Improving Throughput, Mythbusting, Pediatrics

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?

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Improving Outcomes, Pediatrics

Baby LPs, ultrasounds, and fragility

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How fitting that the SMACCdub talk, What Scares You, has recently been released, and, to some extent, discusses pediatric bleeding. Well, this paper discusses high risk peds (febrile infant <60 days) and (post LP) bleeding, and whether or not ultrasound assisted guidance helps.

SPOILER ALERT: (it probably does).

From February 2007-December 2007 (wow, talk about a knowledge translation delay), the authors attempted to enroll 46 total patients to either standard LP without ultrasound vs ultrasound assisted LP. Here’s one key point – while ultrasound guidance means direct visualization of the needle into the desired space (like for central lines or paracentesis), ultrasound assisted means that landmarks were sonographically visualized, and then they marked the skin and estimated how deep was too deep for the needle, then performed the LP (without direct visualization.-Basically they performed an ultrasound to determine a “maximum safe depth” to limit needle advancement to avoid traumatic taps, since this is a common element of LP failure in this age group.

Patients with known spinal abnormality or VP shunt were excluded, and the procedures were done by either a house officer or pediatric NP with MD oversight (so, I’m not certain how applicable this is to those of us with significant experience in this age group). Unfortunately, the study was terminated prior to reaching their goal of enrolling 23 patients into each group due to academic calendar demands of the lead author (21 vs 22 patients in either arm – meh.) Success was defined as <10k RBC and whether or not CSF was obtained. Their 5 month historical failure rate was 44%.

The groups did not differ in terms of prematurity, patient weight or length, there was a lower median age in ultrasound assisted group (38 days vs 45 days p=0.02), which may give them a bit more of an uphill battle. The results are seen below:

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On first glance, these look good – less frequent traumatic taps, more frequently obtaining CSF with NNTs of 3.7 and 5.6 respectively. However, with such a small sample size, a Fragility index of 1, and having house officers and NP’s do the tap (with an unclear level of experience), I’m not certain this is broadly applicable to all providers, particularly when you add that 19 sono-assisted attempts are not enough to reach 80%  success in this study.  With that said, we commonly perform interventions with much lower NNTs with higher risks to the patient than a few ultrasonic waves. This is a cant hurt, will probably help intervention that we should probably be utilizing more frequently for all of our patients, not just our pediatric population.

For a great review on this topic check out sonomojo for more on ultrasound use for LPs.

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Mythbusting

PA’s- making Ada Plumer Proud.

Many years ago, nursing was not allowed to place IVs. Now, in some places, they place ultrasound guided PICCs, and in a handful of places, ultrasound guided central lines.   Nursing can titrate vasopressors, and in some facilities, they run ACLS during codes.

 

So…. Have you ever experienced or asked “for the doctor (or consultant)?”

Have you ever been concerned and wondered do PA’s provide appropriate care in the ED?

This study is done at the world famous Our Lady of Lourdes in Camden,NJ, with none other than the EM famous Al Sacchetti- and should aim to answer some of these concerns, at least in the pediatric population

Over a 24 month period, over 10,000 patients age 6 or younger were restrospectively evaluated for bounce back rates and broken down into 3 groups based on their provider: attending only care, PA only care, or co-evaluation by both EP and PA.  Here’s the twist- in this department, policy permits PA’s to evaluate treat and discharge patients of any age independent of the attending physician.  There are no specific protocols for assigning specific patients to specific providers, though they do state that PA’s do not perform LP’s in the study department, and that febrile infants <8 weeks were brought to the immediate attention of the attending physician by the triage nurse.  Essentially, the PA seemingly functions at a high level and fairly autonomous.

So what’d they find?  Are you more likely to “bounceback” based on who you’re seen by?

Well, as one would likely expect, a higher percentage of higher acuity patients were seen by the attending physician (85% ESI-2, 70% ESI-3, 60% ESI 4/5.), and the younger the patient, the more likely they were an “attending only” case.

Bounce backs?  Only 0.4% of PA only cases vs 0.6% of attending only cases bounced back and were admitted – not statistically significant – and below the national average of 0.83%.  Only 0.9% of PA only cases were admitted vs 4.1% of attending only cases (and 3.4% of PA/MD cases.  This was statistically significant, and likely reflects higher acuity of the cases the MD is involved in.  There was a higher rate of return visits in MD only cases – 8% vs 6.8% (statistically significant) – but the rate of return for combined MD/PA cases was highest – 9.3%.

Amongst ESI 2,3, & 4s, bounceback rates for EP only eval was consistently higher than PA only eval, and bounceback rates for MD/PA co-evaluation was consistently higher than both PA only and MD only eval.

So, what’s the take home?  For one, its that PA’s can provide high level care without a significant drop off in care… and that in order for medicine to progress, we have to cognitively offload to expand our boundaries.  This may include expanding services to nursing or PAs (as discussed above)…

And here is the most important message:

Dont be that person – if someone (nursing, PCA’s, PA/NP’s, etc) comes to you with a concern – go see a patient.  We’re all on the same team.  Take it as a compliment – as evidenced by this paper it’s likely a complex or clinically ambiguous case with a higher bounceback rate, and who doesnt like a challenge!

 

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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.

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Improving Outcomes, Pediatrics

Peds Concussions last a looong time

Little Billy is a star hockey player at 13 years old.  So much so, that he is pushing the envelop and playing with the 14-16 year old class.  Billy gets checked into the glass one day and visits your ED, clearly concussed.  He’s dizzy, easily irritated by family, nauseated, and, of course, has a headache.  How long will these symptoms last? 

The Zurich Protocol suggests that most symptoms are resolved within 10 days, with 5-10% having prolonged symptoms.

However, this is the second study I’ve seen that suggests a prolonged duration in pediatrics.  This prospective cohort study of patients aged 13-18 years of age with an ED diagnosis of concussion were referred to one of 3 hospital-affilated sports medicine clinics.  The patients were evaluated using a variety of methods (neurological exam, computerized neurocognitive testing, post concussion symptom score), with duration of symptoms the main outcome.  Mean symptom duration was 44.5 days, with 48% of patients having symptoms beyond 28 days, and 13% of patients having symptoms persisting beyond 90 days (!).  Essentially, the less physically mature the patient, the longer it took for symptoms to resolve – 54.5 days vs 33.4 days to complete recovery.

Given the high likelihood that Billy will have prolonged symptoms, it would behoove those of us on the frontline to educate parents about this, and set up family expectations accordingly.

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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?

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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.

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