid Therapy (IVFT)

    • Treatment of choice for severely dehydrated child or those who cannot tolerate/take ORT

    • Immediate onset; can follow with ORT

    • Challenges

      • Intravenous access can be difficult and time consuming

      • Multiple attempts are often needed

      • Painful to child

      • Upsetting to parents

      • Consumes resources (staff, time, equipment)

      • May delay treatment and increase risks

     2009 Fitzgerald Health Education Associates, Inc.


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    Infuse Pediatric Hydration Study: Hospitalized ChildrenRehydration Efficacy

    • 51 patients, mean age 1.9 years

      • mild-moderate dehydration

      • admitted to hospital emergency departments

    • Inclusion criteria

      • Age 2 months to 10 years

      • Body weight <42 kgs

      • Need for parental fluids because of failed ORT or failed IV attempts

      • 1-5 points on dehydration scale

        • Allen CH, Et a. Subcutaneous hydration in children using recombinant Human hyaluronidase: Safety and ease of use. American College of Emergency Physicians, 2008.

     2009 Fitzgerald Health Education Associates, Inc.


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    Infuse Pediatric Hydration Study: Hospitalized ChildrenRehydration Efficacy

    • Exclusion criteria

      • Severe dehydration/shock

      • Substantial rehydration immediately prior to enrollment (ORT or IVFT)

      • Known hyponatremia, hypernatremia, or hypokalemia

      • Known hypersensitivity to hyaluronidase

        • Allen CH, Et a. Subcutaneous hydration in children using recombinant Human hyaluronidase: Safety and ease of use. American College of Emergency Physicians, 2008.

     2009 Fitzgerald Health Education Associates, Inc.


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    INFUSE Pediatric hydration Study: Hospitalized ChildrenRehydration Efficacy (N=51)

     2009 Fitzgerald Health Education Associates, Inc.


    Infuse pediatric hydration study rehydration efficacy n 51118 l.jpg
    INFUSE Pediatric hydration Study: Hospitalized ChildrenRehydration Efficacy (N=51)

     2009 Fitzgerald Health Education Associates, Inc.


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    INFUSE Pediatric Hydration Study: Hospitalized ChildrenOther Findings

    • Baseline Gorelick dehydration score

      • Baseline=3.5 ±1.2

      • End of treatment = .5 ± 0.9

    • Catheter placement

      • 1st attempt successful 86%

      • 2nd attempt successful 12%

      • 1 patient required 3 attempts

        • All patients achieved successful placement of catheter on each attempt however they were kids and catheters dislodged and had to be replaced

  • 2 minutes = median time to initiate fluid therapy

  • No patient required change of infusion site

  •  2009 Fitzgerald Health Education Associates, Inc.


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    MOA: Subcutaneous hydration Hospitalized Children

    • Subcutaneous hydration (hypodermoclysis) has been an alternative option to the traditional intravenous route for over 50 years.

    • Hydrostatic forces allow the subcutaneous administration of fluids via diffusion and perfusion.

    • Comparisons of subcutaneous fluid administration with intravenous fluid administration have found no significant differences in electrolyte measurements or osmolalities.

    1 Barton, R., Fuller, & Dudley, N. (2004) Using subcutaneous fluids to rehydrate older people:current practices and future challenges. Q J Med 2004; 97:765–768.

    2 Frisoli, A., de Paula, A., Feldman, D., & Nasri, F. (2000) Subcutaneous hydration by hypodermoclysis Drugs & Aging 16 (4) 313-319.

     2009 Fitzgerald Health Education Associates, Inc.


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    Advantages and disadvantages of subcutaneous fluid administration

    Adapted from Khan, M., Younger, G., Promoting safe administration of subcutaneous infusions. Nursing Standard, 2007, 21(31), page 51, table 1

     2009 Fitzgerald Health Education Associates, Inc.


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    Contraindications for subcutaneous infusion administration

    • Generalized edema or poor peripheral circulation

    • Bleeding or coagulation disorders

    • Should not be used when fluids must be administered rapidly and in large amounts (shock, severe dehydration)

    • Signs of infection or broken skin at infusion sites

    • Not suitable for administration of colloid or macromolecular fluids, blood or total parenteral nutrition.

    Adapted from Khan, M., Younger, G., Promoting safe administration of subcutaneous infusions. Nursing Standard, 2007, 21(31), 52, table 2

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


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    Mechanism of action of hyaluronidase administration

    • Hyaluronidase is a spreading or diffusing substance that modifies the permeability of connective tissue through the hydrolysis of hyaluronic acid

    • The administration of hyaluronidase temporarily decreases the viscosity of the cellular cement and promotes diffusion of injected fluids, thus facilitating their absorption

    • Hyaluronidase causes rapid spreading, provided local interstitial pressure is adequate to furnish the necessary mechanical impulse

    Reference: hylenex PI

     2009 Fitzgerald Health Education Associates, Inc.


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    INFUSE-LR: representative subject: baseline and mid-infusion administration

    Control

    hylenex (rHuPH20)

    Baseline

    Baseline

    200 cc

    200 cc

    Thomas, JR, Yocum, RC, Haller, MF, von Gunten, CF (2007). Assessing the role of human recombinant hylauronidase in gravity-driven subcutaneous hydration: The INFUSE-LR study. Journal of Palliative Medicine, 10 (6), 1312-1320. (Figure 3)


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    INFUSE-LR: representative subject: end-infusion and return to baseline circumference

    Control

    hylenex rHuPH20

    hylenex (rHuPH20)

    400 cc

    400 cc

    Resolution

    Resolution

    Thomas JR, et al. hylenex recombinant hyaluronidase human injection dose comparison study of subcutaneous hydration: The Infuse-LR Study. Poster presented at: The American Academy of Hospice and Palliative Medicine (AAHPM), February 17, 2007, Salt Lake City, Utah.


    Hylenex recombinant for subcutaneous administrationsite selection l.jpg
    hylenex to baseline circumferencerecombinant for subcutaneous administrationsite selection

    • Select an insertion site with adequate subcutaneous tissue

    • In adults, sites may include: supraclavicular area, anterior chest wall, lower abdomen, outer aspects of arms and thigh

    • Avoid sites that are:

      • Scarred / bruised

      • Contain areas of skin breakdown

      • Edematous

      • Hard, painful, or infected

    Adapted from: Infusion Nurses Society. Policies and Procedures for Infusion Nursing. 3rd ed. Norwood, MA: Infusion Nurses Society; 2006 page 167.

     2009 Fitzgerald Health Education Associates, Inc.


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    Fluid Selection for SQ Infusion to baseline circumference

    For infants and children < 3 years old, the volume of a single clysis should be limited to 200 mL; for premature infants or during the neonatal period, the daily dosage of the clysis should not exceed 25 mL/kg of body weight. The rate of administration should not be greater than 2 mL/minute

     2009 Fitzgerald Health Education Associates, Inc.



    Slide129 l.jpg

    Meanwhile, back to our office to baseline circumference

     2009 Fitzgerald Health Education Associates, Inc.


    Slide130 l.jpg

    Your next patient is also 6 months old and has a fever. The child hasn’t been feeding normally and mom states the baby “feels cool.” Past history is unremarkable; parents have “declined” immunizations for fear of autism.

     2009 Fitzgerald Health Education Associates, Inc.


    Slide131 l.jpg

    On exam, the baby has a temp of 97.0 child hasn’t been feeding normally and mom states the baby “feels cool.” Past history is unremarkable; parents have “declined” immunizations for fear of autism. 0F, pulse is 180. The child is lethargic and has a capillary refill of 4 seconds. He is offered a bottle but wants nothing to do with it. You are concerned about SBI and refer to ED.

    An hour later, the ED physician calls to tell you that the child has purulent CSF.

     2009 Fitzgerald Health Education Associates, Inc.


    Cns defenses l.jpg
    CNS Defenses child hasn’t been feeding normally and mom states the baby “feels cool.” Past history is unremarkable; parents have “declined” immunizations for fear of autism.

    • Skull

    • Blood-brain barrier

      • Tight junctions between the cells in the cerebral vasculature

    • Vertebrae and dura matter

      • Protect from contiguous area infection

     2009 Fitzgerald Health Education Associates, Inc.


    Routes of entry cns infection l.jpg
    Routes of Entry: CNS Infection child hasn’t been feeding normally and mom states the baby “feels cool.” Past history is unremarkable; parents have “declined” immunizations for fear of autism.

    • Direct CNS Penetration

      • Trauma

      • Surgery

    • Migration from neighboring site

      • Mastoiditis

    • Hematogenous spread from other location (including distant)

     2009 Fitzgerald Health Education Associates, Inc.


    Slide134 l.jpg
    Which of the following has had the greatest impact on the decrease in cases of bacterial meningitis in children in the past two decades?

    • Haemophilus influenzae type B vaccine

    • Heptavalent pneumococcal vaccine

    • Varicella vaccine

    • Meningococcal vaccine

    • Improved hand-washing for fear of MRSA

     2009 Fitzgerald Health Education Associates, Inc.


    Slide135 l.jpg

     2009 Fitzgerald Health Education Associates, Inc. decrease in cases of bacterial meningitis in children in the past two decades?


    Median age of meningitis l.jpg
    Median Age of Meningitis decrease in cases of bacterial meningitis in children in the past two decades?

    • 1986 = 15 months

    • 1986, Haemophilus influenzae vaccine introduced

    • 1995, median age = 25 years

    • We fearmeningitis in children

    • We seemeningitis is adults

     2009 Fitzgerald Health Education Associates, Inc.


    Meningitis causative organisms l.jpg
    Meningitis: Causative Organisms decrease in cases of bacterial meningitis in children in the past two decades?

     2009 Fitzgerald Health Education Associates, Inc.


    Epidemiology of meningitis in children l.jpg
    Epidemiology of Meningitis in Children decrease in cases of bacterial meningitis in children in the past two decades?

    2001-2004

    2001-2006

    Mongelluzzo, et al. JAMA 2008;299:2048-55

    Nigrovic, et al. Acad Emer Med 2008;15:522-28

     2009 Fitzgerald Health Education Associates, Inc.


    Clinical manifestations of meningitis 1954 l.jpg
    Clinical Manifestations of Meningitis, 1954 decrease in cases of bacterial meningitis in children in the past two decades?

     2009 Fitzgerald Health Education Associates, Inc.


    Meningitis signs and symptoms l.jpg
    Meningitis: decrease in cases of bacterial meningitis in children in the past two decades?Signs and Symptoms

    Fleisher GR, et al, Textbook of Pediatric Emergency Medicine, 2006 (page 791)

     2009 Fitzgerald Health Education Associates, Inc.


    Viral vs bacterial meningitis signs and symptoms l.jpg
    Viral vs Bacterial Meningitis: decrease in cases of bacterial meningitis in children in the past two decades?Signs and Symptoms

    Viral3

    Bacterial1-3

    • Confusion and combativeness

    • Lethargy

    • Kernig/Brudzinski signs

    • Rigid arching of the back

    • Seizures

    • Loss of consciousness

    • Alert and oriented

    Headache

    Low-grade fever

    Stiff neck

    Photophobia

    Vomiting

    Rash1-3

    1. Ross GH, et al. In: Pharmacotherapy—A Pathophysiologic Approach. 2002:1831; 2. McGee ZA, Baringer JR. In: Principles and Practice of Infectious Diseases. 1990:741; 3. Farley JA, et al. In: Pathophysiology: The Biologic Basis for Disease in Adults and Children. 1994:587.

     2009 Fitzgerald Health Education Associates, Inc.


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    Physical Examination decrease in cases of bacterial meningitis in children in the past two decades?

    • Vitals

    • Neuro exam

    • Skin exam

    • Kernig & Brudzinski

      • Described in 1884, advanced bacterial or tuberculous meningitis

    • Nucchal rigidity

     2009 Fitzgerald Health Education Associates, Inc.


    Brudzinski sign l.jpg
    Brudzinski Sign decrease in cases of bacterial meningitis in children in the past two decades?

    • Positive in 3/66 patients with meningitis

      • Sensitivity 4.5%

    • Negative in 162/170 patients without meningitis

      • Specificity 95%

    • Positive PV = 27%

    • Negative PV = 72%

    Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. CID 2002;35:46-52.

     2009 Fitzgerald Health Education Associates, Inc.


    Kernig s sign l.jpg
    Kernig’s Sign decrease in cases of bacterial meningitis in children in the past two decades?

    • Positive in 3/66 patients with meningitis

      • Sensitivity 5%

    • Negative in 163/171 of 171 pt without meningitis

      • Specificity 95%

    • PPV = 27%

    • NPV = 72%

    Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. CID 2002;35:46-52.

     2009 Fitzgerald Health Education Associates, Inc.


    Nuchal rigidity l.jpg
    Nuchal Rigidity decrease in cases of bacterial meningitis in children in the past two decades?

    • Positive in 24/80 patients with meningitis

      • Sensitivity 30%

    • Negative in 148/217 patients without meningitis;

      • specificity 68%

    • 24 of 93 patients with nuchal rigidity had meningitis,

      • PPV = 26%

    • 148 of 204 patients without nuchal rigidity did not have meningitis

      • NPV = 73%

    Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. CID 2002;35:46-52.

     2009 Fitzgerald Health Education Associates, Inc.


    Ct scan before lp l.jpg
    CT SCAN BEFORE LP? decrease in cases of bacterial meningitis in children in the past two decades?

    • New onset seizures

    • Immunocompromised patients

    • Moderate to severe impairments of consciousness

    • Suspicious for space occupying lesions

      • Seizures, papilledema

    • Focal neurologic abnormalities

    Van de Beek, et al. NEJM 2006;354-44-53.

     2009 Fitzgerald Health Education Associates, Inc.


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     2009 Fitzgerald Health Education Associates, Inc. decrease in cases of bacterial meningitis in children in the past two decades?


    Successful pediatric lp l.jpg
    Successful Pediatric LP? decrease in cases of bacterial meningitis in children in the past two decades?

    • 1459 pediatric lumbar punctures

      • Traumatic = > 10,000 rbc/mm3,

      • Unsuccessful = failed initial attempt

    • Predictive of Failure

      • Lack of providor experience

      • Inadequate/no anesthesia

      • Pt movement

      • Failure to remove stylet after through dermis

        • Nibrovic, et al. Ann Emerg Med 2007;49:762-71.

          Family member presence did not affect success rates

        • Nibrovic, et al. Pediatrics, 2007;120:e777-82.

     2009 Fitzgerald Health Education Associates, Inc.


    Ultrasound assisted lumbar puncture l.jpg
    Ultrasound Assisted Lumbar Puncture decrease in cases of bacterial meningitis in children in the past two decades?

    • Adults: 22 normal, 24 ultrasound

      • 6/22 failed with traditional landmarks

      • 1/24 failed with ultrasound

      • In obese patients,

        • 4/7 traditional attempts failed

        • 0/5 ultrasound assisted attempts failed

          • Nomura, et al. J Ultrasound Med, 2007;26:1341-8.

  • Children < 60 days old (n= 43)

    • 80% successful without U/S

    • 100% successful with U/S

      • Gorn, Abstracts from SAEM 2008 (286)

  •  2009 Fitzgerald Health Education Associates, Inc.


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     2009 Fitzgerald Health Education Associates, Inc. decrease in cases of bacterial meningitis in children in the past two decades?


    Typical cerebrospinal fluid findings bacterial infection l.jpg
    Typical Cerebrospinal Fluid Findings: Bacterial Infection decrease in cases of bacterial meningitis in children in the past two decades?

    Modified from Sabella C. in Intensive Review of Pediatrics, 2006, p 407.

     2009 Fitzgerald Health Education Associates, Inc.


    Typical cerebrospinal fluid findings viral infection l.jpg
    Typical Cerebrospinal Fluid Findings: Viral Infection decrease in cases of bacterial meningitis in children in the past two decades?

    Modified from Sabella C. in Intensive Review of Pediatrics, 2006, p 407.

     2009 Fitzgerald Health Education Associates, Inc.


    Typical cerebrospinal fluid findings partially treated bacterial infection l.jpg
    Typical Cerebrospinal Fluid Findings: decrease in cases of bacterial meningitis in children in the past two decades?Partially treated Bacterial Infection

    Modified from Sabella C. in Intensive Review of Pediatrics, 2006, p 407.

     2009 Fitzgerald Health Education Associates, Inc.


    Predictors of bacterial meningitis when gram stain is negative or unavailable l.jpg
    Predictors of Bacterial Meningitis when gram stain is negative or unavailable

    Bonsu, et al. Acad Emerg Med, 2008;15:437-4.

     2009 Fitzgerald Health Education Associates, Inc.


    Meningitis treatment 1873 l.jpg
    Meningitis: Treatment: 1873 negative or unavailable

    “The treatment of meningitis ought to be very decisive. We should apply, early in the disease, two, four, or six leeches at the base of the maxilla; the application of refrigerant compresses to the head, the administration of calomel and other purgatives, and finally the application of several blisters to the legs or arms , should form the basis of the treatment”

    Copeman E., The Cerebral Affections of Infancy, 1873 (p 88).

     2009 Fitzgerald Health Education Associates, Inc.


    Slide156 l.jpg

    A 5 year-old male presents to the emergency department with complaints of fever, stiff neck, and photophobia. Physical examination remarkable for temp 103.0, irritability, nuchal rigidity, and a purpuric rash on the extremities.

     2009 Fitzgerald Health Education Associates, Inc.


    Slide157 l.jpg

    Respiratory distress develops and the patient is intubated without difficulty. He is transferred to the ICU with droplet precautions and all healthcare workers don masks and gowns. Lumbar puncture reveals gram negative intracellular diplococci consistent with N. meningitidis.

     2009 Fitzgerald Health Education Associates, Inc.


    Which of the health care workers require antibiotic prophylaxis l.jpg
    Which of the health care workers require antibiotic prophylaxis?

    A. All staff present in the emergency department and ICU

    B. All staff who examined the patient in the ICU and ER

    C. The physician who intubated the patient in the emergency room

    D. Prophylaxis is not required for any health care worker

     2009 Fitzgerald Health Education Associates, Inc.


    Correct answer is c l.jpg
    Correct Answer is C prophylaxis?

    • Person to person transmission occurs via the respiratory route

    • Routine prophylaxis of health care workers is not required if droplet precautions are observed

    • Always wear a mask with face shield when you intubate febrile patients

      • For that matter, Always wear a mask/shield

     2009 Fitzgerald Health Education Associates, Inc.


    Neisseria meningitidis l.jpg
    Neisseria meningitidis prophylaxis?

     2009 Fitzgerald Health Education Associates, Inc.


    Clinically significant n meningitidis serogroups l.jpg
    Clinically Significant prophylaxis?N meningitidis Serogroups

     2009 Fitzgerald Health Education Associates, Inc.

    1. Granoff DM, et al. In: Vaccines. 2004:959.


    Fatalities from meningococcal disease in the us 1997 2002 l.jpg
    Fatalities From Meningococcal Disease in the US, 1997 prophylaxis?–2002

    299

    156

    155

    158

    121

    106

    102

    67

    61

    63

    53

    1. Centers for Disease Control and Prevention (CDC). National Vital Statistics Reports. 1999;47(19):52; 2. CDC. National Vital Statistics Reports. 2000;48(11):51; 3. CDC National Vital Statistics Reports. 2001;49(8):27; 4. CDC. National Vital Statistics Reports. 2002;50(15):28; 5. CDC. National Vital Statistics Reports. 2003;52(3):30; 6. CDC. National Vital Statistics Reports. 2004;53(5):29.

     2008 Fitzgerald Health Education Associates, Inc.


    Common clinical presentations of meningococcemia l.jpg
    Common Clinical Presentations of Meningococcemia prophylaxis?

    Rash

    Vascular damage

    Disseminated intravascular coagulation

    Multi-organ failure

    Death can occur within 24 hours

    Shock

    5-20% of cases of meningococcal case

    Up to 40% fatality rate

    1. Rosenstein NE, et al. N Engl J Med. 2001;344:1378.

     2009 Fitzgerald Health Education Associates, Inc.


    Common clinical presentations of meningococcal meningitis l.jpg
    Common Clinical Presentations of Meningococcal Meningitis prophylaxis?

    Flu like symptoms (fever, headache)

    Stiff neck

    Nausea

    Altered mental status

    Seizures

    Represents about 50% of cases of meningitis

    3-10% fatality rate

    1. Rosenstein NE, et al. N Engl J Med. 2001;344:1378.

     2009 Fitzgerald Health Education Associates, Inc.




    Morbidity in infants children and adolescents with meningococcal disease l.jpg
    Morbidity in Infants, Children, and Adolescents with Meningococcal Disease

    *From 159 cases (19 years of age or younger) at 10 US children’s hospitals, Jan 1, 2001 to Mar 15, 2005

    †From 146 surviving children during or after hospitalization

    1. Kaplan SL, et al. Pediatrics. 2006;118:e979-e984.


    Late stage meningococcal infection in a 15 year old boy l.jpg
    Late-Stage Meningococcal Infection Meningococcal Disease in a 15-Year-Old Boy

    Reprinted with permission from Schoeller T, Schmutzhard E. N Engl J Med. 2001;34:1372.

     2009 Fitzgerald Health Education Associates, Inc.


    Gangrene caused by n meningitidis infection l.jpg
    Gangrene Caused by Meningococcal DiseaseN meningitidis Infection

     2009 Fitzgerald Health Education Associates, Inc.

    Courtesy of R Rudoy, MD, Honolulu, Hawaii,



    Meningococcal disease incidence l.jpg
    Meningococcal Disease Incidence * Meningococcal Disease

    6

    Male

    Female

    5

    4

    Incidence Rate (cases per100,000 population)

    3

    2

    1

    0

    0-4

    5-9

    10-14

    15-19

    20-24

    25-29

    30-34

    35-39

    40-44

    45-49

    50-54

    55-59

    60-64

    65-69

    70-74

    75-79

    80-84

    ≥ 85

    Age (years)

    *In California, Georgia, Maryland, Tennessee, Connecticut, Minnesota, and Oregon, 1992–19961. Rosenstein NE, et al. J InfectDis. 1999;180:1894.

     2009 Fitzgerald Health Education Associates, Inc.


    Most cases in adolescents and young adults are potentially vaccine preventable l.jpg
    Most Cases in Adolescents and Young Adults Are Potentially Vaccine-Preventable*

    Potentially Vaccine-Preventable

    65%

    62%

    41%

    86%

    70%

    46%

    72%

    36%

    *Serogroup distribution by age group, United States, 1999–2005; potentially vaccine-preventable was calculated assuming 100% efficacy using an A/C/Y/W-135 quadrivalent vaccine

    1. CDC. Active Bacterial Core Surveillance (ABCs) Report. Neisseriameningitidis. 1999-2005.

    Available at:. http://www.cdc.gov/ncidod/dbmd/abcs/reports.htm#reports

    2008 Fitzgerald Health Education Associates, Inc.


    Impact of meningococcal vaccines in the us military l.jpg

    Monovalent (group C) Vaccine-Preventable*

    Bivalent(A/C)

    Quadrivalent (A/C/Y/W-135)

    Impact of Meningococcal Vaccines in the US Military

    *Bars indicate hospitalization frequencies; line indicates rates

    1. DeFraites RF. MSMR. 2000;6:2.

     2009 Fitzgerald Health Education Associates, Inc.


    Disease risk for contacts of individuals with meningococcal disease l.jpg
    Disease Risk for Contacts of Individuals with Meningococcal disease

     2009 Fitzgerald Health Education Associates, Inc.



    Corticosteroids and meningitis l.jpg
    Corticosteroids and Meningitis disease

    • In theory, steroids will inhibit or diminish the host inflammatory response to the debris from killed bacteria

      • Dog models support this

    • In turn, this may reduce

      • Increased ICP

      • Cerebral Edema

      • Altered cerebral blood flow

    • And hopefully, this will reduce CNS injury

     2009 Fitzgerald Health Education Associates, Inc.


    Slide177 l.jpg

    STEROIDS disease

     2009 Fitzgerald Health Education Associates, Inc.


    Corticosteroids in meningitis l.jpg
    Corticosteroids in Meningitis? disease

    • Neonatal

      • Insufficient data though limited studies suggest no benefit on survival

    • Infants and Children

      • No effect on survival, length of hospital stay, or charges (Mongezzullo, 2008, Cochrane review (subgroup analysis, 2007)

        • 3rd study from Latin America which included 1/3 of cases from H. influenzae: no benefit on mortality

     2009 Fitzgerald Health Education Associates, Inc.


    Corticosteroids and meningitis in children l.jpg
    Corticosteroids and meningitis in Children disease

    • Numerous studies have demonstrated decrease in hearing loss in children

      • Initially with H. influenzaebut subsequent studies have shown efficacy in S. pneumoniaemeningitis

    • Effects on other CNS damage and mortality are less dramatic

      • Trend towards beneficial but not statistically significant

     2009 Fitzgerald Health Education Associates, Inc.


    Risks of corticosteroids l.jpg
    Risks of Corticosteroids disease

    • Decrease CNS penetration of some antibiotics, especially Vancomycin

      • Some advocate addition of rifampin until sensitivities (for cephalosporins) are available

    • Gastrointestinal bleeding

    • May mask infection related fever

     2009 Fitzgerald Health Education Associates, Inc.


    Aap red book 2006 l.jpg
    AAP Red Book, 2006 disease

    Haemophilus influenzae Infection

    “Dexamethasone may be beneficial for treatment of infants and children with HiB meningitis to diminish the risk of neurologic sequelae, including hearing loss, if given before or concurrently with the first dose of antimicrobial agent(s). There probably is no benefit if dexamethasone is given more than 1 hour after antimicrobial agent.”

     2009 Fitzgerald Health Education Associates, Inc.


    Slide182 l.jpg

    A 4-year old female who has a 3-day history of progressive earache and fever is hospitalized after becoming unresponsive. Medical history is otherwise unremarkable; she has no allergies and takes no medications.

     2009 Fitzgerald Health Education Associates, Inc.


    Slide183 l.jpg

    On physical exam, her temperature is 103.0, pulse 170, bp 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    Lumbar puncture is performed and reveals 2500 neutrophils, glucose of 20, and protein of 230 mg/dl.

    Gram stain is shown on the next slide

     2009 Fitzgerald Health Education Associates, Inc.


    Slide184 l.jpg

     2009 Fitzgerald Health Education Associates, Inc. 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.


    Best initial therapy is intravenous l.jpg
    Best initial therapy is (intravenous) 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • Penicillin + Vancomycin

    • Dexamethsone + Vancomycin

    • Dexamethasone + Vancomycin +cefotaxime

    • Dexamethasone + Ceftriaxone + Aminoglycoside

    • Chloramphenicol + Ampicillin

     2009 Fitzgerald Health Education Associates, Inc.


    Slide186 l.jpg

     2009 Fitzgerald Health Education Associates, Inc. 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.


    Aap red book 2006187 l.jpg
    AAP Red Book, 2006 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    Streptococcus pneumoniae Infection

    “For infants and children 6 weeks of age and older, adjunctive therapy with dexamethasone may be considered after weighing the potential benefits and risks . . . Data are not sufficient to demonstrate a clear benefit in children. If used, dexamethasone should be given before or concurrently with first dose of antimicrobial.”

     2009 Fitzgerald Health Education Associates, Inc.


    Pneumococcal vaccine l.jpg
    Pneumococcal Vaccine 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • Model for success was conjugated HIB

    • 23 valent vaccine available since 1977 but ineffective in children younger than 2 years (polysaccharide)

    • Conjugate vaccine (PCV7) approved in 2000 and routine immunization began

      • Covered 7 serotypes + cross reactivity with two more, thereby covering 9 serogroups responsible for about 80% of invasive disease

     2009 Fitzgerald Health Education Associates, Inc.


    Pneumococcal vaccine189 l.jpg
    Pneumococcal Vaccine 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • Marked decrease in pneumococcal disease

    • Still leading cause of bacterial meningitis in children

    • 50% of cases are “non-vaccine” serotypes

      • ?? Increasing antibiotic resistance in this subgroup (esp 19A)

        • (MMWR 2007;56:1077-80,

        • Ongkasuwan J et al . Pediatrics 2008;122:34-9.

  • Serotype “replacement” seen in otitis and this appears to be happening in meningitis

  •  2009 Fitzgerald Health Education Associates, Inc.


    Slide190 l.jpg

     2009 Fitzgerald Health Education Associates, Inc. 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.


    Delay in administering antibiotics l.jpg
    Delay in Administering Antibiotics 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • Frequent basis for action in malpractice suits, though data to support this are weak

    • Average time is to administration is between two and three hours

    • Concern for altering CSF findings if given before lumbar puncture performed (and the role of dexamethasone )

      • Since it is only clearly indicated for HIB, this shouldn’t be a concern in immunized children

     2009 Fitzgerald Health Education Associates, Inc.


    Fluid therapy l.jpg
    Fluid Therapy 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • Previous standard: restrict fluid to 2/3 maintenance to avoid SIADH

    • Cochrane meta-analysis review (2005) of 3 controlled studies

      • In sickest patients, those with maintenance fluids were less likely to develop spasticity, seizures, and neurologic deficits at 3 months

        • Extrapolation to other groups not feasible

          • Maconochie I, et al. Cochrane Database Syst Rev. 2005;(3)cd004786.

     2009 Fitzgerald Health Education Associates, Inc.


    Fluid therapy193 l.jpg
    Fluid Therapy 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • My Conclusions

      • Isotonic fluids are the fluids of choice

      • Assess electrolytes frequently

      • Maintenance fluid if adequate to maintain blood pressure and urine output

      • Remember rule # 1—oxygen and glucose to the brain

     2009 Fitzgerald Health Education Associates, Inc.


    Future directions l.jpg
    Future Directions 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • Effective Group B (Neisseria) vaccine

      • Technically very difficult

      • New Zealand trials on going

      • Early studies suggest 73% efficacy with marked decrease in invasive disease

        • Kelly, et al. Am J Epidemiol2007;166:817-23

  • Increased serotypes in pneumococcal vaccine

  •  2009 Fitzgerald Health Education Associates, Inc.


    Quick fire cases l.jpg
    “Quick Fire Cases” 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • A four-year old child is found unresponsive in the living room the morning after the parents had a party.

      • Exam:

        • cool, clammy, HR 80, rr 20

        • No signs of trauma

        • You get one test

     2009 Fitzgerald Health Education Associates, Inc.


    Check the glucose l.jpg

    Rule # 1 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.: The goal of emergency medicine is to ensure oxygen and glucose delivery to the brain.

    Check the glucose

     2009 Fitzgerald Health Education Associates, Inc.


    Quick fire cases197 l.jpg
    “Quick Fire Cases” 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

    • A four month-old child is presents to the office for lethargy and poor feeding. No other symptoms, past history unremarkable.

     2009 Fitzgerald Health Education Associates, Inc.


    Slide198 l.jpg

    On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to count. What rhythm does the monitor show?

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Supraventricular tachycardia l.jpg
    Supraventricular Tachycardia 60 breaths/min and a heart rate that is too rapid to count. What rhythm does the monitor show?

    • History of

      • Irritability, poor feeding

  • Cardiac monitor

    • HR > 220 bpm, narrow QRS, R to R interval regular, no visible p waves

  •  2009 Fitzgerald Health Education Associates, Inc.


    Treament priorities svt l.jpg
    Treament Priorities: SVT 60 breaths/min and a heart rate that is too rapid to count. What rhythm does the monitor show?

    • Supplemental oxygen

    • Obtain IV access

      • IV or IO if necessary

    • Convert rhythm based on stability

      • Stable: vagal maneuvers or adenosine

        • Adenosine .1mg/kg (up to 6 mg); repeat at twice dose (up to 12 mg)

      • Unstable: synchronized cardioversion

     2009 Fitzgerald Health Education Associates, Inc.


    Sinus tachycardia l.jpg
    Sinus Tachycardia 60 breaths/min and a heart rate that is too rapid to count. What rhythm does the monitor show?

    • History of

      • fever, vomiting, diarrhea, hemorrhage

  • Cardiac monitor

    • HR < 220 bpm, narrow QRS, variable R to R interval, p waves present and upright

  •  2009 Fitzgerald Health Education Associates, Inc.


    Quick fire cases202 l.jpg
    “Quick Fire Cases” 60 breaths/min and a heart rate that is too rapid to count. What rhythm does the monitor show?

    • A four month-old child presents to your office for cough. Mother called for an appointment and said she would come in later “if the child didn’t get better.” She runs through the front door carrying her limp, pale child. Miraculously you get a monitor and an iv instantly.

     2009 Fitzgerald Health Education Associates, Inc.


    Slide203 l.jpg

    The monitor shows the following rhythm 60 breaths/min and a heart rate that is too rapid to count. What rhythm does the monitor show?.

    What are your treatment priorities for this patient?

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Slide204 l.jpg

    Patient’s heart rate improved to 70 beats/min with assisted ventilation.

    Color, CRT and pulse quality improves.

    After BVM, patient’s RR increases to 20 breaths/min, good chest rise

    Rapid glucose check 100 mg/dL

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Conclusion l.jpg
    Conclusion assisted ventilation.

    Cardiovascular compromise in children is often related to respiratory failure, hypovolemia, poisoning or sepsis.

    Management priorities for shock include airway management, oxygen and fluid resuscitation.

    Treat rhythm disturbances emergently only if signs of respiratory failure or shock are present.

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Rule number one l.jpg
    Rule Number One assisted ventilation.

    Oxygen and Glucose to the Brain

     2009 Fitzgerald Health Education Associates, Inc.


    Slide207 l.jpg

    A mother calls and states that her 6 week-old baby “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    On arrival to the ed l.jpg
    On Arrival to the ED “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.

    Healthy appearing infant with a vigorous cry, normal vital signs, normal exam. Old records and office EMR reviewed; uncomplicated pregnancy, delivery, and newborn period, weight gain of 3 pounds thus far, no sick visits, no significant family or social history

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Apparent life threatening event l.jpg
    Apparent Life Threatening Event “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.

    “An episode that is frightening to the observer, that is characterized by some combination of apnea (centrally or occasionally obstructive), color change (usually cyanotic or pallid, but occasionally erythematous or plethoric), marked change in muscle tone (limpness), choking or gagging. In some cases, the observer feels that the infant has died”

    (NIH Consensus development conference on infantile apnea and home monitoring. Pediatrics 1987;79:292-9).

     2009 Fitzgerald Health Education Associates, Inc.

     2008 Fitzgerald Health Education Associates, Inc.


    Similar appearing events that are not altes l.jpg
    Similar Appearing Events that are “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.NOT ALTEs

    • Periodic breathing

      • Benign periodic pauses without changes

    • Apnea of infancy

      • Unexplained respiratory pauses lasting more than 20 seconds or less than 20 seconds if accompanied by pallor, cyanosis, bradycardia, or hypotonia

      • Term infants with no other problems

     2009 Fitzgerald Health Education Associates, Inc.


    Similar appearing events that are not altes211 l.jpg
    Similar Appearing Events that are “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.NOT ALTEs

    • Apnea of prematurity

      • Apnea lasting for 20 or more seconds

      • Accompanied by bradycardia, cyanosis, hypotonia, or other signs

      • Preterm, resolves by 37 weeks

    • SIDS

     2009 Fitzgerald Health Education Associates, Inc.


    Slide212 l.jpg
    SIDS “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.

    “The sudden death of an infant under 1 year of age that remains unexplained after a thorough case investigation, including performance of an autopsy, examination of the death scene, and review of the clinical history”

    Willinger M et al. Definining SIDS, Pediatr Pathol 1991;11:677-84.

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Risk factors for sids l.jpg

    Winter Months “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.

    Young maternal age

    Low birth weight

    Poverty

    Smoking

    Drug use

    Alcohol use

    Male Gender

    Prematurity

    Single parenthood

    Poor prenatal care

    High parity

    Multiple gestation

    Prone/side sleeping position

    Risk Factors for SIDS

    Hunt, CE, Hauck FR. Sudden infant death syndrome; CMAJ 2006;20;174:1861-9.

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Does breastfeeding reduce the risk of sids l.jpg
    Does Breastfeeding reduce the risk of SIDS? “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.

    • 333 infants from Germany who died from SIDS and 998 age-matched controls

    • Breastfeeding at 2 weeks

      • 49.6% of cases, 82.9% of controls

     2009 Fitzgerald Health Education Associates, Inc.


    Slide215 l.jpg

    FIGURE 1 Proportion of infants who were breastfed (both exclusively and partially) according to month of age for controls and cases

    Vennemann, M.M. et al. Pediatrics 2009;123:e406-e410

    Copyright ©2009 American Academy of Pediatrics


    Aap risk factors for alte l.jpg
    AAP Risk factors for ALTE exclusively and partially) according to month of age for controls and cases

    • Previous cyanosis, apnea or ALTE

      • When in care of same person

    • Simultaneous or near simultaneous death of twin

    • Previous death of infants while in care of same unrelated person

    • Previous unexplained (or unexpected) death in sibling

    • Sibling who died when older than 6 months

    • Discovery of blood on infant’s nose or mouth in association with ALTE

      • Farrell PA, et al. SIDS, ALTE, and the use of home monitors. Pediatr Rev 2002;23:3.

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Alte differential diagnosis l.jpg

    Cardiac exclusively and partially) according to month of age for controls and cases

    Gastrointestinal

    Pulmonary

    Infectious

    Neurologic

    Metabolic

    Hematologic

    Other

    Trauma

    ingestions

    ALTE: Differential Diagnosis

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Alte most common underlying diagnosis l.jpg
    ALTE: Most Common Underlying Diagnosis exclusively and partially) according to month of age for controls and cases

    • Gastroesophageal Reflux (31%)

    • Seizure (11%)

    • Lower respiratory track infection (8%)

      • Pertussis, RSV

        • Kaji A, Gausche-Hill M. Managing infants after an apparent life threatening event. Emerg Med 2008; 15-19.

     2009 Fitzgerald Health Education Associates, Inc.


    Alte history of present illness l.jpg

    Time & duration exclusively and partially) according to month of age for controls and cases

    Sleeping?

    Feeding

    Time of last feed

    Type of feeding

    What alerted caregiver there was a problem

    Color change

    Tone change

    Resuscitative efforts

    Recent illness

    Change in behavior or activity

    Sleeping conditions

    ALTE: History of Present Illness*

    *Adapted from DePiero AD. Apparent life-threatening events: An evidence-based approach. Pediatr Emerg Pract 2006,3(7)

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Alte additional history l.jpg

    PMH exclusively and partially) according to month of age for controls and cases

    Similar episode

    Monitoring

    Prenatal course

    Newborn course

    Sick visits

    H/o reflux

    Social history

    Caretakers

    Smoking

    medications

    Medication

    Prescription

    OTC, Herbs, Supplements

    Alternative

    Family History

    SIDS or other infant deaths

    ALTE

    Seizure

    Illnesses in family (Seizures, cardiac, developmental delay, inborn errors)

    ALTE: Additional History*

    *Adapted from DePiero AD. Apparent life-threatening events: An evidence-based approach. Pediatr Emerg Pract 2006,3(7)

     2008 Fitzgerald Health Education Associates, Inc.


    Alte ed workup l.jpg
    ALTE: ED Workup exclusively and partially) according to month of age for controls and cases

    • Careful history

      • Most common components

        • Apnea

        • cyanosis

    • Careful physical examination

      • PE may be normal in the ED even in the setting of significant pathology

     2009 Fitzgerald Health Education Associates, Inc.


    Alte diagnostic workup l.jpg
    ALTE: Diagnostic Workup exclusively and partially) according to month of age for controls and cases

    • No evidence-based data on the ED workup of ALTE

    • No consensus on workup

     2009 Fitzgerald Health Education Associates, Inc.


    Alte my ed workup l.jpg

    Chest xray exclusively and partially) according to month of age for controls and cases

    Literature reports ¼ abnormal

    EKG

    Cath Urinalysis

    Basic chemistry

    CBC

    CRP

    Other testing as dictated by pt

    RSV

    Pertussis

    Influenza

    Inborn errors of metabolism

    Toxins (UDS)

    ALTE: My ED workup

     2009 Fitzgerald Health Education Associates, Inc.


    Alte disposition l.jpg
    ALTE: Disposition exclusively and partially) according to month of age for controls and cases

    • No data on who can safely be discharged after ALTE

    • Observation in ED or admission should be considered

    • Even less clear what do to with patients with “marginal” history

    • Monitors change little if anything in this decision process

     2009 Fitzgerald Health Education Associates, Inc.


    Alte high risk l.jpg
    ALTE: High Risk exclusively and partially) according to month of age for controls and cases

    • Age less than one month

    • Multiple episodes

    • Severe episodes

      • Claudis I, et al. Do all infants with apparent life-threatening events need to be admitted. Pediatrics 2007;119:267.

     2009 Fitzgerald Health Education Associates, Inc.


    Alte okay to discharge if l.jpg
    ALTE: Okay to Discharge if? exclusively and partially) according to month of age for controls and cases

    • Single brief, not severe, self-resolving episode

    • Evidence that the cause is non- progressive (e.g., GERD)

    • Infant appears well and has no co-morbidities

      • Fu LY, Moon RY. Apparent life-threatening events and the use of home monitors. Pediatr Rev 2007;28:203.

     2009 Fitzgerald Health Education Associates, Inc.


    Alte sids and monitors l.jpg
    ALTE, SIDS, and Monitors exclusively and partially) according to month of age for controls and cases

    • No data that monitoring prevents SIDS

    • AAP Consensus Statement, 2003

      (Pediatrics, 2003;111:914-7.) http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/914)

      “.. Monitors should not be prescribed to prevent SIDS”

      “.. May be warranted for premature infants at high risk of apnea, bradycardia, and hypoxemia after discharge. . . Limited to 43 weeks PCA or until events stop. ..”

      “parents should be advised that home monitoring has not been proven to prevent SIDS”

     2009 Fitzgerald Health Education Associates, Inc.


    Pitfalls to avoid alte l.jpg

    Appearance exclusively and partially) according to month of age for controls and cases

    Most look well

    URI

    RSV, pertussis

    Repeat event

    Why?

    Tachypnea

    May be acidotic

    Minor trauma

    What am I missing

    Reflux

    Monitors

    Should not use to provide sense of “safety”

    Pitfalls to AVOID: ALTE

    Modified from DePiero AD. Apparent life-threatening events: An evidence-based approach. Pediatr Emerg Pract 2006,3(7

     2009 Fitzgerald Health Education Associates, Inc.


    Most frequent signs and symptoms of anaphylaxis l.jpg
    Most Frequent Signs and Symptoms of Anaphylaxis exclusively and partially) according to month of age for controls and cases

     2009 Fitzgerald Health Education Associates, Inc.


    General descriptive definition anaphylaxis l.jpg
    General Descriptive exclusively and partially) according to month of age for controls and casesDefinition: Anaphylaxis

    “Anaphylaxis is an acute, allergic systemic reaction, during which all or some of the following are present: urticaria/angioedema, upper airway obstruction, bronchospasm, and hypotension. In some cases, these manifestations may be accompanied by cardiovascular and/or gastrointestinal disturbances. Anaphylaxis can be fatal without evidence of cutaneous involvement.”

    Adapted from Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology. 1998.

     2009 Fitzgerald Health Education Associates, Inc.


    Causes of anaphylaxis l.jpg

    Foods: exclusively and partially) according to month of age for controls and cases

    Children: milk, eggs, wheat, soy

    Adults: peanuts, tree nuts, fish, shellfish

    Drugs:

    antibiotics, NSAIDs, vaccines

    Insect stings:

    wasps, bees, fire ants

    Latex

    Idiopathic

    Vaccines

    Radiocontrast

    Biologics

    Rheumatologics, etc

    Exercise

    Causes of Anaphylaxis

     2009 Fitzgerald Health Education Associates, Inc.


    Anaphylaxis the risk is increasing l.jpg
    Anaphylaxis: The Risk Is Increasing exclusively and partially) according to month of age for controls and cases

    • The prevalence of peanut allergy has doubled in American children <5 years old in the past 5 years

      • The prevalence of food hypersensitivities is greatest during the first few years of life, affecting 6% of infants <3 years old

      • Food allergy remains a leading cause of anaphylaxis

    Sampson HA. Update on food allergy. J Allergy Clin Immunol. 2004;113:805-819.

     2009 Fitzgerald Health Education Associates, Inc.


    Fatal food induced anaphylaxis l.jpg
    Fatal Food-Induced Anaphylaxis exclusively and partially) according to month of age for controls and cases

    Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001;107:191-193.

     2009 Fitzgerald Health Education Associates, Inc.


    Children may be different l.jpg
    Children may be different exclusively and partially) according to month of age for controls and cases

    • Children present differently

    • Peds ED Study

      • 526 children with generalized allergic reactions; 57 with anaphylaxis

    • Respiratory symptoms most common

    • Cutaneous features present in only about 80% of patient

    Arch Dis Child. Published Online First: 24 November 2005.

     2009 Fitzgerald Health Education Associates, Inc.


    Diagnosing anaphylaxis l.jpg
    Diagnosing Anaphylaxis exclusively and partially) according to month of age for controls and cases

    • Anaphylaxis may be difficult to diagnose, especially when patients present with

      • Bradycardia

      • Syncope

    Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology. J Allergy Clin Immunol. 1998;101(suppl):S464-S528. Sampson HA. Pediatrics. 2003;111:1601-1608.

     2009 Fitzgerald Health Education Associates, Inc.


    Management of the acute anaphylactic event immediately l.jpg
    Management of the Acute Anaphylactic Event: Immediately exclusively and partially) according to month of age for controls and cases

    • Place in recumbent position, feet elevated

    • Check airway and secure if necessary

    • Administer epinephrine

    • Initiate oxygen

    Lieberman P. Annals Allergy Asthma Immunol. 2005;95:217.

     2009 Fitzgerald Health Education Associates, Inc.


    Epinephrine the treatment of choice for anaphylaxis l.jpg
    Epinephrine: The Treatment of Choice for Anaphylaxis exclusively and partially) according to month of age for controls and cases

    • Epinephrine is the treatment of choice for anaphylaxis

    • There is no absolute contraindication to epinephrine use in anaphylaxis

    Sicherer S. J Respir Dis Pediatrician. 2003;5(5):191-198.

    Simons FE. J Allergy Clin Immunol. 2004;113:837-844.

     2009 Fitzgerald Health Education Associates, Inc.


    Time to demise l.jpg
    Time to Demise exclusively and partially) according to month of age for controls and cases

    35

    Food Stings Drugs

    30

    25

    20

    15

    10

    5

    0

    <1 1-2 2.1-4.5 4.6-6.9 10-20 21-45 46st-99 100-214 >215

    Minutes from First Exposure to First Arrest

     2009 Fitzgerald Health Education Associates, Inc.

    Pumphrey RSH. J Allergy Clin Immunol. 2003;112(2):451.


    Im vs sq epinephrine l.jpg
    IM vs SQ Epinephrine exclusively and partially) according to month of age for controls and cases

    Intramuscular Epinephrine (EpiPen®)

    Subcutaneous Epinephrine

    34 ± 14(5-120) minutes

    p<0.05

    5 10 15 20 25 30 35

    Time to Cmax after Injection (minutes)

    Simons. J Allergy Clin Immunol. 2004;113:838.

     2009 Fitzgerald Health Education Associates, Inc.


    Myths regarding the administration of epinephrine l.jpg
    Myths Regarding the exclusively and partially) according to month of age for controls and casesAdministration of Epinephrine

    • Absolutely contraindicated in ischemic heart disease

    • Absolutely contraindicated in hypertension

    • Epinephrine reduces wheeze but has little effect on blood pressure

    • Other agents (e.g., antihistamines) should be be substituted in milder cases

     2009 Fitzgerald Health Education Associates, Inc.


    Slide241 l.jpg

    Treatment of Anaphylaxis exclusively and partially) according to month of age for controls and cases

    • Subsequent emergency care that may be necessary depending on response to epinephrine

    • Consider:

      • Placement in recumbent position

      • Establish airway

      • O2

      • IV fluids

    • Consider:

      • Epinephrine infusion

      • H1 and H2 Antihistamines

      • Inhaled bronchodilators

      • Corticosteroids

      • Glucagon

      • Vasopressors

      • Transport to emergency department or ICU

    2005 Parameters. J Allergy Clin Immunol. 2005;115:s483.

     2009 Fitzgerald Health Education Associates, Inc.


    Treatment of anaphylaxis l.jpg
    Treatment of Anaphylaxis exclusively and partially) according to month of age for controls and cases

    • Repeat epinephrine if symptoms persist or increase after 10–15 minutes

    • Repeat antihistamine ± H2-blocker if symptoms persist

    • Observe for a minimum 4 hours

    • Discharge patient with an anaphylaxis protocol

      • Refer to allergist

    • Arrange follow-up care, provide EpiPen® or EpiPen® Jr Rx,and education

    • Office staff preparation

    Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology.

    J Allergy Clin Immunol. 1998;101(suppl):S464-S528.

     2009 Fitzgerald Health Education Associates, Inc.


    Epinephrine the treatment of choice for anaphylaxis243 l.jpg
    Epinephrine: The Treatment of Choice for Anaphylaxis exclusively and partially) according to month of age for controls and cases

    • Epinephrine is the treatment of choice for anaphylaxis

    • There is no absolute contraindication to epinephrine use in anaphylaxis

    Sicherer S. J Respir Dis Pediatrician. 2003;5(5):191-198.

    Simons FE. J Allergy Clin Immunol. 2004;113:837-844.

     2009 Fitzgerald Health Education Associates, Inc.


    Slide244 l.jpg

    Epinephrine Is the Drug of Choice; exclusively and partially) according to month of age for controls and casesYet Underutilized

    • Only 49% of 79 children diagnosed in ED in Australia received EpiPen®

    • Only 32% of Canadian children with episodes were given EpiPen®

    • When patients know the antigen they are less likely to keep kit with them

    J Allergy Clin Immunol. 2002:109,s181.

    Allergy Clin Immun Int. 2003:18s.

     2009 Fitzgerald Health Education Associates, Inc.


    Take home message l.jpg
    Take home message exclusively and partially) according to month of age for controls and cases

    • Anaphylaxis is real

    • Anaphylaxis is fatal

    • Anaphylaxis cannot always be prevented, but it can be treated

    • Health care providers can do better

    • Patients and parents can do better

     2009 Fitzgerald Health Education Associates, Inc.


    Slide246 l.jpg

    So what happens when a patient gets exposed to an antigen in an unsuspecting manner, in an unsuspecting place, with an unprepared caregiver?

     2009 Fitzgerald Health Education Associates, Inc.


    Categories of respiratory dysfunction l.jpg
    Categories of Respiratory Dysfunction an unsuspecting manner, in an unsuspecting place, with an unprepared caregiver?

    • Respiratory distress:

      • Increased work of breathing to maintain adequate oxygenation and ventilation

    • Respiratory failure:

      • Compensatory mechanisms fail, inadequate oxygenation and/or ventilation

    • Respiratory arrest:

      • Absence of breathing

     2009 Fitzgerald Health Education Associates, Inc.


    Etiology of respiratory problems l.jpg
    Etiology of Respiratory Problems an unsuspecting manner, in an unsuspecting place, with an unprepared caregiver?

     2009 Fitzgerald Health Education Associates, Inc.


    Hypotension and shock l.jpg
    Hypotension and Shock an unsuspecting manner, in an unsuspecting place, with an unprepared caregiver?

    • Hypotension

      • Decreased systolic blood pressure

    • Shock

      • Inadequate tissue perfusion

      • Inadequate tissue oxygen delivery

      • Shock can occur with normal, low, or increased systolic blood pressure

     2009 Fitzgerald Health Education Associates, Inc.


    Two types of shock l.jpg
    Two Types of Shock an unsuspecting manner, in an unsuspecting place, with an unprepared caregiver?

     2009 Fitzgerald Health Education Associates, Inc.


    Causes of pediatric out of hospital cardiopulmonary arrest l.jpg
    Causes of Pediatric Out-of-Hospital Cardiopulmonary Arrest* (%)

    Table modified and compiled from Table 2 of Brown L. Pediatric Out-of-hospital cardiopulmonary arrest. . Pediatric Emergency Practice, September 2005

    2008 Fitzgerald Health Education Associates, Inc.


    Initial cardiac rhythm identified in children with out of hospital cardiopulmonary arrest l.jpg
    Initial Cardiac Rhythm Identified in Children with Out-of-Hospital Cardiopulmonary Arrest


    Potential causes of pediatric out of hospital cardiopulmonary arrest l.jpg

    Anaphylaxis Out-of-Hospital Cardiopulmonary Arrest

    Asthma

    Auto vs. Pedestrian

    Brain tumor

    Burns

    Cancer

    Carbon monoxide

    Cardiomyopathy

    Complications of prematurity

    Congenital heart disease

    Dehydration

    Drowning or near-drowning

    Dysrhythmia

    Electrocution

    Foreign body aspiration

    Heat stroke

    Inborn errors of metabolism

    Ingestions

    Meningitis

    Motor vehicle accidents

    Myocarditis

    Non-accidental trauma

    Sepsis

    Penetrating trauma

    Pneumonia

    SIDS

    Status epilepticus

    Traumatic Asphyxiation

    Potential Causes of Pediatric Out-of-hospital Cardiopulmonary Arrest

     2009 Fitzgerald Health Education Associates, Inc.


    Outcome of ventricular fibrillation in children l.jpg
    Outcome of Ventricular Fibrillation in Children Out-of-Hospital Cardiopulmonary Arrest

    • If recognized and treated promptly, survival may be up to 35% of the survivors, neurologic outcome may be favorable in the majority

      • Skewed in that this is a hospital study

    Samson RA et AL. N Engl J Med 2006;354:2328-39.

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Outcome of ventricular fibrillation in children255 l.jpg
    Outcome of Ventricular Fibrillation in Children Out-of-Hospital Cardiopulmonary Arrest

    • Ventricular tachycardia or Ventricular fibrillation has a more favorable prognosis if it is the presenting rhythm than if it develops during the course of CPR

    Samson RA et AL. N Engl J Med 2006;354:2328-39.

     2008 Fitzgerald Health Education Associates, Inc.

     2009 Fitzgerald Health Education Associates, Inc.


    Key points for out of hospital cardiopulmonary arrest l.jpg
    Key Points for Out-of-Hospital Cardiopulmonary Arrest Out-of-Hospital Cardiopulmonary Arrest

    • Pediatric out-of-hospital cardiopulmonary arrest is uncommon

    • The most common initial rhythm is asystole

    • Most cases of cardiopulmonary arrest occur at home

    Brown, L, Pediatric Emergency Practice, 9-2005

     2009 Fitzgerald Health Education Associates, Inc.


    Key points for out of hospital cardiopulmonary arrest257 l.jpg
    Key Points for Out-of-Hospital Cardiopulmonary Arrest Out-of-Hospital Cardiopulmonary Arrest

    • The majority of cases of pediatric cardiopulmonary arrest occur in the first year

    • Although AEDs are now available for children, PAD programs are unlikely to be effective

    Brown, L, Pediatric Emergency Practice, 9-2005

     2009 Fitzgerald Health Education Associates, Inc.


    Should family be present during invasive procedures resuscitation l.jpg
    Should family be present during invasive procedures/ resuscitation?

    1200 physicians; 83% reported participation in resuscitations with family present

    50% believed it helpful for the family

    93% would allow families present

    70% thought this would be stressful for residents though 80% thought residents should be trained in this

    Gold KJ, Forenflow DW, Schwenk TL, Batton SL. Physician experieince with family presence during CPR in children. PediatrCrit Care Med 2006;7:428-33.

     2009 Fitzgerald Health Education Associates, Inc.


    End of presentation l.jpg
    End of Presentation! resuscitation?

    Thank you for your time and attention.

    John D. Rowlett, MD, FAAP

    Website: www.fhea.com E-mail: [email protected]

     2009 Fitzgerald Health Education Associates, Inc.


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