Improving Outcomes, Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pediatrics

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 films 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.

Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pediatrics

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?

Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pediatrics, Pulmonary

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.

Improving Throughput, Mythbusting, Pediatrics, Pediatrics

Paging Dr Buckle, Part Two.

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.

Critical Care, Improving Outcomes, Mythbusting, Pediatrics, Pediatrics

Discharge the LP with 4 WBCs? Not so fast…

At what point do you consider discharging a patient after an LP? Less than 5 WBCs in CSF?  Less than 10?  Less than 20?  What if, after you have empirically given them dexamethasone, ceftriaxone, and compazine, they feel well and have only 8 WBCs?  Perhaps you’re using the bacterial meningitis score?

Well, a single-center study recently looked at outcomes for CSF culture positive bacterial meningitis for pediatric patients, aged 1 month to 18 years.  35% of these patients were under 3 months young, another 26% were 4-11 months, while only 7% were 7-10 years young, and another 4.6% 11-18 years young, so the data was quite skewed towards a younger population, which probably reflects our higher frequency of doing LPs in these age groups.  They excluded traumatic taps.

Bad outcomes were defined as physical or psychological morbidities lasting longer than 6 months after the meningitis episode, including mental retardation, cerebral palsy, ataxia, hearing impairment, and epilepsy.  Lost to follow up was defined as an inability to reach the patient at 6 months after the meningitis episode.  Sequelae were defined as physical or psychological morbidities lasting longer than 6 months after the meningitis episode, including mental retardation, cerebral palsy, ataxia, hearing impairment, and epilepsy.  Lost to follow up was defined as an inability to reach the patient at 6 months after the meningitis episode.

The results?Screen Shot 2015-01-05 at 10.06.00 PM

The numbers are small, but the message concerning:  patients with >5000 WBCs had essentially the same prognosis as those with <5 WBCs.  There have been case reports of this in adults, generally with poor outcomes.  Going forward, if patients have any WBCs, consider placing patients in observation for monitoring and consideration of repeat LP.

GI, Improving Outcomes, Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pediatrics

Stop with the IV Zofran for Peds Gastroenteritis.


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?

Screen Shot 2014-03-15 at 1.14.56 PM

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.


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
Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pulmonary, Pulmonary

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.”




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

Pediatrics, Pediatrics

A Call for Appropriate Care for Pharyngitis

There has been a fair amount of twitter buzz about antibiotics for strep throat, and, given the number of pediatric sore throats I have seen this month, it is time to revisit the evidence on this topic.

The major concern for providers is post streptococcal glomerulonephritis, rheumatic fever, and abscess formation. The major concern for parents is the suffering of their child.

Even the IDSA states that PSGN and ARF are extremely rare in the developed world. A recent Cochrane Review reviewed 12,835 cases of sore throat, and found there were too few cases of PSGN to make any conclusions. Mortality from PSGN? 0.028 per 100,000 in North America. (Fun facts, 23.8 per 100,000 in sub-Australia and 4.32 per 100,000 in Mauritius!) As for abscess formation, I was only able to pull up a single retrospective analysis from the UK of 606 cases of peritonsillar abscesses. They conclude that providing an antibiotic on initial evaluation does not significantly reduce the risk of developing an abscess – i.e., providing antibiotics to a sore throat does not reduce the number of PTAs. There is no protective or preventative effect.


So what is the best way to treat the family’s concern?


The pink elephant in the room…

A Cochrane Review of 5352 patients shows penicillin, cephalosporins, and macrolides all have similar efficacy. You have the choices of bicillin x 1 dose, Penicillin x 10 days, the beloved Z-pack, or 5 days of Cefuroxime or Clarithromycin. You have about 12-16 fewer hours of pain with antibiotic treatment. But with that said, a randomized trial of 700 patients, comparing 10 days of antibiotics to 3 days of watchful waiting to no prescription found that 69% of the watchful waiting group did not fill the script. There was no significant differences in duration of illness, missed school or work days, proportion of patients satisfied, and percentage of patients better by Day 3 amongst all three groups. The number needed to harm (diarrhea, abdominal pain, nausea, etc) is ten.



Steroids have been shown to increase the likelihood of resolution of pain at 24 hours by more than three times. The NNT? Under 4. Route does not matter – oral decadron seems as efficacious as IM. Oral dexamethasone daily for three days seems to work faster than a one time dose at resolving pain, but there is no change in return to activity level between one time dosing and 3 day dosing.


Jenny McCarthy

As you are wrapping up your discussion with the family, mom drops the bomb that she does not believe in antibiotics, steroids, or vaccinations for that matter. Not coincidentally, she loves yoga, PETA, and natural remedies. What else can you do? In trials that are admitted not of high quality, a few Chinese herbals seem to work reasonably well. Compound dandelion soup was more effective than penicillin, and Yanhouling mixture was found to be more effective than an atomized gentamicin inhalation (the obvious standard of care). Benzocaine lozenges performed superior to placebo for short-term pain control with onset within 20 minutes on average without adverse effects in a study of 165 patients.


The gist: I encourage and offer PO steroids as a one time dose to all sore throats. My facility swabs throats in triage, so I try and do wait & see treatment for positive swabs. I’ll also offer anesthetic lozenges, but not quite willing to discuss Chinese Herbals yet.


  1. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America
  2. Use of antibiotics for sore throat and incidence of quinsy. PMID: 17244424
  3. Antibiotics for people with sore throats. PMID: 17054126
  4. Systemic Review: Estimation of global burden of non-suppurative sequelae of upper respiratory tract infection: rheumatic fever and post-streptococcal glomerulonephritis. PMID: 21371205
  5. Different antibiotics for group A streptococcal pharyngitis. PMID: 20927734
  6. Chinese medicinal herbs for sore throat. PMID: 22419300
  7. Antibiotics for sore throat. PMID: 24190439
  8. Open randomised trial of prescribing strategies in managing sore throat. PMID: 9116551
  9. Corticosteroids for pain relief in sore throat: systemic review and meta-analysis. PMID: 19661138
  10. A randomized clinical trial of oral versus imtramuscular delivery of steroids in acute exudative pharyngitis. PMID: 11772663
  11. A pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis. PMID: 16732143
  12. Efficacy of a benzocaine lozenge in the treatment of uncomplicated sore throat. PMID: 22015737