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September 08, 2016

CanadiEM Blog: TREKK Series | Multisystem Trauma

TREKK and CanadiEM have come together to translate the latest guidelines in pediatric emergency medicine. The second post in this blog series is on multisystem trauma. Join Drs. Ashley Lubberdink and Kaif Pardhan as they translate the TREKK Bottom Line Recommendation and run through the case - a 10 year old boy brought into the Pediatric ED after he has been in a collision on an ATV. 

Read the blog here.

 

 
 

From team: New and Events



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July 20, 2016

CanadiEM blog: TREKK Series | Bronchiolitis

TREKK and CanadiEM have come together to translate the latest guidelines in pediatric emergency medicine.  First up in this blog series: bronchiolitis.  Join Drs. Ashley Lubberdink and Kaif Pardhan as they translate the TREKK Bottom Line Recommendations and run through the case - a 5 month old male who presents to a community ED with a 4-day history of cough and nasal congestion. 

Read the blog here.

From team: New and Events



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December 18, 2015

Oral vs. IV rehydration for gastro related dehydration

This week, we are highlighting a Cochrane summary on oral versus intravenous rehydration for gastroenteritis related dehydration.

Cochrane summary:

Children with dehydration due to gastroenteritis need to be rehydrated, and this review did not show any important differences between giving fluids orally or intravenously

Dehydration is when body water content is reduced causing dry skin, headaches, sunken eyes, dizziness, confusion, and sometimes death. Children with dehydration due to gastroenteritis need rehydrating either by liquids given by mouth or a tube through the nose, or intravenously. The review of 17 trials (some funded by drug companies) found that the trials were not of high quality; however the evidence suggested that there are no clinically important differences between giving fluids orally or intravenously. For every 25 children treated with fluids given orally, one child would fail and require intravenous rehydration. Further, the results for low osmolarity solutions, the currently recommended treatment by the World Health Organization, showed a lower failure rate for oral rehydration that was not significantly different from that of intravenous rehydration. Oral rehydration should be the first line of treatment in children with mild to moderate dehydration with intravenous therapy being used if the oral route fails. The evidence showed that there may be a higher risk of paralytic ileus with oral rehydration while intravenous therapy carries the risk of phlebitis (ie inflammation of the veins).

Authors' conclusions:

Although no clinically important differences between ORT and IVT, the ORT group did have a higher risk of paralytic ileus, and the IVT group was exposed to risks of intravenous therapy. For every 25 children (95% CI 14 to 100) treated with ORT one would fail and require IVT.

 

Check out the full Cochrane systematic review below:

Hartling, L., Bellemare, S., Wiebe, N., Russell, K., Klassen, T. P., & Craig, W. (2006). Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database Syst Rev(3), Cd004390. doi: 10.1002/14651858.CD004390.pub2

 

Related TREKK Resources:

____________________________________________________________________________________

This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

From team: blogging team

tags: Gastroenteritis Dehydration    



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December 11, 2015

Tissue adhesives for traumatic lacerations

This week, we are highlighting a Cochrane summary on tissue adhesives.

Cochrane summary:

Tissue adhesives for traumatic lacerations in children and adults

 Cuts (lacerations) often need to be closed to ensure proper healing, and prevent infection or unattractive scarring. Wounds may be closed with stitches (sutures), staples, tapes or glue (tissue adhesive). The review found that glue is an excellent substitute for stitches, staples or tapes to close simple cuts. Glue causes less pain, is quicker and needs no follow up for removal. A slightly higher number of cuts may break open (dehisce) after being glued, compared to cuts closed with stitches, staples or tapes. Though there are a few different types of glue available, no one glue seems to be superior.

Authors' conclusions:

Tissue adhesives are an acceptable alternative to standard wound closure for repairing simple traumatic lacerations. They offer the benefit of decreased procedure time and less pain, when compared to standard wound closure. A small but statistically significant increased rate of dehiscence with tissue adhesives is observed.

 

Check out the full Cochrane systematic review below:

Farion, K. J., Russell, K. F., Osmond, M. H., Hartling, L.,  Klassen, T. P., & Vandermeer, B. (2002). Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev, 3, CD003326. doi: 10.1002/14651858.CD003326

 

Related TREKK Resources:

____________________________________________________________________________________

This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

From team: blogging team

tags: Procedural Pain    



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December 04, 2015

IV immunoglobulins for sepsis

This week, we are highlighting a Cochrane summary on intravenous immunoglobulins for treating patients with severe sepsis and septic shock.

Cochrane summary:

Intravenous immunoglobulins for treating patients with severe sepsis and septic shock

Sepsis is the inflammatory response of the body to severe infection, which can be caused by a variety of micro-organisms including bacteria, viruses and fungi. Signs of sepsis include fever, hypothermia, rapid heart rate and respiration; and a laboratory finding of increased or decreased white blood cell count. Deaths as a result of sepsis and septic shock remain high despite giving antibiotics, especially if the functions of a person’s vital organs such as the lungs, heart and kidneys are affected. Several studies have looked into other agents than antibiotics to help the body fight the effects of sepsis. Intravenous immunoglobulin preparations contain antibodies that help the body to neutralize bacterial toxins. There are two types of preparations. These are polyclonal immunoglobulins that contain several antibodies directed at endotoxin and inflammatory mediators, and monoclonal immunoglobulins which target a specific inflammatory mediator or antigen. Intravenous immunoglobulins are blood products, specifically pooled sera derived from human donor blood.

For this updated Cochrane review, we searched the medical literature databases to January 2012. We included 43 randomized controlled trials (RCTs); 25 were RCTs of polyclonal intravenous immunoglobulins (IVIGs) with 17 in adults (1958 participants) and eight in newborn infants (3831 participants) including a large polyclonal IVIG trial on infants with sepsis that was published in 2011. The remaining 18 trials (a total of 13,413 participants) were of monoclonal antibodies. Both standard and immunoglobulin M (IgM)-enriched polyclonal immunoglobulins decreased the number of deaths in adults but not in infants. However, no reductions in adult deaths were seen with polyclonal IVIG using high quality trials only. Among newborn infants with sepsis, there is definitive evidence that standard polyclonal IVIG does not reduce the number of deaths. In the monoclonal immunoglobulin trials, anti-endotoxin antibodies showed no benefit while the anti-cytokines showed a very small reduction in deaths among adults with sepsis.

The polyclonal immunoglobulin trials in adults were small compared to the trials of monoclonal agents. The reduction in deaths observed with polyclonal IgM-enriched preparations as add-on therapy for sepsis needs to be confirmed in large studies that use high quality methods.

Authors' conclusions:

Polyclonal IVIG reduced mortality among adults with sepsis but this benefit was not seen in trials with low risk of bias. Among neonates with sepsis, there is sufficient evidence that standard polyclonal IVIG, as adjunctive therapy, does not reduce mortality based on the inclusion of the large polyclonal IVIG trial on neonates. For Ig-M enriched IVIG, the trials on neonates and adults were small and the totality of the evidence is still insufficient to support a robust conclusion of benefit. Adjunctive therapy with monoclonal IVIGs remains experimental.

 

Check out the full Cochrane systematic review below:

Alejandria, M. M., Lansang, M. A., Dans, L. F., & Mantaring, J. B., 3rd. (2013). Intravenous immunoglobulin for treating sepsis, severe sepsis and septic shock. Cochrane Database Syst Rev, 9, Cd001090. doi: 10.1002/14651858.CD001090.pub2

 

Related TREKK Resources:

____________________________________________________________________________________

This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

From team: blogging team

tags: Sepsis    



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November 27, 2015

Glucocorticoids for Croup

This week, we are highlighting a Cochrane summary on glucocorticoids for croup.

Cochrane summary:

Glucocorticoids for croup

Croup is common in children and is thought to be triggered after a viral infection. Croup causes swelling in the throat and windpipe (trachea) and causes hoarseness, a barking cough and noisy breathing. Croup usually gets better by itself but sometimes drugs are used to try and improve this condition. The review looked at trials of one type of steroid drug, glucocorticoids. Glucocorticoids can reduce the swelling and make it easier for the child to breathe. We found that glucocorticoids can start improving croup in children within six hours (14 studies, 1031 children). The effect lasts about 12 hours (eight studies, 532 children), lessens the need for other drugs, and shortens hospital stays by 12 hours (eight studies, 795 children). There were no adverse events associated with glucocorticoids. Additional studies are needed to determine the best dose of glucocorticoids.

Authors' conclusions:

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence.

 

Check out the full Cochrane systematic review below:

Russell, K. F., Liang, Y., O'Gorman, K., Johnson, D. W., & Klassen, T. P. (2011). Glucocorticoids for croup. Cochrane Database Syst Rev(1), Cd001955. doi: 10.1002/14651858.CD001955.pub3

 

Related TREKK Resources:

____________________________________________________________________________________

This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

From team: blogging team

tags: Croup    



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November 20, 2015

Psychological interventions for needle-related procedural pain

This week, we are highlighting a Cochrane summary on psychological interventions for needle-related procedural pain and distress in children and adolescents.

 

Cochrane summary:

Psychological interventions for needle-related procedural pain and distress in children and adolescents

 

Psychological interventions (for example, distraction, hypnosis, coping skills training) are treatments used to reduce pain and distress (anxiety and fear, or both) that children and adolescents experience while undergoing medical procedures involving needles. There is strong evidence that distraction and hypnosis are effective in reducing the pain and distress that children and adolescents experience during needle procedures. Distraction techniques can often be quite simple, such as reading the child stories, watching television, listening to music, or talking about something other than the needle. Sometimes parents or nurses are involved in helping to distract the child, although that is not always necessary. Interventions such as hypnosis may require some teaching by a trained professional for a child to learn. Other psychological treatments, such as explaining what is going to happen before or during the procedure (labelled 'providing information or preparation or both'), using virtual reality (for example, interactive video equipment, goggles, computers showing images, games, stories), or a combination of various strategies have been tested. More research is needed to know whether they are effective for reducing children's pain and distress during needles.

 

Authors' conclusions:

Overall, there is strong evidence supporting the efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents, with no evidence currently available for preparation and information or both, combined CBT, parent coaching plus distraction, suggestion, or virtual reality. Additional research is needed to further assess interventions that have only been investigated in one RCT to date (that is, memory alteration, parent positioning plus distraction, blowing out air, and distraction plus suggestion). There are continuing issues with the quality of trials examining psychological interventions for needle-related pain and distress.

 

Check out the full Cochrane systematic review below:

 

Uman, L. S., Birnie, K. A., Noel, M., Parker, J. A., Chambers, C. T., McGrath, P. J., & Kisely, S. R. (2013). Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev, 10, Cd005179. doi: 10.1002/14651858.CD005179.pub3

 

Related TREKK Resources:

____________________________________________________________________________________

This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

From team: blogging team

tags: Procedural Pain    



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November 13, 2015

Treating multisystem trauma: Blood-clot promoting drugs

This week, we are highlighting a Cochrane summary on blood clot promoting drugs for children with acute traumatic injury.

 

Cochrane summary:

Blood-clot promoting drugs for acute traumatic injury

This is an update of an existing Cochrane review, the last version was published in 2012. 

Background

Injury is the second leading cause of death for people aged five to 45 years. Over four million people worldwide die of injuries every year, often because of extensive blood loss. Antifibrinolytic drugs promote blood clotting by preventing blood clots from breaking down. Some examples of antifibrinolytic drugs are aprotinin, tranexamic acid (TXA), epsilon-aminocaproic acid and aminomethylbenzoic acid. Doctors sometimes give these drugs to patients having surgery to prevent blood loss. These drugs might also stop blood loss in seriously injured patients and, as a result, save lives.

The authors of this review searched for randomised trials assessing the effects of antifibrinolytics in trauma patients.

Search date

The evidence in this review is current to January 2015.

Study characteristics

We found three randomised trials which met inclusion criteria and included well data from over 20,000 patients recruited in 40 countries.

Of these, one small trial (n = 77) looked at the effect of aprotinin in patients aged 12 and older who had suffered trauma involving broken bones and shock.

Two trials assessed the effect of TXA in patients aged 16 and over. The largest (n = 20,211) involved patients suffering from a variety of types of trauma, and the other (n = 240) only those who had suffered traumatic brain injury.

Results

The trial assessing the effect of aprotinin was too small to provide reliable data.

Results for TXA suggest that, when given early, TXA reduces the risk of death compared to patients who do not receive TXA without increasing the risk of side effects.

However, there is still some uncertainty about the effect of TXA in patients who have bleeding inside the brain from a head injury, but are not bleeding from injuries elsewhere. It is possible that the effects of TXA are different in this specific patient group.

We have found two ongoing trials that are trying to answer this question.

The authors of this review conclude that TXA can safely reduce death in trauma patients with bleeding and should be given as soon as possible after injury. However, they cannot conclude whether or not TXA is also effective in patients with traumatic brain injury with no other trauma, until the ongoing trials have been completed.

Quality of the evidence

Evidence for important outcomes including mortality, need for further surgery and blood transfusion, came from high-quality evidence, meaning we have confidence in the findings. There was moderate-quality evidence for important adverse events including vascular occlusive events (including heart attacks, deep vein thrombosis, stroke and pulmonary embolism).

Authors' conclusions:

TXA safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events.  TXA should be given as early as possible and within three hours of injury, as further analysis of the CRASH-2 trial showed that treatment later than this is unlikely to be effective and may be harmful. Although there is some promising evidence for the effect of TXA in patients with TBI, substantial uncertainty remains. 

Two ongoing trials being conducted in patients with isolated TBI should resolve these remaining uncertainties.

 

Check out the full Cochrane systematic review below:

Ker, K., Roberts, I., Shakur, H., & Coats, T. J. (2015). Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev, 5, Cd004896. doi: 10.1002/14651858.CD004896.pub4

 

Related TREKK Resources:

____________________________________________________________________________________

This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

From team: blogging team

tags: Multiple Trauma    



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November 06, 2015

Anti-emetics for gastroenteritis

This week, we are highlighting a Cochrane summary on anti-emetics for gastroenteritis.

Cochrane summary:

Anti-sickness medication for vomiting in acute stomach upsets in children

 

Vomiting caused by acute gastroenteritis is very common in children and adolescents. Treatment of vomiting in children with acute gastroenteritis can be problematic and there is lack of agreement among clinicians on the indications for the use of antiemetics. There have also been concerns expressed about apparently unacceptable levels of side effects with some of the older generation of antiemetics. The small number of included trials provided evidence which appeared to favour the use of antiemetics over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. A single oral dose of ondansetron given to children with mild to moderate dehydration can control vomiting, avoid hospitalization and intravenous fluid administration which would otherwise be needed. There were no major side effects other than a few reports of increased frequency of diarrhea.

 

Authors' conclusions:

Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting.

 

 

Check out the full Cochrane systematic review below:

Fedorowicz, Z., Jagannath, V. A., & Carter, B. (2011). Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev(9), Cd005506. doi: 10.1002/14651858.CD005506.pub5

 

Related TREKK Resources:

____________________________________________________________________________________

This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

From team: blogging team

tags: Gastroenteritis    



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October 30, 2015

Nerve blocks for presenting pain

This week, we are highlighting a Cochrane summary on nerve blocks for initial pain management of thigh bone fractures in children.

 

Cochrane summary:

Nerve blocks for initial pain management of thigh bone fractures in children

Fractures (breaks) of the thigh bone can be very painful, particularly when a child arrives in a stressful emergency environment and is undergoing assessment. Moving the child to get X-rays or transferring the child to a special bed to support the leg in traction (keeping the leg straight) can cause additional pain, as can placing traction (a pulling force) on the broken thigh. This means that prompt provision of pain relief is an essential part of initial emergency management. This review investigated whether a nerve block, involving the injection of a freezing/numbing medication at the top of the thigh, would provide more effective pain relief than pain medicine given by mouth or into a vein (intravenously, e.g. morphine).

We searched several medical databases and trial registries up to January 2013 and contacted researchers. We found one study that looked at the comparison we were interested in. This study was potentially biased, mainly because the care providers, parents and children were aware of the type of pain relief the children received. The study was small, involving 55 children aged 16 months to 15 years, and showed that the children who received one of the two main types of nerve block tended to have less pain after 30 minutes than those who received intravenous morphine for initial pain control. The nerve blocks led to some pain and redness at the injection site in a few cases, while intravenous morphine caused more serious problems such as depressed breathing (lack of oxygen), excessive sleepiness and vomiting in a small number of children.

Moreover, children who had nerve blocks continued to have lower pain scores over a six-hour period with less need for additional pain relief. There was insufficient evidence to determine whether children or parents were more satisfied with one method of pain relief than the other. Use of resources (e.g. nursing time, cost of medications) was not measured.

The quality of the study included in this review was low and so these conclusions are not certain. Further well designed studies investigating whether nerve blocks are more effective and safer than other means of pain relief are needed.

 

Authors' conclusions:

Low quality evidence from one small trial suggests that FICB provides better and longer lasting pain relief with fewer adverse events than intravenous opioids for femur fractures in children. Well conducted and reported randomised trials that compare nerve blocks (both FNB and FICB) with systemic analgesia and that use validated pain scores are needed.

 

Check out the full Cochrane systematic review below:

Black, K. J., Bevan, C. A., Murphy, N. G., & Howard, J. J. (2013). Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev, 12, Cd009587. doi: 10.1002/14651858.CD009587.pub2

 

Related TREKK Resources:

____________________________________________________________________________________

This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

From team: blogging team

tags: Presenting Pain    



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