Digest of Dr. Herbert’s Monthly Audio CME Series: Myths in EM

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A digest of Mel Herbert’s monthly audio CME series
edited by Chris Feier, MD

1. Myths in EM

by Andrew Johnson, MD
Myth:     Do not use antiemetics in children with gastroenteritis
Truth:     Ondansetron decreases vomiting, improves oral intake. -Significantly more diarrhea in Zofran group (1.4 episodes versus 0.5, p<0.001). May give anti-emetic while in waiting room and immediately begin oral rehydration. Phenergan not an ideal anti-emetic in pediatrics because of side effects, particularly respiratory depression in children less than 2 years old.

Myth:     Nailbed injuries must be repaired

Truth:    Tintinalli says: if >25% hematoma→ remove nail, explore, repair any injuries (myth)

Trephination vs primary repair of nailbed injury→ no difference in cosmetic 

outcome (J Hand Surg 1999; 24A:1166–1170)
Warn parents that there may be a defect in the future
Just relieve the subungal hematoma with trephination


2. Pearls from the All LA Conference, 
Pediatric Panel

Pediatric Fever:
-If parents state that the child had a fever at home→ believe the parents and continue work-up as if the child were febrile.  Subjective fever, reported by the parents, is fairly reliable.
-Bundling a child can raise their skin temperature but has no effect on their core temp
-Febrile infants less than one month merit full work-up and admission
-Work-up for the febrile infant between 1-2 months is controversial. If the child is well appearing, work-up can include blood, urine and possibly lumbar puncture. If the child is deemed low-risk by clinical criteria (Philadelphia, Boston, Rochester) then they can be sent home with close follow-up. If they are not low risk, then they will likely need antibiotics and admission..If you don’t see a lot of febrile, 45-day olds, you diagnostic skills probably aren’t as sharp as those who do.  Err on the side of the work up.
-In febrile infants >2 months we can now begin to clinically diagnose SBI and meningitis. Consider blood work, UA, and possible work-up for meningitis depending on the appearance of the child.
-Consider admission for the infant <3 months that is febrile with a UTI
-Ultrasound of the bladder prior to catheterization can determine if urine is present and help avoid unnecessary catheterizations.

Minor Head Trauma
-Hypothetically, CT scans can increase the potential for future malignancies to 1:500-1:1500
-Inclusion and exclusion criteria for the application of AAP recommendations for children with minor CHI are given (Pediatrics 1999;104:1407)
-If >2-y-o, well-appearing, and without concerning history→ will not likely need CT
-If well appearing, asymptomatic but concerning history (vomit, LOC…)→ may opt to observe and then decide on CT or CT on arrival
-If not well appearing and symptomatic (lethargy, repeated vomiting, headache…)→ CT scan
-Children <2yo are difficult to asses and limited data is available. Scalp hematomas are a very important marker of significant head injury in this age group.
3. INR is too high, what do I do?
There are many options of how to treat a patient with a supratherapeutic INR FFP is the liquid component of blood that contains coagulation factors and proteins. This can give a short-term improvement in INR and is the first line choice for serious or life-threatening bleeding (retroperitoneal, intracranial bleeding, drop in hemoglobin…). Vitamin K has differing efficacies based on the routes of absorption. The oral route is safe but may take up to 24 hours for full effect. SQ route is unreliable and erratic. The IV route is the most efficacious but also most dangerous because of a possible anaphylactoid reaction.  Prothrombin Complex Concentreate (PCC, Beriplex) has been in use throughout Europe and other countries but is not FDA approved in the US. It is a mixture derived from human plasma and rich in factors II, VII, IX and X. The dose of 25-50 units/kg IV begins working in <30 minutes and has minimal risk of thrombotic complications.  See Chest Guidelines for full recommendations (Chest 2004; 126: 204S-233S).
Source:  Sanjay Arora MD


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