April 26, 2018

Background: There has been lots of research published in past years on how to minimize pain and anxiety in children brought to the ED.  Unfortunately, as we all know there is often a lag time from research publication to clinical application.  It has been my experience that health care professionals tend to provide inconsistent and inadequate pain control for children.  In this episode of REBEL Cast we are going to interview Sebrina Perkins, a pediatric emergency medicine physician working for the Greater San Antonio Emergency Physicians (GSEP) group, on pediatric pain management pearls.

April 9, 2018

Background: Bronchiolitis is an acute inflammatory injury of the distal smaller airways, most commonly caused by viral infections.  There have been a host of medications studied in the treatment of bronchiolitis, including steroids, albuterol, epinephrine, and  inhaled hypertonic saline, with none proving to be effective in treatment.  Oxygen therapy via high-flow nasal cannula (HFNC) as opposed to standard nasal prongs provides some positive airway pressure which decreases work of breathing, improves oxygenation, and rates of intubation.  The trial we are going to review today (The PARIS Trial) evaluated early high-flow oxygen therapy vs standard oxygen therapy in infants with bronchiolitis and hypoxemia in both the emergency department and general pediatric ward settings.

September 4, 2017

Button Batteries: Small, disc shaped battery cells which are designed for use in small electronic devices. Common sources are kids toys, watches, calculators and hearing aids. Most batteries use lithium as a power source

Button Battery Ingestion Danger:

  • Contact with mucosal surfaces (oropharynx, esophagus, nasal passage) results in transmission of current
  • Current transmission causes chemical burns and necrosis via alkaline injury (sodium hydroxide)
  • Tissue damage can progress rapidly and result in devastating injuries
  • Nasal passage and esophagus are most susceptible to injury (narrow places for battery to become lodged)
  • Injury Patterns
    • Viscous perforation
    • Fistula formation
    • Erosion into blood vessels and resultant bleeding and possible catastrophic bleeding with erosion into aorta

July 27, 2017

Background: Fluid resuscitation with crystalloid is one of the most basic initial management approaches to adult and pediatric patients with severe sepsis and septic shock. However, which fluid should we be giving, and does it matter?  Should we give an unbalanced, chloride rich solution such as normal saline or a balanced, chloride restrictive fluid, such as lactated ringers, Plasma-Lyte, or Normasol? Interestingly, the 2016 Surviving Sepsis Guidelines, added resuscitation with balanced fluids into the guidelines, although a weak recommendation with low quality of evidence. This recommendation was based on some growing adult data, albeit retrospective, showing that resuscitation strategies using normal saline may be harmful and associated with increased risk of AKI (1), need for CRRT (1) and increased mortality (2-3). The effects of balanced fluids however, have not been studied in the resuscitation of children in severe sepsis and septic shock.

May 11, 2017

Background: Fever without source in infants less than three months old presents a difficult diagnostic dilemma for ED physicians.  Over the past 25 years several algorithms have been developed to help guide clinicians, most notably the Rochester, Philadelphia and Boston Criteria, in determining which infants require admission vs. outpatient management.  These studies were designed published between 1992 and 1994 prior to the wide spread use of HiB and pneumococcal vaccines in children, maternal GBS screening and the development of many new biomarkers. 

The Step-by-Step approach to febrile infants was developed by a European group of pediatric emergency physicians with the objective of identifying low risk infants who could be safely managed as outpatients without lumbar puncture or empiric antibiotic treatment. The algorithm was designed using retrospective data and this study attempts to prospectively validate it.