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. 
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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.