Intranasal Ketamine

I am delighted to bring you this special episode of PEM Currents, the Pediatric Emergency Medicine podcast. It’s all about intranasal ketamine and its use for acute pain management in the Pediatric Emergency Department. I had the pleasure of interviewing Theresa Frey, Assistant Professor from the Division of Emergency Medicine at Cincinnati Children’s. Theresa is the 2016 winner of the Ken Graff Award from the AAP’s Section on Emergency Medicine. Funding from the award supported her study comparing intranasal fentanyl and intranasal ketamine in a randomized controlled trial for the treatment of acute, long bone fracture pain. We talk about the existing evidence, what’s to come in the future and how you can learn more about intranasal ketamine.

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References

Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children With Limb Injuries. Annals of emergency medicine. 2015;65(3):248-254.e241.

Reynolds SL, Bryant KK, Studnek JR, et al. Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2017.

Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: a pilot study. Emergency medicine Australasia : EMA. 2013;25(2):161-167.

Pelvic Avulsion Fractures

Pop goes the apophysis! In teenage athletes the apophyseal cartilage is the weak point along the pelvic rim. Learn about these common injuries in this edition of PEM Currents, the Pediatric Emergency Medicine podcast.

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References

Kocher MS, Tucker R. Pediatric athlete hip disorders. R.Clin Sports Med. 2006 Apr;25(2):241-53, viii.

Pediatric Emergency Medicine Morsels: Pelvic Avulsion Fractures

Acute Flaccid Myelitis

Acute Flaccid Myelitis is a rare but serious disease characterized by rapid onset of muscle weakness. Diagnosis also requires an MRI with lesions in multiple spinal levels or CSF pleocytosis. cases have been reported over the past several years and though a specific cause is unknown strains of enterovirus are suspected culprits.

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References

AAP – Acute Flaccid Myelitis in Children

CDC / Council of State and Territorial Epidemiologists: Revision to the Standardized Surveillance and Case Definition for Acute Flaccid Myelitis

CDC: Acute Flaccid Myelitis

Otitis Externa

With summer pool season in full swing allow me to freestyle a little on a common topic that many Emergency Departments and Urgent Cares seem to be swimming in every summer. This episode of PEM Currents dives right into Otitis  Externa – AKA Swimmer’s Ear and reviews diagnosis and treatment. If you were treading water and looking for this topic the wade is over.

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References

Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care. 2004;20(4):250.

Osguthorpe JD, Nielsen DR. Otitis externa: Review and clinical update.. Am Fam Physician. 2006;74(9):1510.

Roland PS, Younis R, Wall GM. A comparison of ciprofloxacin/dexamethasone with neomycin/polymyxin/hydrocortisone for otitis externa pain. Adv Ther. 2007;24(3):671.

Rosenfeld RM, Singer M, Wasserman JM, Stinnett SS. Systematic review of topical antimicrobial therapy for acute otitis externa. Otolaryngol Head Neck Surg. 2006;134(4 Suppl):S24. 

Russell JD, Donnelly M, McShane DP, Alun-Jones T, Walsh M. What causes acute otitis externa?J Laryngol Otol. 1993;107(10):898.

Kawasaki Disease

Kawasaki Disease, AKA Mucocutaneous Lymph Node Syndrome, is one of the most common vasculitides of childhood. The hallmark is fever ≥5 days plus 4/5 of the following; mucous membrane changes, conjunctivitis, polymorphous rash, extremity changes and lymph node enlargement. It can also lead to coronary artery aneurysms, which is why its so important to make an accurate diagnosis.

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References

Dominguez SR, Anderson MS, El-Adawy M, Glodé MP. Preventing coronary artery abnormalities: a need for earlier diagnosis and treatment of Kawasaki disease. Pediatr Infect Dis J. 2012 Dec;31(12):1217-20.

Kawasaki T. Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children. Arerugi. 1967;16(3):178.

McCrindle BW, Rowley AH, Newburger JW, Burns JC, Bolger AF, Gewitz M, Baker AL, Jackson MA, Takahashi M, Shah PB, Kobayashi T, Wu MH, Saji TT, Pahl E, American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Epidemiology and Prevention. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association.. Circulation. 2017;135(17):e927. Epub 2017 Mar 29.

Son MB, Gauvreau K, Ma L, Baker AL, Sundel RP, Fulton DR, Newburger JW. Treatment of Kawasaki disease: analysis of 27 US pediatric hospitals from 2001 to 2006. Pediatrics. 2009;124(1):1.

Acute Otitis Media

OK, so this is the least exciting topic in Pediatric Emergency Medicine… With that being said, you will all see it. And we need to be good at looking at ears, diagnosing acute otitis media, and appropriately choosing when and which antibiotic to prescribe.

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References

Karma PH, et al., Pneumatic otoscopy and otitis media: The value of different tympanic membrane findings and their combinations. In: Recent advances in otitis media: proceedings of the Fifth International Symposium, Lim DJ, Bluestone CD, Klein JO, et al (Eds), Decker, Burlington, Ontario 1993. p.41.

Lieberthal et al., The Diagnosis and Management of Acute Otitis Media. Pediatrics, March 2013, Volume 131 / Issue 3.

Rothman et al., Does this child have acute otitis media? JAMA. 2003;290(12):1633.

Shaikh et al., Development of an algorithm for the diagnosis of otitis media. Acad Pediatr. 2012;12(3):214. Epub 2012 Mar 28.

Thompson M, et al., Duration of symptoms of respiratory tract infections in children: systematic review. TARGET Programme BMJ. 2013;347:f7027. Epub 2013 Dec 11.

Venekamp RP, et al., Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 201.

Dental Infections

To tell you the tooth you’ll probably see quite a few kids with dental related complaints in the Pediatric Emergency Department. This can range from cavities to invasive infections. Brush up on all things dental infections in this episode of PEM Currents. And yes, those puns were intentional. I must’ve flossed my mind!

PEMBlog Briefs: Odontogenic Infections 

Sandor et al. Antimicrobial Treatment Options In the Management Of Odontogenic Infections. Journal of the Canadian Dental Association, 1998.

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Testing for Influenza

You don’t need a flu test to diagnose the flu! But there are situations where rapid antigen testing or PCR is valuable. Listen to this episode of PEM Currents, the Pediatric Emergency Medicine podcast, to learn more about the test characteristics of common assays and when to obtain testing when prevalence rates for the flu are high.

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References

CDC: Rapid Diagnostic Testing for Influenza

CDC: Guidance for Clinicians on the Use of RT-PCR and Other Molecular Assays for Diagnosis of Influenza Virus Infection

Silvennoinen H, Peltola V, Lehtinen P, VainionpääR, Heikkinen T. Clinical presentation of influenza in unselected children treated as outpatients. Pediatr Infect Dis J. 2009;28(5):372. 

Merckx J, Wali R, Schiller I, Caya C, Gore GC, Chartrand C, Dendukuri N, Papenburg J. Diagnostic Accuracy of Novel and Traditional Rapid Tests for Influenza Infection Compared With Reverse Transcriptase Polymerase Chain Reaction: A Systematic Review and Meta-analysis. Ann Intern Med. 2017 Sep 19;167(6):394-409. doi: 10.7326/M17-0848. Epub 2017 Sep 5.

Mansour et al. Comparative Cost Analysis Between PCR Testing and DFA Testing for Diagnosing Respiratory Virus Infections. American Journal of Clinical Pathology, Volume 144, Issue suppl_2, 1 October 2015, Pages A209.

Bronchiolitis

I’m sure that you’ll probably see a case of bronchiolitis this winter. Call it a hunch. In this episode of PEM Currents you’ll learn why suctioning and ensuring hydration are still the mainstays of therapy, and why albuterol, racemic epinephrine, steroids and more don’t have a place in routine cases. And if you read any publication to supplement this podcast make it the most recent American Academy of Pediatrics Guideline on Bronchiolitis.

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