With the closure of several Seattle Pain Clinics, it is important to know the signs of symptoms of opiate withdrawal, as well as appropriate steps to help patients in opiate withdrawal from the emergency department. Below are recommendations from the Washington State Department of Health as well as a table of medications that may be considered from Up To Date (TM)

Here is an excellent link from EmCrit about diagnosis of posterior circulation strokes and the "HINTS" exam.  >>LINK<<

Here is a sample Epic based dot phrase you can adopt for documentation:

Patients definition of dizziness: ***
Duration of symptoms: ***
Peripheral signs / symptoms: ***
Any elements of syncope or focal weakness / sensory changes?: {YES, NO, UNSURE:108699::NO}
Abnormal objective workup findings: ***
Abnormal findings on neuro exam: ***
    Diplopia: {YES, NO, UNSURE:108699::NO}
    Dysarthria: {YES, NO, UNSURE:108699::NO}
    Dysphagia: {YES, NO, UNSURE:108699::NO}
    Dysphonia: {YES, NO, UNSURE:108699::NO}
    Dysmetria: {YES, NO, UNSURE:108699::NO}
    Head Impulse Test: {YES, NO, UNSURE:108699::NO}
    Nystagmus (vertical or rotatory): {YES, NO, UNSURE:108699::NO}
    Test of skew abnormal?: {YES, NO, UNSURE:108699::NO}
    Gait: {YES, NO, UNSURE:108699::NO}
    Other cerebellar testing: {YES, NO, UNSURE:108699::NO}

Sepsis
Overall no new major updates since 2006. In children tachycardia likely most sensitive marker. Don’t forger hypothermia is just as concerning as fever. Viruses can also cause sepsis and is treated the same with regard to resuscitation. Consider epinephrine for low cardiac output failure, and norepinephrine for high output failure and septic shock. No changes in broad spectrum empiric antibiotics. 

Non-Accidental Trauma
For screening, consider using TEN <4 pneumonic. For any fracture in children <4 months, or in children <4 years look for bruising to the “Trunk” area typically covered by a swimming suit, “Ears,” or “Neck.” Red flags continue to be any fracture in non-ambulatory patients (typically <4 mo), metaphyseal fractures, “bucket handle” fractures, any perineal brushing, brushing or other injuries in linear patterns or burn patterns. Also consider round burns (cigarette burns). 

Myocarditis
Consider diagnosis in chest pain and fever. Look for signs of heart failure (hepatomegaly, edema, rales, hypotension / tachycardia). ECG findings continue to be rare but typically new BBB and concave diffuse ST elevation. TNI insensitive. Echocardiogram most useful for pericarditis. Consider dobutamine for low output failure, amiodarone for arrhythmia, cardioversion for instability. Therapy for pericarditis is NSAIDs (ibuprofen). No longer using steroids or IVIG. Antibiotics or viral only for suspected causes. 

Antimicrobials

• UTI: consider in febrile non symptomatic girls <1yr and boys uncirc <2 yr and circ <1 yr. Must have both signs of infection (pyuria or nitrite pos) and urine culture with >50,000 disease causing organisms. Still most likely E. coli. If does not meet this definition or culture results, avoid prescribing or stop antibiotics. In kids and with local resistance patterns, consider amox-clav, cefazolin, ceftriaxone, ciprofloxacin. Can consider TMP-SMX but higher resistance. If nitrite neg, consider amox-clav (Augmenting) as more likely non E. coli pathogen and more sensitive to this agent. Usually treat 7-14 days, but in afebrile females 3-5 days should be sufficient. 
• Pneumonia, antimicrobials not recommended routinely for kids 3mo-4yr, healthy appearing without respiratory distress, immunized with CAP as mostly viral in etiology. If rapid viral testing is positive, avoid antibiotics. Unless, unionized, sick, septic child then consider bacterial co-infection. 90% of CAP in >3 mo to 4yrs due to viral causes. However, poor evidence for this and few if any prospective trials looking out morbidity and mortality. Ok not to get chest X-ray and no other testing necessary except for possibly viral testing. Most commonly pneumococcus and mycoplasma. Best empiric therapy is for high dose amoxicillin. Sick inpatients can also receive ceftriaxone. Older children (>12 yo) still ok for macrolide monotherapy. 
• Skin Infections, still drive by IDSA and Clinical Infectious Disease. MB has a practice guidelines. Cutaneous abscess without cellulitis or sepsis do not need empiric antibiotics following I&D (with exception of immunocompromised host or systemic signs / symptoms of SIRS). Consider Loop drain in place of packing, studies showing more comfortable and more effective. When using antibiotics for skin / soft tissue infections, consider Clinda and TMP-SMX for staph aureus susceptibility. Currently TMP-SMX > Clinda. For MRSA, consider TMP-SMX 8-12 mg/kg/day for TMP divided BID. Up to 2 DS tabs BID (larger kids and adults). 7 days should be adequate in most cases.  

Wheezing
Still no indication for X-ray or labs in bronchiolitis. consider only for critically ill, severely hypoxic, asymmetric chest exam. Current therapy recommendations continue to not support bronchodilators. Consider only with recurrent wheezing despite suction in children >12 mo or strong family history of atopy / asthma. No role for steroids or antibiotics unless evidence of secondary bacterial infections. Trials under way regarding hypertonic saline (PECARN). Consider using respiratory scores for comment language, especially for admissions and consults. Use the MBED Pathways (intranet only) for the MBED protocol. No indication for viral testing, HTS, racemic epic, albuterol or radiography. Disposition mainly dependent on work of breathing, oxygen sat <90% awake (88% asleep), and respiratory score (see protocol). 

Severe pediatric asthma, go straight to continuous albuterol 20 mg over the first hour. Dexamethasone ok for steroid use. For moderate exacerbation, can also use 8-12 MDI puffs. Higher doses of atrovent likely more beneficial than previously thought. With severe asthma, don’t forget fluid bolus 20 ml/kg and consider PPV and mag (2 mg/kg/dose up to 2g). 

Suspected aspiration, especially with asymmetric lung exam, still indication for bronchoscopy, many foreign bodies not radio opaque. 

Thanks to the Marry Bridge Pediatric Emergency Department for hosting the 2014 Pediatric EM Conference. Here are a few pearls for those who were not able to make it. 
MBED 253-403-1418
One Call 253-792-6767 / 855-647-1010

ORTHOPEDICS

• Salter Harris fractures type 1 really don't need follow-up radiographs, treat for comfort. Complication rates are low and diagnosis of this is really not important. 
• Similarly, there may be little to no benefit for casting / splinting buckle fractures. Short arm splint for a few weeks may be helpful for comfort only. 
• Displacement is more tolerable in the plane of motion, especially with younger ages. 
• Consider plaster splints for kids <1 year. This may be more moldable and have fewer sharper edges than pre-formed fiberglass splints. 

ASTHMA AND BRONCHIOLITIS 

• MDI just as effective as a nebulizer... if you use a spacer (the other 1/2 of the MDI) - 2013 Cochrane Database
• 4-6 puffs on MDI = 2.5 mg neb, 8-12 puffs on MDI = 5 mg neb (1:4-6)
• Xopenex is NOT more effective than racemic albuterol, but is more expensive. There is similar efficacy, similar ED length of stay, and similar side effect profile. 
• Early administration of oral corticosteroids (within 1 hour) will improve asthma outcomes. dexamethasone as single IM dose, or 2 days orally, 0.6 mg/kg, is comparable to standard 5 days of prednisone (Keeney Pediatrics 2014). In ED can give the injectable liquid orally, and Rx for pills that can be crushed and given with chocolate syrup. 
• During the appropriate season, diffuse bilateral wheezing = bronchiolitis, don't need a chest x-ray or viral testing
• Serious bacterial illness in children 2-3 months concurrent with bronchiolitis is pretty rare, however, UTI concurrence is about 3.3% - so if anything, check a urine. 
• If improvement with albuterol in bronchiolitis in the ED, ok to send home with, but most will not have improvement with albuterol. If it doesn't help in the ED, likely no benefit at home. 
• Hypertonic salie may help but questionable data. Will not reduce ED length of stay or bounce backs 
• So what does work for bronchiolitis? fever treatment, suction nose, and oral fluids. good return precautions and follow up. 
• MBED Bronchiolitis Pathway

DIABETES AND DKA

• MBED DKA Pathway
• Check a glucose in your sick kids, 25% of DM type I present in DKA, with 15,000 new DM diagnosis each year!
• Common precipitants of DKA: stress, infection, inappropriate or missed dosing of insulin, initial presentation of type I DM
• Initial fluid bolus 10-20 ml/kg NS over first you, no more than 40 ml/kg in first 4 hours
• Continuous regular insulin at 0.1 U/kg/hr WITHOUT BOLUS (increases risk of cerebral edema)
• Goal decrease in glucose 50-100 mg/dL/hr, when glucose is <250 add glucose to fluids
• If K+ level is normal or low and urinating patient, include 20-40 mEq in maintenance fluids
• ICU criteria: impaired circulation, age <5, bicarb <15
• Consider cerebral edema with abnormal pain, neurologic abnormality, altered mental status, low HR, incontinence, headache, lethargy, intractable vomiting
• If cerebral edema, slow fluid rate to 75% maintenance, mannitol, elevated head of bed, consider 5 mL/kg of 3% hypertonic saline, airway protection with high minute ventilation 

CONSTIPATION

• Severe constipation may present with frequency small stools or diarrhea around stool balls
• Stool avoidance behaviors often precipitated by passage of painful, large stools
• Delayed passage of muconium (> 24 hours) may be an indicator of Hirschsprung's disease
• Multiple radiograph grading systems available, possible Leech et al. most reproducible - if you want to do this... google it. No clear indication for  imaging in constipation. 
• Soiling or encopresis, consider disimpaction
• Don't forget behavioral modifications and toiling education for kids
• Oral fluids, dietary fiber, laxatives (PEG 1 g/kg/day for 3-6 days) with Rx weaning 
• Maintenance dose of PEG is 0.4 g/kg/day
• PEG may be superior to lactulose for re-impaction (0 vs 23% at 3 mo)

CIRCUMCISION COMPLICATIONS

• Bleeding most commonly at the frenulum, Control with soak in gauze with epinephrine 1:1,000 to promote clotting, direct pressure, consider Dermabond (R), consider QuickClot [bbc comment], last resort... sutures 
• Other common complications: retained or migrated Plastibel, urinary retention, infection, excessive skin removal, amputation. 

SUBSTANCE ABUSE & TOXICOLOGY 

• "Butt chugging" becoming more popular - rectally absorbed alcohol to avoid taste, calories, etc. also inhaled vaporized, soaked gummy candies, soaked tampons more common. 
• 2012 most common high school intoxicants marijuana and synthetic derivatives
• New methods of marijuana use: Chapstick, gummy candy, lollipops, baked goods, crackers
• Often home made, variable amounts of THC, last longer than smoking, more likely to cause anxiety, agitation and paranoia 
• "Wax" is a new method, also called "dabbing" with 50-80% THC concentration refined marijuana 
• Mixed marijuana products hitting market - often with PCP, cocaine, amphetamines, (aka rocket fuel) to create distinct and marketable high
• Synthetic marijuana (aka spice K2, skunk, fire) more common in younger teenagers 
• Oral Rx opiate abuse more common, ? leading to heroin abuse, much more prevalent over past decade
• Acetyl Fentanyl - "not for human consumption" and currently not a controlled substance, may require more naloxone as it is 5-15x more potent than heroin, will show up as opioid on fox screen
• Codeine, promethazine and soda / alcohol (aka Purple Drank, Sizzurp, Lean, Syrup) 
• look for patches, naloxone therapy, hydration, airway protection, check tylenol levels and hepatotoxicity 
• Stimulants (aka Vit A, Godin's Potion, D-ral, Adderall) common in high school and college students for performance enhancing, very accessible due to heavy Rx in community
• "Molly", ecstasy, MDMA still common
• Bath Salts, amphetamine like, still available but legislation pending. Derived from the Khat plant (aka Ivory Wave, etc), treat with benzodiazepines and fluids, BP management 
• Cocaine, now on top 5 fastest growing in last decade, all Sx treatment with benzodiazepines 

EPI-PENS

• Most anaphylaxis is monophasic, however, 1/3 will have a biphasic reaction from 1-8 hours, mostly occurring 4-6 hours later
• IM faster and more reliable onset than SC
• OK to give through clothing
• OK to use CLEAR appearing medication in an expired Epi-Pen
• Auvi-Q, has IM epinephrine with talking instruction on device 

FEVER

• Consider UTI in girls <2 and boys <1
• Occult pneumonia has very poor IOR on chest x-ray, mostly viral lower airway disease anyway
• CBC has very poor predictability in healthy, well appearing, immunized and immunocompetent children (Bonsu Ped Inf Dis Journ 2005)
• Due to PCV vaccine, no more need for empiric CBC and blood cultures in febrile healthy kids >3mo
• If 2 doses of PCV given, no need for blood cultures in otherwise well febrile children
• If non-innunized or behind on immunizations, consider CBC and blood cultures
• Neonates and young infants ( <3mo) should get CBC, blood cultures, UA, +/- chest x-ray, consider CSF, empiric ampicillin + cefotaxime (consider acyclovir) 
• Check RSV if season appropriate, if > 2 weeks and RSV + with symptoms, normal CBC and UA, may be able to forgo LP and empiric antibiotics 
• Sickle cell patients should have empiric CBC, blood cultures, chest x-ray and empiric ceftriaxone 50 mg/kg EVEN if they have a known source of infection. Consider hematology consultation. 

ABDOMINAL PAIN

Need a refresher on splint basics? Know the difference between a 3-way and a thumb spica? Feel free to review these slides on the TECP basic splinting workshop! 

ACEP joins ABIM in the Choosing Wisely campaign!  Below are the initial 5 topics that ACEP chose to focus on. Read more on the ACEP clinical policies page. 

Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules. 

Minor head injury is a common reason for visiting an emergency department. The majority of minor head injuries do not lead to injuries such as skull fractures or bleeding in the brain that need to be diagnosed by a CT scan. As CT scans expose patients to ionizing radiation, increasing patients’ lifetime risk of cancer, they should only be performed on patients at risk for significant injuries. Physicians can safely identify patients with minor head injury in whom it is safe to not perform an immediate head CT by performing a thorough history and physical examination following evidence-based guidelines. This approach has been proven safe and effective at reducing the use of CT scans in large clinical trials. In children, clinical observation in the emergency department is recommended for some patients with minor head injury prior to deciding whether to perform a CT scan. 

Avoid placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can void, or for patient or staff convenience. 

Indwelling urinary catheters are placed in patients in the emergency department to assist when patients cannot urinate, to monitor urine output or for patient comfort. Catheter-associated urinary tract infection (CAUTI) is the most common hospital-acquired infection in the U.S., and can be prevented by reducing the use of indwelling urinary catheters. Emergency physicians and nurses should discuss the need for a urinary catheter with a patient and/or their caregivers, as sometimes such catheters can be avoided. Emergency physicians can reduce the use of indwelling urinary catheters by following the Centers for Disease Control and Prevention’s evidence-based guidelines for the use of urinary catheters. Indications for a catheter may include: output monitoring for critically ill patients, relief of urinary obstruction, at the time of surgery and end-of-life care. When possible, alternatives to indwelling urinary catheters should be used.

Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.

Palliative care is medical care that provides comfort and relief of symptoms for patients who have chronic and/or incurable diseases. Hospice care is palliative care for those patients in the final few months of life. Emergency physicians should engage patients who present to the emergency department with chronic or terminal illnesses, and their families, in conversations about palliative care and hospice services. Early referral from the emergency department to hospice and palliative care services can benefit select patients resulting in both improved quality and quantity of life. 

Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up. 

Skin and soft tissue infections are a frequent reason for visiting an emergency department. Some infections, called abscesses, become walled off and form pus under the skin. Opening and draining an abscess is the appropriate treatment; antibiotics offer no benefit. Even in abscesses caused by Methicillin-resistant Staphylococcus aureus (MRSA), appropriately selected antibiotics offer no benefit if the abscess has been adequately drained and the patient has a well-functioning immune system. Additionally, culture of the drainage is not needed as the result will not routinely change treatment. 

Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children. 

Many children who come to the emergency department with dehydration require fluid replacement. To avoid the pain and potential complications of an IV catheter, it is preferable to give these fluids by mouth. Giving a medication for nausea may allow patients with nausea and vomiting to accept fluid replenishment orally. This strategy can eliminate the need for an IV. It is best to give these medications early during the ED visit, rather than later, in order to allow time for them to work optimally. 

Fall is coming, and with that pediatric respiratory illness. There have been excellent reviews of bronchiolitis on EMRAP with Dr. Sloas, and here is some text your can turn into a dot phrase in Epic to help with your charting and clinical decision making in patients with suspected bronchiolitis. Enjoy!
___________________________________________________________________________________________________________
Patient is a @AGE@ @SEX@ with significant birth history of ***, presents with symptoms of {URI ASSESSMENT:101712} and initial emergency department vital signs of respiratory rate *** and oxygen saturation of ***. The ddx above was considered. Their emergency department workup was remarkable for ***. Initial therapy consisted of ***. Based on the below considerations, they were given *** therapy based on a bronchiolitis score of ***.  

The bronchiolitis scoring system was used with the following considerations 

Inclusion
Age <2 yrs (peak 3-6mo)
Viral symptoms present and increase with work of breathing & lower respiratory tract symptoms that may include: increased work of breathing, persistent cough, feeding difficulty, +/- wheezing, rapid shallow respirations, +/- fevers
Prematurity and/or age <12 weeks - expect a more severe course of illness

Exclusion (high risk factors)
Hemodynamically significant cardiac disease
Anatomic airway defects
Neurologic disease
Immunodeficiency 
Chronic lung disease

General risk factors
Previously healthy infant with sat <95%
Age < 3mo
GA < 34 wks
Respiratory rate >70

variable 0 points 1 point 2 points 3 points
RR
< or = 2mo < or = 60 61-69 > or = 70
2-12 mo < or = 50 51-59 > or = 60
1-2 yr < or = 40 41-44 > or = 45
retractions none subconstal or intercostal 2 of the following: subcostal, intercostal, substernal, or nasal flaring (infant) 3 of the following: subcostal, intercostal, substernal, suprasternal, supraclavicular OR nasal flaring / head bobbing (infant) 
dyspnea
0-2 yrs Normal feeding. Vocalizations and activity 1 of the following: difficulty feeding, decreased vocalization or agitation 2 of the following: difficulty feeding, decreased vocalization or agitation Stops feeding, no vocalization or drowsy and confused 
auscultation Normal breath sounds, no wheezing present End-expiratory wheeze only expirotory wheez only (greater than end-expiratory wheeze) Inspiratory and expiratory wheeze OR diminished breath sounds OR both

General therapeutic considerations
Suction 
Assess for fluid needs
Oxygen if hypoxemic
Consider bronchodilators if history of reactive airway disease or ill appearing 
Consider 4ml of 3% hypertonic saline *

Therapy generally not recommended
Albuterol (however reasonable to assess for reactive airway disease component)
Racemic epinephrine
Hypertonic saline *
Steroids
Chest physiotherapy
Inhaled steroids
Routine viral testing

Consider IV fluids if
Poor orally intake
Poor urine output
RS 9-12
Respiratory rate >60

Admission / Transfer considerations (higher risk for apnea) 
 Ann Emerg Med. 2006 Oct;48(4):441-7 
Prior history of pulmonary disease
Hypoxemia
Respiratory rate >40/min
Dehydration requiring IV fluids
Unreliable home situation
<1 mo and febrile
Premature birth and <48 weeks age post conception 
Underlying cardiac / lung disease (with judgement)
History of apnea

* considerations with hypertonic saline: there is a discrepancy between Seattle Children's hospital and Marry Bridge Children's hospital in the use of hypertonic saline. There are several studies looking at this, Chaundry in Annals of Emerg Med in Jan of 2010 which showed clinical severity score improves with hypertonic saline, with slight difference in length of stay, but no difference in admit rate for outpatient studies. Also Grewal in Arch Peds Adol Med in Nov of 2009, which did not show any difference in admission or re-visit rates in hypertonic versus regular saline nebulizer therapy. 

2014 has seen increasing numbers of measles cases, including Pierce Co. Here are some basic reminders about diagnosis and management. Below in italics are excertps from the June 2014 CDC MMWR regarding measles with a link to the original article.

• Consider measles in patients with rash, fever, cough, coryza and/or conjunctivitis
• Testing is confirmed with a measles IgM, isolation of virus or nucleic acids 
• Certain cases should be reported to the state health department
• Measles in generally an acute and self limiting disease
  Patients with severe immunocompromised conditions can be considered for IV Ig (MultiCare response guidelines)
  
• Ensure adequate nutrition, hydration and supportive care
• Give vitamin A which can decrease severity of illness (0-6mo 50,000 IU, 6-12mo 100,000 IU, >1yr 200,00 IU) given on day 1, 2 and in 3 weeks. 
• Treat fever with acetaminophen
• Evaluate for corneal abrasions / clouding and give topical antibiotics prn 
• Assess and treat for concurrent secondary bacterial infections  
• Families should be educated about spreading the disease

CDC SUMMARY OF RECENT CASES
Measles is a highly contagious, acute viral illness that can lead to serious complications and death. CDC evaluated cases reported by states from January 1 through May 23, 2014. A total of 288 confirmed measles cases have been reported to CDC, surpassing the highest reported yearly total of measles cases since elimination (220 cases reported in 2011). The large number of cases this year emphasizes the need for health-care providers to have a heightened awareness of the potential for measles in their communities and the importance of vaccination to prevent measles.

Confirmed measles cases in the United States are reported by state and local health departments to CDC using a standard case definition.


A measles case is considered confirmed if it is laboratory-confirmed or meets the clinical case definition (an illness characterized by a generalized rash lasting ≥3 days, a temperature of ≥101°F [≥38.3°C], and cough, coryza, and/or conjunctivitis) and is linked epidemiologically to a confirmed case. 


Measles cases are laboratory confirmed if there is detection in serum of measles-specific immunoglobulin M, isolation of measles virus, or detection of measles virus nucleic acid from a clinical specimen. 


Cases are considered imported if at least some of the exposure period (7–21 days before rash onset) occurred outside the United States and rash occurred within 21 days of entry into the United States, with no known exposure to measles in the United States during that time. An outbreak of measles is defined as a chain of transmission of three or more confirmed cases.

Patients with reported measles cases this year have ranged in age from 2 weeks to 65 years; 18 (6%) were aged <12 months, 48 (17%) were aged 1–4 years, 71 (25%) were aged 5–19 years, and 151 (52%) were aged ≥20 years. Forty-three (15%) were hospitalized, and complications have included pneumonia (five patients), hepatitis (one), pancytopenia (one), and thrombocytopenia (one). No cases of encephalitis and no deaths have been reported.

Measles cases have been reported from 18 states and New York City. Most cases were reported from Ohio (138), California (60), and New York City (26). Fifteen outbreaks have accounted for 227 (79%) of the 288 cases. The median outbreak size has been five cases (range: 3–138 cases). There is an ongoing outbreak involving 138 cases, occurring primarily among unvaccinated Amish communities in Ohio.

Of the 288 cases, 280 (97%) were associated with importations from at least 18 countries. The source of measles acquisition could not be identified for eight (3%) cases. Forty-five direct importations (40 U.S. residents returning from abroad and five foreign visitors) have been reported. Almost half (22 [49%]) of these importations were travelers returning from the Philippines, where a large outbreak has been occurring since October 2013. Imported cases were also associated with travel from other countries in the World Health Organization (WHO) Western Pacific Region (seven cases), as well as countries in the WHO South-East Asia (eight), European (four), Americas (three), and Eastern Mediterranean (one) regions. 

Most of the 288 measles cases reported this year have been in persons who were unvaccinated (200 [69%]) or who had an unknown vaccination status (58 [20%]); 30 (10%) were in persons who were vaccinated. 

Health-care providers should maintain a high suspicion for measles among febrile patients with rash. Patients with clinical symptoms compatible with measles (febrile rash plus cough, coryza, and/or conjunctivitis), should be asked about recent travel abroad and contact with returning travelers, and their vaccination status should be verified. 


Where possible, because of the high transmissibility of measles, patients with suspected measles should be promptly screened before entering waiting rooms and appropriately isolated (i.e., in an airborne isolation room or, if not available, in a separate room with the door closed), or have their office appointments scheduled at the end of the day to prevent exposure of other patients (4). To assist state and local public health departments with rapid investigation and control efforts to limit the spread of disease, suspected measles cases should be reported to local health departments immediately. State health departments should notify CDC about cases of measles within 24 hours of detection. 



Measles update June, 2014 CDC MMWR

We recently did a review of neonatal fever and sepsis. Attached is the lecture handout. Here is a summary table of the risk stratification tools. Items in RED are the most conservative recommendations of the assessment tools. 

Neonatal Fever Lecture Handout
Seattle Children's Hospital Neonatal Fever Protocol

"Half of everything we are taught in medical school will turn out to not be true. The problems is you don't know which half." - every medical school professor

In this era of evidence based medicine, medical traditions and dogma are constantly being re-evaluated and studied. Many of our dearest medical traditions have been passed down in text books and preached on morning rounds. But as most medical professors will attest to, half of what we are taught turns out to be wrong... or incomplete information. This is why we, as healthcare providers, are all required to continue our medical education to maintain our license. We culturally, and legally, acknowledge that if we don't keep up to date, we fall behind and unnecessarily exposure our patients to costly, and sometimes harmful medical interventions with little or no benefit.

The bloodletting knife, pictured above, was a sure sign of a competent physician in its day. It is also a symbol of evidence based medicine, one of the first stories in our history of how the scientific method eventually dispelled the myth that bloodletting cured all. Today, a physician would be considered a quack for suggesting such an intervention. Not that long ago, however, to argue against it was medical heresy. We so much different today?

ACEP Now - The Official Voice of Emergency Medicine is a publication of the American College of Emergency Physicians. In recent months, author Kevin Klauer, DO, EJD, FACEP published a 2 part series on Myths in the Emergency Department: rooted in culture, based on tradition Part 1 & Part 2 (click red link to see original article and references). Below is a summary of some of the key points discussed in the article. 

• Tramadol is less effective at 8 hours than ibuprofen for pain
• "Banana bags" are expensive and not superior to oral vitamins in most cases for alcohol intoxicated or malnourished patients
• Glucagon is no better than placebo for esophageal obstructions
• Patients with syncope and wi ECG changes or chest pain do not benefit from cardiac enzymes 
• Dilution should not be an explanation for your patient's anemia
• Penicillin allergy is actually very rare, and there is only a 1% cross-reaction to cephalosporins (first and second generation with R chains)
• Iodine is not an allergen, and shellfish allergy is not a contraindication to IV contrast for a CT scan
• There is no evidence supporting the use of empiric antibiotics with nasal packing
• Tap water is likely the best irrigation solution for wounds
• CT brain is not routinely indicated prior to lumbar puncture

Read something intriguing or controversial? Want to read more or find the original references? Link to Myths in the Emergency Department: rooted in culture, based on tradition Part 1 & Part 2 to find out more. 

Procalcitonin is likely one of the most misunderstood laboratory tests in our armory of diagnostics. For many it is viewed as a holy grail for determining if an infection is bacterial, and thus requires antibiotics, or viral, and thus needs supportive care. As an emergency physician, I am constantly asked to order this test - lets looks look at the studies to see how it may be useful. 

In 2006 in Critical Care Medicine it was shown to likely be superior to WBC and CRP for predicting mortality, however, when studies again in 2010 by Critical Care Medicine in a meta-analysis of 7 randomized clinical control trials, it did not demonstrate any difference in mortality, however, did results in overall 4 days less antibiotic use on average. The journal Shock in 2008 published a small study in a non - U.S. site which suggested that procalcitonin was superior to CRP for predicting mortality. The FDA approved its use based on this when used in conjunction with other indicators at a cutoff of < 0.5 being low risk, and > 2 being high risk. 

The Cochrane collaboration in 2012 showed that there was again no different when procalcitonin was used and the confidence intervals demonstrated to statistical significance. 

If you look at the mortality and treatment failure data, procalcitonin was not a clinically or statistically significant indicator of either of these outcomes. Thus, the early studies were hopeful that this would be a useful tool in early identification of sick patients with bacterial illness, better than CRP and WBC - however, in larger trials, it doe snot show any difference in mortality outcomes or treatment failures. It may help decrease the duration of empiric antibiotic therapy. Its use is now recommended by the surviving sepsis campaign for the reduction in empiric antibiotic therapy course duration in admitted patients. 

Hopefully we will have a magic test in the future that will clearly distinguish between bacterial and viral sources of infection, however, in the meantime... keep using your clinical gestalt.