Inching closer to discharging an ICH from the ED?

A few years ago, I was with an attending who was discharged a pediatric patient.  Staff in general seemed hesitant, but this was a well-loved doc who’s reply was somewhere along the lines of, “this kid looks great! Do you know how many times my kids probably had a bleed and did fine? We over CT these young things! And if he has a bleed, what are they really going to do anyway besides charge a lot of money for no appreciable intervention?”

And with that, comes this retrospective single center study of 202 children 0-18 years of age with an acute CHI, an abnormal CT (defined as both nondepressed and depressed skull fractures, subdurals, epidurals, subarachnoids, intraparenchymal hemorrhage, and intraventricular hemorrhage), and a GCS 14 or higher.

Essentially, the question is, can these patients be safely treated in an obs unit?

Exclusions were multisystem trauma, nonaccidental trauma, prior neurosurgical conditions and coagulopaths were excluded as well.   86% of patients were 5 years of age and under, and only half of all patients presented to the ED in under 6 hours.  My first reaction to this was “huh?” –  but the authors go on to state the 73% of patients had a hematoma, 11% had LOC, 30% vomited, 28% had a change in behavior, etc… so I guess it makes sense that there was a delayed presentation since parents may have initially thought their child was alright, only to later to suspect something was afoot (or perhaps patients were transferred to their ED from outside facilities?).

Fun sidenote: 17% of patients had no exam findings, so I gotta ask – why were they scanned?  To put it another way, much like the aforementioned doc had asked- how many kids have we discharged without a head CT with clinically insignificant ICH?

 

So what did the authors find?  ZERO children were intubated, required neurosurgical intervention, PICU admission, or died.  All were discharged within 72 hours, and 86% of patients with >1 CT finding were discharged within 24 hours!   Surprisingly, this is actually somewhat consistent with prior studies.

 

Ultimately, before starting this at your institute, note that there are some subtleties in the data- like that 25% epidurals with a repeat CT (3 of 12) showed a larger bleed. But really, looking at the data on patients that were admitted, I have to ask – which of these *really* needed an admission? None had an intervention aside from continued analgesia / anti-emetics.

 

Of note, this hospitals EDOU had an admission rate of 3-4 % – wayyyyy below national average of 15-20% – so either they’re sending home a ton of kids from obs unnecessarily, their ED is placing way too many in obs, or the rest of us have it wrong.  Which leads me to agree with the authors on the following:

“For those well-appearing children in whom CT abnormalities are visualized, an EDOU is still an appropriate place for these patients, or should early discharge with home observation also be considered?”

 

Will we see a time when certain types of head bleeds are treated like low risk chest pain – accelerated protocols and an abundance of EBM suggesting early discharge? Or arranging for telemedicine to circumvent many of these transfers to tertiary care centers?

SCI still rare in kids.

This paper demonstrates that once again, kids are quite durable.

The authors looked at 3701 patients under 19 years old evaluated for a cervical spine injury. Of the 44 patients with clinically significant cervical spine injury (CSI), 32 had plain films, none of which missed an injury.

32 out of 3701… or 0.86%

-There were ZERO patients under two years old with a CSI

Here is the caveat- one injury begets another. Of the 32 patients with CSI, ten (31%) had multiple lesions, with plain films not identifying all lesions in 4 patients. Given that, I think its fair to say CT (or admission for MRI) is warranted once an abnormality is found.

In summary, relevant cervical injuries in kids are rare (<1%), and plain films are a reasonable screening tool. CT is once again rarely needed, but beware since one injury seemingly begets another. I pretty much agree with the authors on this one,

“Our calculated 100 % sensitivity (90% on PECARN, finding 168 of 186 CSI) does come with a large confidence interval and it should be expected that plain film’s sensitivity for CSI is likely lower in clinical practice. However, the small risk of missed injuries from plain films must be balanced against the increased risk of malignant trans- formation from performing CT scans on all children with suspected CSI. “

Should you MRI Salter Harris 1’s?

As I’ve discussed, oh, once, twice, or maybe three times in the past, ankle or wrist sprains (or even buckle fractures) do NOT need a splint.  Today’s article from JAMA Pediatrics  echoes this sentiment. 

We’ll keep this simple: 271 patients aged 5-12, with a clinically suspected Salter Harris Type one ankle fracture were approached, 140 parents consented to participate.  All patients were initially placed with a removable brace (hooray!), then underwent bilateral ankle MRI imaging (?!?! boo!!!) one week later. 

Of the 135 patients that underwent MRI imaging, 4 (3%) had MRI confirmed Salter Harris type 1 fractures, 2 of which had partial growth plate injuries.  108 (80%) pateitnts had ligamentious injuries and 27 (22%) patients had isolated bone contusions.  38 patients had radiographically occult fibular avulsion injuries. 

Importantly, of those with MRI detected fractures, there was no difference in outcomes from those without fractures (82% vs 85.5% on the Activity scale for Kids score).

So… while you can certainly MRI these patients – and find things – the question is, if they are not clinically relevant, why do it in the first place?

Do we need to give (alot) more Magnesium to asthmatics?

Some of us have quirky things we like to do that not everyone else does– dexamethasone for sore throats, ketamine for the agitated patient (or anything really), et cetera… This paper looks at one of those things – Magnesium in asthmatics. 

This was a prospective, randomized open-label study of patients between 6 and 18 years of age over a two year period who presented to an ED in Asuncion, Paraguay and were admitted for a severe asthma exacerbation.  Patients were excluded if given antibiotics before or during the ED visit, febrile, or if there was suspicion for infectious etiology.  All patients enrolled had no relief despite 2 hours of treatment which included dexamethasone 0.2mg/kg IV, nebulized salbutamol every 20 minutes up to 5mg and nebulized albuterol every 2 hours.  There were two treatment arms, each with 19 patients: one received a 50mg/kg bolus of MgSO4, while the other group received 50mg/kg/hr/4 hrs (ie, up to 2g / hr for 4 hours – up to 8g total).  Physicians in charge of patient disposition, after the initial 8 hours, were not part of the study group and blinded to the treatment received.  Primary outcome was discharge at 24 hours, with secondary outcomes total LOS and cost implications.  The two groups were similar in terms of age, sex, initial Wood-Downes asthma score, and peak flows.

Despite the numerous downfalls to this study (single center, open-label, prospective, small sample size…), the results are intriguing- bolus magnesium had an average LOS of 48 hours vs 34 hours for high dose prolonged infusions, had a higher cost ($834 vs $603), and fewer patients with a LOS <24 hrs (10.5% vs 47.4%).  It took almost two years to get under 40 patients in this single-center study,  but still, there were no adverse events and no bounceback visits within a week from discharge.  Interestingly, there were no obese patients in the study – so how applicable this study is to the US patient population, I do not know (plus, salbutamol is not widely used for acute asthma in the US).   That, and even for this mag-o-phile 8g per hour for 4 hours seems like alot!

Should this change your practice?  Not quite yet – unless you’re not giving magnesium.  In the meantime, I’ll add another one to the list of trials I’d love to see.

Increased sono, decreased negative peds appy rate.

Academia and community ED settings are very different, and sometimes one community to the next is often times very different as well. This study– which included 35 pediatric ED’s and 52,000+ cases of appendicitis demonstrates this. Essentially, the authors took all their appendicitis data from 2010-2013, and looked at what imaging, if any, the patient received, negative appendectomy rates, length of stay, frequency of perforation, and 3 day bounceback rates from initial ED visit (ie, did ultrasound or CT “miss” an eventual appendicitis?)

Ultrasound use increased from 24% in 2010 to 35.3% in 2013 for the sole diagnostic modality in what eventually was diagnosed as appendicitis. CT rate decreased 21.4% in 2010 to 11.6% in 2013. Almost 50% of the patients (25,254 out of 52,153) had neither CT or US (!). The negative appendectomy rate in 2010 was 4.7%, while in 2013, it was 3.6%. There was no difference in length of stay, frequency of perforation, or 3 day bounce back rates from 2010 to 2013.

Ok. If you work in a community ED, raise your hand if 50% of your potential appendicitis cases get seen by surgery without any imaging. Only 11.6 % CT use? I think most community surgeons would be less than thrilled to be called at 2am for a “rule out” appendicitis evaluation without imaging.

While I think the authors live in an alternate universe, I think this paper makes a great argument to do the right thing. It would be great if non-academic settings could utilize US and surgical consultations for a “hot belly” without shipping them off to radiology. Or better yet, have surgery perform POCUS with you to confirm findings.

Paging Dr Buckle, Part Two.

Soft shell taco, sir?
http://www.ncbi.nlm.nih.gov/pubmed/24350129

We can add two more pieces of literature to suggest that removable splinting alone is sufficient for the management of distal forearm torus fractures. This piece looked at 142 pediatric patients randomized to short arm cast or removable wrist splint for 3 weeks without a significant difference in pain, compliance, or complications.

Then there is this article that looked at 119 consecutive pediatric torus fractures over a one year period seen by an APRN who were immobilized with a soft cast. There were no adverse events, and no subsequent visit to fracture clinic. In comparison to previous standards of fracture clinic referral, there was a cost savings of $18596 euro (20k USD) in total.

The AAOS says, “The use of removable splints is an option when treating minimally displaced distal radius fractures.”  Since this 2009 recommendation, there are now 5 publications (the two articles above, plus three from this previous post suggesting nondisplaced pediatric Torus fractures can be safely treated with a removable splint at a significant cost savings to all involved.

Stop with the IV Zofran for Peds Gastroenteritis.

Quick:

How much does a liter of Normal Saline cost?

If you said $400 or more, you win, and if you ordered it without PO challenging your patient, your patient just lost. Now for children, ask a parent what they would rather prefer – having their terrified & vomiting child stuck few times & made miserable – all for over $400! – or an attempt at giving the same medication orally to watch and see how the child does?

Put it that way, and parents now see the light. Bottom line is that they do not want to see their child suffer any more than we want to hear them yell down the hall after getting stuck 4 times. And besides, how much of that liter of Normal Saline that you ordered gets placed intravascularly?

about an 8oz can of delicious Shasta Ginger Ale. ( or about 25 % ) 

The Evidence:

A Cochrane Review found the NNT from providing oral Zofran reduced hospital admissions (NNT: 17), and oral zofran / oral hydration vs IV Zofran / IV hydration made no difference in 72 hour bounceback or readmission – treat 6 patients with PO hydration first to prevent 1 IV placement.

A separate Cochrane Review found 1 in 33 patients given oral Zofran developed a paralytic ileus, but this was no different than the recommended low osmolarity solutions recommended by the World Health Organization. For every 25 children treated with PO Zofran, one would fail and require an IV.

Its part of the Choosing Wisely Campaign. I’ve had conversations with parents about IV or PO zofran, and most prefer not have their child tortured. They leave the ED sooner and happier, without compromising safety. Document a repeat abdominal exam, give good belly precautions to family, and you have saved everyone a good bit of time and hassle.

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Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework.  PMID: 22815462 

Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. PMID: 16856044

Removing Suture Removals From Your ED.

After waiting 2 hours to get sutured at their local ED, why should patients wait another 2 hours to get their sutures removed? Wouldn’t it be awesome if there were an easier way to do this?

There have been RCT for absorbable vs non-absorbables with done by orthopaedics, plastics, colorectal surgery, and general surgery. They have found no difference in infection rate. Patients are reportedly more comfortable with the absorbables in place. They report better cosmetic outcomes.

ED studies have been done amongst all flavors of lacerations- pediatric facial lacs, pediatric traumatic lacs, and all ages facial lacs & traumatic lacs. There are no significant differences in rates of infection, wound dehiscence, or keloid formation. In terms of future preference, caregivers & parents favored absorbables.

So why don’t providers favor them?

FWIW, I recommend fast acting gut or vicryl rapide. I find it takes a little bit longer to complete suturing since the thread is clear, and sometimes it breaks easier when tying knots so I bring an extra pack.  Otherwise, they work well!

 

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Cosmetic outcome and surgical site infection rates of antibacterial absorbable (Polyglactin 910) suture compared to Chinese silk suture in breast cancer surgery: a randomized pilot research. PMID: 21528565

A Randomized, Controlled Trial Comparing Long-term Cosmetic Outcomes of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut Versus Nonabsorbable Nylon Sutures. PMID: 15231459

Emergency department repair of hand lacerations using absorbable vicryl sutures.PMID: 9348057

Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable and non absorbable sutures PMID 15258862

Does the choice of suture material affect the incidence of wound infection? PMID: 1106807

Randomized controlled trial comparing subcuticular absorbable suture with conventional interrupted suture for wound closure at elective operation of colon cancer. PMID: 24439741

Continuous Absorbable Intradermal Sutures Yield Better Cosmetic Results than Nonabsorbable Interrupted Sutures in Open Appendectomy Wounds: A Prospective, Randomized Trial. PMID: 24318410

Most PO antibiotics are equivalent to their IV counterpart.

If you have ever said to a patient – and meant it – that they needed to stay for “antibiotics in the IV” and you were not giving CefeVancoSyn, read further and take your educational beating.  There is a paucity of data on IV being equivalent to PO, but at least there is some – and its reviewed in this post.  However, there is no significant data on an IV antibiotic being better, faster, stronger than its PO counterpart – for just about anything clinically significant, except for very antibiotic-specific instances (example: IV vs PO vanco, for SSTI or CDiff).

In a comparison of PO Augmentin vs IV Augmentin transitioned to PO Augmentin vs IV Cephalosporin transitioned to PO Cephalosporins for lower respiratory tract infections, there were no significant differences between clinical outcome or mortality. Patients in the PO only group, shockingly, had a reduced hospital stay.

In a Cochrane Review, oral treatment has been show to be an acceptable alternative to IV antibiotic treatment in febrile neutropenic patients without pneumonia or skin / soft tissue infection, organ failure, or central line infection, who are also hemodynamically stable. Mortality and treatment failure were similar. I am not saying to discharge them on oral antibiotics from the ED – despite MASCC saying you can – but you may transition them home sooner and stop the snowball effect “the need for IV antibiotics” can have on a patient.

There are a handful of studies which show PO antibiotics equivalent to IV antibiotics for initial management of pediatric pyelonephritis – with comparable renal scarring, adverse reactions, and treatment failure as well.

Next time you start IV Levaquin for “a loading dose” on a patient that can tolerate oral antibiotics, think about this post, the added cost to the patient, and nursing time spent setting up IV treatment. Stop the snowball effect in the ED, the patient can continue PO on the floor, and likely leave the hospital sooner, without compromising safety.

Do NOT even consider “an IV dose in the ED and go home.”

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Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients. PMID: 15495074

Oral versus intravenous antibiotics for community acquired lower respiratory tract infection in a general hospital: open, randomised controlled trial. PMID: 7787537

Are oral antibiotics equivalent to intravenous antibiotics for the initial management of pyelonephritis in children? PMID: 21358894