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Acute Otitis Media
Acute Otitis Media  Bottom Line Recommendations

Bottom Line Recommendations: Acute Otitis Media

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Le Saux, N and TREKK Network

Bottom line recommendations for the treatment and management of acute otitis media. Published online: October 2016.

Recommandations de Base: Otite moyenne aiguë

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Le Saux, N & TREKK Network

Bottom line recommendations for the treatment and management of acute otitis media - French. Published online: December 2016.

Bottom Line Recommendations: Flow diagram for the management of children with suspected and confirmed acute otitis media

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Le Saux N, Robinson JL, Canadian Paediatric Society, Infectious Diseases and ...

This flow diagram from the position statement of the Canadian Paediatric Society illustrates the management of children with suspected and confirmed acute otitis media.

Bottom Line Recommendations: Videos in clinical medicine. Diagnosing otitis media--otoscopy and cerumen removal

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Shaikh N, Hoberman A, Kaleida PH, Ploof DL, Paradise JL

Pneumatic otoscopy and cerumen removal is discussed in this video. Mastery of otoscopic examination techniques is necessary for the accurate diagnosis of otitis media.

Acute Otitis Media  Clinical guidelines

Clinical Practice Guideline: Management of acute otitis media in children six months of age and older

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Le Saux N, Robinson JL, Canadian Paediatric Society, Infectious Diseases and ...

The present position statement updates a previous Canadian Paediatric Society document released in 2009, outlining the management of acute otitis media in children six months of age and older.

Clinical Practice Guideline: The diagnosis and management of acute otitis media

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Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA,...

This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media guideline from the American Academy of Pediatrics and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated acute otitis media.

Acute Otitis Media  Summaries of systematic reviews

Evidence Summary: Are topical antibiotics an alternative to oral antibiotics for children with acute otitis media and ear discharge?

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Venekamp RP, Prasad V, Hay AD

This summary presents results of a systematic review that searched to identify any published studies comparing the effectiveness of topical antibiotics with oral antibiotics, placebo, or no treatment in children with acute otitis media presenting with ear discharge caused by spontaneous perforation of the eardrum.

Acute Otitis Media  Systematic reviews

Cochrane Systematic Review: Antibiotics for acute otitis media in children

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Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM

The purpose of this review was to assess the effects of antibiotics for children with acute otitis media.

Acute Otitis Media  Key studies

Key Study: Symptomatic and asymptomatic respiratory viral infections in the first year of life: association with acute otitis media development

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Chonmaitree T, Alvarez-Fernandez P, Jennings K, Trujillo R, Marom T, Loeffelh...

The purpose of this study was to determine the clinical significance of asymptomatic respiratory viral infection in infants.

Key Study: Treatment of acute otitis media in children under 2 years of age

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Hoberman A, Paradise JL, Rockette HE, Shaikh N, Wald ER, Kearney DH, Colborn ...

The purpose of this clinical trial was to determine the extent to which antimicrobial treatment affects the course of both symptoms and signs of acute otitis media, irrespective of the apparent severity of the disease, among children 6 to 23 months of age who have been diagnosed with acute otitis media.

Key Study: A placebo-controlled trial of antimicrobial treatment for acute otitis media

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Thtinen PA, Laine MK, Huovinen P, Jalava J, Ruuskanen O, Ruohola A

This randomized, double-blind, placebo-controlled study assessed the efficacy of antimicrobial treatment for acute otitis media.

Anaphylaxis
Anaphylaxis  Bottom Line Recommendations

Bottom Line Recommendations: Anaphylaxis

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Alqurashi W and TREKK Network

Bottom line recommendations for the treatment and management of pediatric anaphylaxis - version 1.2. Published online: December 2018.

Recommandations de Base: Anaphylaxie

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Alqurashi W and TREKK Network

Bottom line recommendations for the treatment and management of pediatric anaphylaxis - en francais. Published online: October 2018.

Feuille d'Ordonnance Medicale pour L’Anaphylaxie

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PedsPac de TREKK sur l'Anaphylaxie

This French pre-printed order (PPO) set is for management of pediatric anaphylaxis in the ED. PPO document is adaptable to your hospitals form policy. Published online: October 2018, Version 1.0.

Anaphylaxis Pre-Printed Order Set

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TREKK Anaphylaxis PedsPac

This pre-printed order (PPO) set is for management of pediatric anaphylaxis in the ED. PPO document is adaptable to your hospitals form policy. Published online: December 2018, Version 1.1.

Anaphylaxis References and Development Team

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TREKK Anaphylaxis PedsPac

This document outlines the references used and team involved in the development of the anaphylaxis PedsPac. Published online: October 2018.

Anaphylaxis Algorithm

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TREKK Anaphylaxis PedsPac

This point of care algorithm is to guide initial management of pediatric anaphylaxis in the Emergency Department. Published online: December 2018, Version 1.1.

Anaphylaxis Pocket Card

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TREKK Anaphylaxis PedsPac

This pocket card contains tips to manage pediatric patients with anaphylaxis. Published online: December 2018, Version 1.1.

Carte de Poche pour L’Anaphylaxie

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PedsPac de TREKK sur l'Anaphylaxie

This pocket card contains tips to manage pediatric patients with anaphylaxis. Published online: October 2018, Version 1.0.

Algorithme pour L’Anaphylaxie

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PedsPac de TREKK sur l'Anaphylaxie

This point of care algorithm is to guide initial management of pediatric anaphylaxis in the Emergency Department. Published online: October 2018, Version 1.0.

Anaphylaxis  Clinical guidelines

Clinical Practice Guideline: Anaphylaxis in Schools & Other Settings, 3rd Edition Revised

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Canadian Society of Allergy and Clinical Immunology

This manual has been developed for primarily non-medical people. It consists of an updated Consensus Statement and an Appendices section from the Canadian Society of Allergy and Clinical Immunology. The Consensus Statement provides recommendations for the management of anaphylaxis in the community, which are based on the most current research. The Appendices section provides resources that will help individuals at risk of anaphylaxis, educators, caregivers, and parents understand the basics of anaphylaxis.

Position Statement: CSACI position statement - epinephrine auto-injectors and children < 15 kg

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Halbrich M, Mack DP, Carr S, Watson W, Kim H

This position statement addresses a number of questions regarding epinephrine administration/prescribing suggestions for the infant under 15kg who is at risk for anaphylaxis, including: What are possible consequences of administering a larger than recommended dose of epinephrine? Are there other ways to prescribe the recommended dose of epinephrine? What are the consequences of not administering epinephrine? What does the Canadian Society for Allergy and Clinical Immunology suggest for the infant less than 15kg?

Clinical Practice Guideline: Anaphylaxis--a practice parameter update 2015

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Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J,...

The objective of this parameter is to update these previous versions and ultimately to improve the care of patients by providing the practicing physician with an evidence-based approach to the diagnosis and management of anaphylactic events.

Clinical Practice Guideline: 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines

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Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF...

The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis provide a unique global perspective on this increasingly common, potentially life-threatening disease. Recommendations made in the original WAO Anaphylaxis Guidelines remain clinically valid and relevant, and are a widely accessed and frequently cited resource. In this 2015 update of the evidence supporting recommendations in the Guidelines, new information based on anaphylaxis publications from January 2014 through mid- 2015 is summarized.

Clinical Practice Guideline: Emergency department diagnosis and treatment of anaphylaxis: a practice parameter

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Campbell RL, Li JT, Nicklas RA, Sadosty AT, Members of the Joint Task Force P...

The recommendations made in this document about the management of anaphylaxis apply to anaphylaxis that occurs in an ED setting. Some of these recommendations might be different if anaphylaxis occurs in an office setting.

Clinical Practice Guideline: Anaphylaxis: Guidelines from the European Academy of Allergy and Clinical Immunology

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Muraro A, Roberts G, Worm M, Bil MB, Brockow K, Fernndez Rivas M, Santos AF, ...

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis.

Clinical Practice Guideline: World Allergy Organization guidelines for the assessment and management of anaphylaxis

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Simons FE, Ardusso LR, Bil MB, El-Gamal YM, Ledford DK, Ring J, Sanchez-Borge...

The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment.

Anaphylaxis  Systematic reviews

Review: Do Corticosteroids Prevent Biphasic Anaphylaxis?

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Alqurashi W, Ellis AK

This review analyzes the use of corticosteroids for reducing anaphylaxis severity and preventing biphasic anaphylaxis.

Comprehensive Review: Pitfalls in the use of epinephrine for anaphylaxis: patient and provider opportunities for improvement

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Cohen MB, Saunders SS, Wise SK, Nassif S, Platt MP

The purpose of this study was to identify the scope of epinephrine pitfalls and opportunities for improvement in the management of allergy emergencies.

Systematic Review: Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-analysis

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Lee S, Bellolio MF, Hess EP, Erwin P, Murad MH, Campbell RL

The aim of this study was to evaluate the time of onset and predictors of biphasic anaphylactic reactions.

Review: Anaphylaxis: Unique aspects of clinical diagnosis and management in infants (birth to age 2 years)

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Simons FE, Sampson HA

In this rostrum we aim to increase awareness of anaphylaxis in infancy in order to improve clinical diagnosis, management, and prevention of recurrences.

Review: Risk multipliers for severe food anaphylaxis

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Smith PK, Hourihane JO, Lieberman P

This paper reviews the factors that contribute to the risk of severe anaphylactic events and provides a framework for the ongoing management of patients at risk of severe food allergy.

Systematic Review: H2-antihistamines for the treatment of anaphylaxis with and without shock: a systematic review

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Nurmatov UB, Rhatigan E, Simons FE, Sheikh A

The objective of this systematic review was to assess the benefits and harms of H2-antihistamines in the treatment of anaphylaxis.

Cochrane Systematic Review: Glucocorticoids for the treatment of anaphylaxis

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Choo KJ, Simons FE, Sheikh A

We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis.

Cochrane Systematic Review: Adrenaline auto-injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community

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Sheikh A, Simons FE, Barbour V, Worth A

The objective of this systematic review was to assess the effectiveness of adrenaline (epinephrine) auto-injectors in relieving respiratory, cardiovascular, and other symptoms during episodes of anaphylaxis that occur in the community.

Cochrane Systematic Review: H1-antihistamines for the treatment of anaphylaxis with and without shock

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Sheikh A, ten Broek VM, Brown SG, Simons FE

The objective of this systematic review was to assess the benefits and harm of H1-antihistamines in the treatment of anaphylaxis.

Anaphylaxis  Key studies

Key Study: Epinephrine Use for Anaphylaxis - A Multi-Incident Analysis

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Institute for Safe Medication Practices Canada

This multi-incident analysis was conducted to identify factors contributing to errors when epinephrine was used for the treatment of anaphylaxis and to suggest strategies to prevent or minimize potential harm when epinephrine is used for this indication.

Key Study: The Risk of Recurrent Anaphylaxis

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O'Keefe A, Clarke A, St Pierre Y, Mill J, Asai Y, Eisman H, La Vieille S, Ali...

factors contributing to errors when epinephrine was

Key Study: Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children

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Brown JC, Tuuri RE, Akhter S, Guerra LD, Goodman IS, Myers SR, Nozicka C, Man...

used for the treatment of anaphylaxis and to suggest

Key Study: Embedded Needles Caused by Epinephrine Autoinjector Use in Children

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Dreborg S, Wen X, Kim L, Tsai G, Nevis I, Potts R, Chiu J, Dominic A, Kim H

strategies to prevent or minimize potential harm

Key Study: Increasing visits for anaphylaxis and the benefits of early epinephrine administration: A 4-year study at a pediatric emergency department in Montreal, Canada

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Hochstadter E, Clarke A, De Schryver S, LaVieille S, Alizadehfar R, Joseph L,...

when epinephrine is used for this indication.

Key Study: Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis

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Alqurashi W, Stiell I, Chan K, Neto G, Alsadoon A, Wells G

The objective of this study was to investigate the incidence and clinical predictors of biphasic reactions in children presenting to the emergency department (ED) with anaphylaxis.

Key Study: Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization

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Fleming JT, Clark S, Camargo CA Jr, Rudders SA

The objective of this study was to identify factors associated with early epinephrine treatment for FIA and to specifically examine the association between early epinephrine treatment and hospitalization.

Key Study: Patients' ability to treat anaphylaxis using adrenaline autoinjectors: a randomized controlled trial

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Umasunthar T, Procktor A, Hodes M, Smith JG, Gore C, Cox HE, Marrs T, Hanna H...

Previous work has shown patients commonly misuse adrenaline autoinjectors (AAI). It is unclear whether this is due to inadequate training, or poor device design. We undertook a prospective randomized controlled trial to evaluate ability to administer adrenaline using different AAI devices.

Asthma
Asthma  Bottom Line Recommendations

Bottom Line Recommendations: Asthma

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Johnson D & TREKK Network

Bottom line recommendations for the treatment and management of asthma. Updated February 2019, Version 1.2.

Recommandations de Base: Asthme

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Johnson D & TREKK Network

Recommandations de base pour l'évaluation et la prise en charge de l'asthme.

Asthma Pre-Printed Order Set

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TREKK Asthma PedsPac

This pre-printed order (PPO) set is for management of pediatric severe asthma in the ED. PPO document is adaptable to your hospitals form policy. This PPO is intended for use on patients > 12 months of age. Published online: December 2018, Version 1.0.

Asthma Algorithm

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TREKK Asthma PedsPac

This point of care algorithm is to guide initial management of pediatric severe asthma in the Emergency Department. This algorithm is intended for use on patients > 12 months of age. Published online: December 2018, Version 1.0.

Asthma Pocket Card

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TREKK Asthma PedsPac

This pocket card contains tips to manage pediatric patients with severe asthma. This pocket card is intended for use on patients > 12 months of age. Published online: December 2018, Version 1.0.

Asthma References and Development Team

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TREKK Asthma PedsPac

This document outlines the references used and team involved in the development of the asthma PedsPac. Published online: December 2018, Version 1.0.

Asthma  Clinical guidelines

Clinical Practice Guideline: Global Strategy for Asthma Management and Prevention (2014)

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GINA Science Committee,

The GINA Science Committee reviews published research on asthma management and prevention, evaluates the impact of asthma research, and provides yearly updates to guidance documents. See Chapter 4, Part D: Management of Asthma Exacerbations in the Emergency Department.

Clinical Practice Guideline: Paediatric Emergency Department Asthma Clinical Pathway (2014)

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Expert Content Working Group of the Ontario Lung Association,

The P-EDACP is for patients aged 1 to 17 years presenting with wheeze and/or cough who have a history of asthma and/or prior history of wheezing. Additional tools include medication guidelines and pre-printed physicians orders (PPO) for each of the four severity levels, a patient education checklist, and discharge instructions with integrated prescription.

Clinical Practice Guideline: Guide Clinique Asthme (2014)

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Trottier, ED, Gauvin, F, Pettersen, G, Marquis, C, Ducharme, F, Lucas, N, Béd...

This French language webpage created by the Centre Hospitalier Universitaire Sainte-Justine, provides guidelines, pathways and order sheets for treating acute asthma in emergency departments.

Clinical Practice Guideline: Asthme: Algorithme status asthmaticus (2014)

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Trottier, ED, Gauvin, F, Pettersen, G, Marquis, C, Ducharme, F, Lucas, N, Béd...

This French language pathway created by the Centre Hospitalier Universitaire Sainte-Justine, provides guidance on treating pediatric patients with severe status asthmaticus.

Clinical Practice Guideline: Pediatric Asthma Assessment for Emergent/Urgent Care (2013)

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Alberta Health Services,

Assessment sheets for pediatric asthma patients, includes PRAM Scoring instructions.

Clinical Practice Guideline: Pediatric Asthma Orders for Emergent/Urgent Care (2013)

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Alberta Health Services,

These orders contain recommendations based on PRAM Score for children aged 12 months - 18 years with a diagnosis of asthma

Clinical Practice Guideline: Pediatric Asthma Education Checklist (2013)

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Alberta Health Services,

This checklist contains education topics to review with patients/caregivers

Asthma  Summaries of systematic reviews

Cochrane Summary: Holding chambers (spacers) versus nebulisers for delivery of beta-agonist relievers in the treatment of an asthma attack (2013)

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Cates, CJ, Welsh, EJ, Rowe, BH,

Review question: When someone is having an asthma attack is it as safe and effective to use a spacer instead of a nebuliser? Background: During an asthma attack, the airways (tubes in the lungs) narrow making breathing difficult. The initial response to an asthma attack is to treat with a drug that can open up the airways and make breathing easier. These drugs are called bronchodilators and in this review we are looking specifically at a class of bronchodilators called beta-agonists (for example salbutamol). These drugs can be taken straight from an inhaler, but during an asthma attack they are easier to take using either a spacer or a nebuliser. A spacer is a hollow chamber. A puff of drug from an inhaler is added to the chamber and then the person breathes in and out normally (also described as tidal breathing), from a mouthpiece on the chamber. A nebuliser is a machine with a mask that goes over the person's mouth and nose and through which a constant stream of drug and air (or oxygen) is breathed in and out normally. What evidence did we find? We found 39 clinical trials involving 1897 children and 729 adults. Thirty-three of the trials were conducted in an emergency room (or emergency department) and community settings (such as a GP's surgery), and six trials were on inpatients (people in hospital) with acute asthma (207 children and 28 adults). Overall we judged the quality of the evidence to be moderate. What do the studies tell us? Taking beta-agonists through either a spacer or a nebuliser in the emergency department did not make a difference to the number of adults being admitted to hospital, whilst in children we can be fairly confident that nebulisers are not better than spacers at preventing admissions. In children, the length of stay in the emergency department was significantly shorter when the spacer was used instead of a nebuliser. The average stay in the emergency department for children given nebulised treatment was 103 minutes. Children given treatment via spacers spent an average of 33 minutes less. In adults, the length of stay in the emergency department was similar for the two delivery methods. However the adult studies were conducted slightly differently which may have made it more difficult to show a difference in the length of stay in the emergency department. Because all the adult studies used a so-called "double-dummy" design, the adults received a spacer AND a nebuliser (either beta-agonist in a spacer and a dummy nebuliser or vice versa) which meant both groups of people were in the emergency department for as long as it took to take both treatments. Lung function tests were also similar for the two delivery methods in both adults and children. Pulse rate was lower in children taking beta-agonists through a spacer (mean difference 5% baseline), and there was a lower risk of developing tremor. Conclusion: Metered-dose inhalers with a spacer can perform at least as well as wet nebulisation in delivering beta-agonists in children with acute asthma, but we are less certain about the results in adults.

Cochrane Summary: Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children (2013)

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Griffiths, B, Ducharme, FM,

Background: In an asthma attack, the airways (small tubes in the lungs) narrow because of inflammation (swelling), muscle spasms and mucus secretions. Other symptoms include wheezing, coughing and chest tightness. This makes breathing difficult. Reliever inhalers typically contain short-acting beta2-agonists (SABAs) that relax the muscles in the airways, opening the airways so that breathing is easier. Anticholinergic drugs work by opening the airways and decreasing mucus secretions. Review question: We looked at randomised controlled trials to find out whether giving inhaled anticholinergics plus SABAs (instead of SABAs on their own) in the emergency department provides benefits or harms in children having an asthma attack. Key results: We found that children with a moderate or severe asthma attack who were given both drugs in the emergency department were less likely to be admitted to the hospital than those who only had SABAs. In the group receiving only SABAs, on average 23 out of 100 children with acute asthma were admitted to hospital compared with an average of 17 (95% CI 15 to 20) out of 100 children treated with SABAs plus anticholinergics. Taking both drugs was also better at improving lung function. Taking both drugs did not seem to reduce the possibility of another asthma attack. Fewer children treated with anticholinergics reported nausea and tremor, but no significant group difference was observed for vomiting. Quality of the evidence and further research: Most of the studies were in preschool- and school-aged children; three studies also included a small proportion of infants under 18 months of age, although there was no evidence that inclusion of these infants with wheezy episodes affected the results. Nine trials (45%) were at a low risk of bias and we regarded the evidence for hospitalisation as high quality. Physicians can administer the dose of anticholinergic and SABA in several different ways; as a single dose, or as a certain number of doses or more flexibly. Most of the trials gave the children two or three doses and we think that more research is needed to improve characterization of children that benefit from, and the most effective number and frequency of doses of, anticholinergic treatment.

Cochrane Summary: Inhaled corticosteroids for acute asthma following emergency department discharge (2012)

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Edmonds, ML, Milan, SJ, Brenner, BE, Camargo, CA, Rowe, BH,

Acuteasthma is a common cause of visits toemergencydepartments (ED) and the majority of patients are treated and discharged home. Some people will have arelapseofacuteasthma within two weeks of being discharged after apparently successful treatment. Beta2-agonist drugs are used to open the muscles in the airways and corticosteroids drugs are used to reduce inflammation of the swollen airways.Corticosteroidscan be inhaled (ICS) or swallowed as a tablet (so-calledoralcorticosteroids). ICS may reduceadverse effectsand get to the airways more directly thanoralcorticosteroids. Thisreviewof trials found that there was insufficient evidence that inhaling corticosteroids as well as taking the drugs orally is better thanoraluse alone, afteremergencydepartment treatment for an asthma attack. There is also insufficient evidence that taking ICS alone is as good as taking them orally, although there is some evidence to support using ICS alone for mild asthma attacks afteremergencydepartment discharge. Moreresearchis needed.

Cochrane Summary: Role of ketamine for management of acute severe asthma in children (2012)

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Jat, KR, Chawla, D,

Children frequently visit theemergencydepartment foracuteexacerbation of asthma. Some of these children fail to respond tostandard treatment(corticosteroids and bronchodilators) with increasedmorbidity. Ketamine has bronchodilatory properties and may be useful foracuteexacerbation of asthma. We evaluated theefficacyof ketamine for management of severeacuteasthma in children who had not responded to standardtherapy. We found, through systematic search, only onestudywhere investigators assessed the usefulness of ketamine for management of severeacuteasthma in children. While this singlestudysuggested that there is a lack of evidence for usefulness of ketamine inacuteexacerbation of asthma in children, more trials are needed regarding the use of ketamine inacuteasthma before more specific recommendations can be made.

Cochrane Summary: What are the effects of educational interventions delivered to children and/or their families, who have experienced an emergency department visit with their asthma within the previous 12 months? (2010)

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Boyd, M, Lasserson, TJ, McKean, MC, Gibson, PG, Ducharme, FM, Haby, M,

Asthma care for children in our society is common and costly. There is now evidence that educationalinterventionfor children who have attended theemergencydepartment for asthma lowers theriskof the need for futureemergencydepartment visits and hospital admissions. Thisreviewlooked at studies which compared usual care for asthma to more intensive educational programmes and the results showed astatistically significantreduction in the treatment groups needing subsequentemergencydepartment visits or hospital admissions. We were not able to determine the most effective type, duration or intensity ofeducationthat should be offered to children to offer the best asthma outcomes.

Cochrane Summary: Magnesium sulfate for treating exacerbations of acute asthma in the emergency department (2009)

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Rowe, BH, Bretzlaff, J, Bourdon, C, Bota, G, Blitz, S, Camargo, CA,

In an asthma attack, the airways (passages to the lungs) narrow from muscle spasms and swelling (inflammation). Bronchodilator drugs (reliever inhalers) can be used to relax the muscles and open the airways, and corticosteroid drugs to reduce the inflammation. Magnesium sulfate is a drug that can also affect muscles, and may reduce inflammation as well. It can be given through a drip in the veins (intravenously). Thereviewof trials found thatintravenousmagnesium sulfate in addition to bronchodilators seems to be safe and beneficial for people with severe asthma attacks, or those for whom bronchodilators are not working.

Cochrane Summary: Early emergency department treatment of acute asthma with systemic corticosteroids (2008)

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Rowe, BH, Spooner, C, Ducharme, F, Bretzlaff, J, Bota, G,

In an asthma attack, the airways (passages to the lungs) narrow from muscle spasms and swelling (inflammation). Bronchodilators (reliever inhalers to open up the lungs and airways) can be used for the spasms, and corticosteroids for the swelling.Corticosteroidscan be inhaled, or taken by mouth (orally) or through a drip into the veins (intravenously). Thereviewof trials found thatsystemic(oralorintravenous) corticosteroids reduce the need for people with asthma attacks to stay in hospital, with fewadverse effects.

Asthma  Systematic reviews

Cochrane Systematic Review: Intravenous and nebulized magnesium sulfate for treating acute asthma in adults and children: a systematic review and meta-analysis

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Shan, Z, Rong, Y, Yang, W, Wang, D, Yao, P, Xie, J, Liu, L,

This systematic review and meta-analysis was conducted to estimate the effects of intravenous and nebulized magnesium sulfate on treating adults and children with acute asthma.

Cochrane Systematic Review: Dexamethasone for acute asthma exacerbations in children: a meta-analysis (2014)

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Keeney, GE, Gray, MP, Morrison, AK, Levas, MN, Kessler, EA, Hill, GD, Gorelic...

This systematic review and meta-analysis aimed to determine whether intramuscular or oral dexamethasone is equivalent or superior to a 5-day course of oral prednisone or prednisolone. The primary outcome of interest was return visits or hospital readmissions.

Cochrane Systematic Review: Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma (2013)

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Cates, CJ, Welsh, EJ, Rowe, BH,

Objectives: To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta(2)-agonists for acute asthma. This review includes a total of 1897 children and 729 adults in 39 trials. Thirty-three trials were conducted in the emergency room and equivalent community settings, and six trials were on inpatients with acute asthma (207 children and 28 adults).

Cochrane Systematic Review: Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children (2013)

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Griffiths, B, Ducharme, FM,

Objectives: To determine whether the addition of inhaled anticholinergics to SABAs provides clinical improvement and affects the incidence of adverse effects in children with acute asthma exacerbations.

Cochrane Systematic Review: Inhaled steroids for acute asthma following emergency department discharge (2012)

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Edmonds, ML, Milan, SJ, Brenner, BE, Camargo, CA Jr, Rowe, BH,

Objectives: To determine the effectiveness of ICS on outcomes in the treatment of acute asthma following discharge from the ED. To quantify the effectiveness of ICS therapy on acute asthma following ED discharge, when used in addition to, or as a substitute for, systemic corticosteroids.

Cochrane Systematic Review: Ketamine for management of acute exacerbations of asthma in children (2012)

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Jat, KR, Chawla, D,

Objectives: To evaluate the efficacy of ketamine compared to placebo, no intervention or standard care for management of severe acute asthma in children who had not responded to standard therapy.

Cochrane Systematic Review: Interventions for educating children who are at risk of asthma-related emergency department attendance (2009)

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Boyd, M, Lasserson, TJ, McKean, MC, Gibson, PG, Ducharme, FM, Haby, M,

Objectives: To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.

Cochrane Systematic Review: Magnesium sulfate for treating exacerbations of acute asthma in the emergency department (2000)

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Rowe, BH, Bretzlaff, JA, Bourdon, C, Bota, GW, Camargo, CA Jr,

Objectives: To examine the effect of additional intravenous magnesium sulfate in patients with acute asthma managed in the emergency department. Seven trials were included (5 adult, 2 pediatric).

Cochrane Systematic Review: Early emergency department treatment of acute asthma with systemic corticosteroids (2000)

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Rowe, BH, Spooner, C, Ducharme, FM, Bretzlaff, JA, Bota, GW,

Objectives: To determine the benefit of treating patients with acute asthma with systemic corticosteroids within an hour of presenting to the emergency department (ED).

Asthma  Key studies

Key Study: The Pediatric Respiratory Assessment Measure: a valid clinical score for assessing acute asthma severity from toddlers to teenagers (2008)

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Ducharme, FM, Chalut, D, Plotnick, L, Savdie, C, Kudirka, D, Zhang, X, Meng, ...

To determine the performance characteristics of the Preschool Respiratory Assessment Measure (PRAM) in preschool and school-aged children with acute asthma.

Key Study: The Preschool Respiratory Assessment Measure (PRAM): a responsive index of acute asthma severity (2000)

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Chalut DS, Ducharme FM, Davis GM

To elaborate and validate a Preschool Respiratory Assessment Measure (PRAM) that would accurately reflect the severity of airway obstruction and the response to treatment in young patients with asthma.

Bronchiolitis
Bronchiolitis  Bottom Line Recommendations

Bottom Line Recommendations: Bronchiolitis

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Plint, A & TREKK Network

Bottom line recommendations for the treatment and management of bronchiolitis. Updated April 2017

Bottom Line: Recommandations de Base: La Bronchiolite

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Plint, A & TREKK Network

Bottom line recommendations for the treatment and management of bronchiolitis - en francais.

Bronchiolitis  Clinical guidelines

Clinical Guideline: Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis

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Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, J...

This guideline is a revision of the clinical practice guideline, Diagnosis and Management of Bronchiolitis, published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation.

Clinical Guideline: Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age

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Canadian Paediatric Society

The goals of this statement are to build on the comprehensive peer-reviewed AAP statement by incorporating new evidence published over the past eight years, while providing the clinician with recommendations to help guide diagnosis, monitoring and management of previously healthy children one to 24 months of age who present with signs of bronchiolitis.

Bronchiolitis  Overviews of systematic reviews

Overview of Systematic Reviews: Evidence Summary: Bronchiolitis

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Alberta Research Centre for Health Evidence (ARCHE)

Evidence summary for the treatment and management of bronchiolitis.

Cochrane Summary: Antibiotics for bronchiolitis in children under two years of age

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Farley R, Spurling GK, Eriksson L, Del Mar CB

This review summarizes evidence on the effect of antibiotics on clinical outcomes in children with bronchiolitis.

Cochrane Summary: Bronchodilators for bronchiolitis for infants with first-time wheezing

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Gadomski AM, Scribani MB

This review summarizes the evidence about the effect of bronchodilators in infants with bronchiolitis.

Overview of Systematic Reviews: The Cochrane Library and safety of systemic corticosteroids for acute respiratory conditions in children: An overview of reviews

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Fernandes RM, Oleszczuk M, Woods CR, Rowe BH, Cates CJ, Hartling L.

Objective: To examine clinically relevant short-term safety outcomes related to acute single or recurrent systemic short-term (<2 weeks) corticosteroid use based on systematic reviews of acute respiratory conditions.

Cochrane Summary: Hypertonic saline solution administered via nebuliser for acute bronchiolitis in infants

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Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP

Objective: to assess the effects of nebulised hypertonic ( 3%) saline solution in infants with acute viral bronchiolitis.

Cochrane Summary: Glucocorticoids for acute viral bronchiolitis in infants and young children under two years of age

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Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, Johnson ...

Objective: to review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis.

Overview of Systematic Reviews: The Cochrane Library and the treatment of bronchiolitis in children: An overview of reviews

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Bialy L, Foisy M, Smith M, Fernandes RM

This updated overview of reviews aims to synthesize evidence from the Cochrane Database of Systematic Reviews (CDSR) on the effectiveness and safety of 11 pharmacologic and non-pharmacologic treatments to improve bronchiolitis symptoms in outpatient, inpatient and intensive care populations.

Cochrane Summary: Epinephrine for acute viral bronchiolitis in children less than two years of age

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Hartling L, Bialy LM, Vandermeer B, Tjosvold L, Johnson DW, Plint AC, Klassen...

Objective: to examine the efficacy and safety of epinephrine in children less than two with acute viral bronchiolitis.

Bronchiolitis  Systematic reviews

Systematic Review: Nebulized hypertonic saline for acute bronchiolitis: A systematic review

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Zhang L, Mendoza-Sassi RA, Klassen TP, Wainwright C.

Objective: The objective of this study was to assess the efficacy and safety of nebulized hypertonic saline (HS) in infants with acute bronchiolitis.

Systematic Review: Antibiotics for bronchiolitis in children under two years of age

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Farley R, Spurling GK, Eriksson L, Del Mar CB

Objective: to evaluate the effectiveness of antibiotics for bronchiolitis in children under two years of age compared to placebo or other interventions.

Systematic Review: Bronchodilators for bronchiolitis

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Gadomski AM, Scribani MB

Objective: to assess the effects of bronchodilators on clinical outcomes in infants (0 to 12 months) with acute bronchiolitis.

Systematic Review: Glucocorticoids for acute viral bronchiolitis in infants and young children

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Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, Johnson ...

Objective: to review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis.

Systematic Review: Nebulised hypertonic saline solution for acute bronchiolitis in infants

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Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP

Objective: to assess the effects of nebulised hypertonic ( 3%) saline solution in infants with acute viral bronchiolitis.

Systematic Review: Epinephrine for bronchiolitis

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Hartling L, Bialy LM, Vandermeer B, Tjosvold L, Johnson DW, Plint AC, Klassen...

Objective: to examine the efficacy and safety of epinephrine in children less than two with acute viral bronchiolitis.

Systematic Review: Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis

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Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, Klassen TP, V...

Objectives: to evaluate and compare the efficacy and safety of bronchodilators and steroids, alone or combined, for the acute management of bronchiolitis in children aged less than 2 years.

Bronchiolitis  Key studies

Key Study: High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): An open, phase 4, randomised controlled trial

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Kepreotes E, Whitehead B, Attia J, Oldmeadow C, Collison A, Searles A, Goddar...

Objectives: Bronchiolitis is the most common lung infection in infants and treatment focuses on management of respiratory distress and hypoxia. High-flow warm humidified oxygen (HFWHO) is increasingly used, but has not been rigorously studied in randomised trials. This study aimed to examine whether HFWHO provided enhanced respiratory support, thereby shortening time to weaning off oxygen

Key Study: Epinephrine and dexamethasone in children with bronchiolitis

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Plint AC, Johnson DW, Patel H, Wiebe N, Correll R, Brant R, Mitton C, Gouin S...

This randomized, double-blind, placebo-controlled, clinical trial with a factorial design at multiple sites was undertaken to determine whether treatment with nebulized epinephrine, a short course of oral dexamethasone, or both resulted in a clinically important decrease in hospital admissions among infants with bronchiolitis who were seen in the emergency department.

Key Study: A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis

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Corneli HM, Zorc JJ, Mahajan P, Shaw KN, Holubkov R, Reeves SD, Ruddy RM, Mal...

The goal of this study was to determine the effectiveness of a single dose of oral dexamethasone in infants with moderate-to-severe bronchiolitis.

Key Study: Evaluation of the utility of radiography in acute bronchiolitis

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Schuh S, Lalani A, Allen U, Manson D, Babyn P, Stephens D, MacPhee S, Mokansk...

Objectives: to determine the proportion of radiographs inconsistent with bronchiolitis in children with typical presentation of bronchiolitis and to compare rates of intended antibiotic therapy before radiography versus those given antibiotics after radiography.

Concussion
Concussion  Bottom Line Recommendations

Bottom Line Recommendations: Concussion

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Zemek R & TREKK Network

Bottom line recommendations for the treatment and management of concussion. Updated: August 2018.

Recommandations de Base: Commotion cérébrale (TCC léger)

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Zemek R and TREKK Network

Bottom line recommendations for the treatment and management of concussion - en francais. Updated: August 2018.

Bottom Line: The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5)

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Davis GA, Purcell L, Schneider KJ, Yeates KO, Gioia GA, Anderson V, Ellenboge...

The Child SCAT5 is a standardized tool for evaluating concussions designed for use by physicians and licensed healthcare professionals. The Child SCAT5 is to be used for evaluating Children aged 5 to 12 years. For athletes aged 13 years and older, please use the SCAT5.

Bottom Line: The Sport Concussion Assessment Tool 5th Edition (SCAT5)

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Echemendia RJ, Meeuwisse W, McCrory P, Davis GA, Putukian M, Leddy J, Makdiss...

The SCAT5 is a standardized tool for evaluating concussions designed for use by physicians and licensed healthcare professionals. The SCAT5 is to be used for evaluating athletes aged 13 years and older. For children aged 12 years or younger, please use the Child SCAT5.

Bottom Line: Management of Acute Symptoms Algorithm

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Ontario Neurotrauma Foundation

This document is intended to guide health care professionals in diagnosing and managing pediatric concussion. See Page 48 of this document for the Management of Acute Symptoms Algorithm (Tool 2.1).

Emergency Medicine Cases Podcast: Pediatric head injury

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Dr. Rahim Valani and Dr. Jennifer Riley

Episode 3:Dr. Rahim Valani and Dr. Jennifer Riley discuss their approach to the workup and management of both minor and major Pediatric Head Injury. They review two recent landmark studies (Kupperman PECARN & CATCH studies) describing clinical decision rules for performing CT head in minor pediatric head injury, as well as practical tips on instructing parents regarding back to sport activities after discharge. In major pediatric head injury, they discuss key clinical pearls on managing blood pressure, the use of hypertonic saline and managing raised intracranial pressure in the treatment of major head injury. Published online: April 2010. 

Bottom Line: Acute Concussion Evaluation (ACE): Physician/Clinician Office Version

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Goia G, Collins M

The ACE is intended to provide an evidence-based clinical protocol to conduct an initial evaluation and diagnosis of patients (both children and adults) with known or suspected mild traumatic brain injury.

Concussion  Clinical guidelines

Guidelines: Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016

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McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cas...

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach.

Guidelines: Guidelines for Diagnosing and Managing Pediatric Concussion: Recommendations for Health Care Professionals

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Zemek R, Duval S, Dematteo C, Solomon B, Keightley M, Osmond M

This document is intended to guide health care professionals in diagnosing and managing pediatric concussion.

Guidelines: Care of the Patient with mild traumatic brain injury

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West TA, Bergman K, Biggins MS, French B, Galletly J, Hinkle JL, Morris J

The purpose of this document is to provide recommendations based on current evidence that will help registered nurses, advanced practice nurses, and institutions provide safe and effective care to injured patients with a mild traumatic brain injury.

Concussion  Overviews of systematic reviews

Evidence Summary: Management of paediatric minor head injuries. Safe discharge?

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Hunter F

This summary answers the question: In paediatric patients with minor head injury, GCS (Glasgow Coma Score) 15 and no focal neurological deficit does a normal computed tomography brain scan allow safe discharge?

Concussion  Systematic reviews

Systematic Review: Predictors of clinical recovery from concussion: a systematic review

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Iverson GL, Gardner AJ, Terry DP, Ponsford JL, Sills AK, Broshek DK, Solomon GS

This is a systematic review of factors that might be associated with, or influence, clinical recovery from sport-related concussion

Systematic Review: Rest and treatment/rehabilitation following sport-related concussion: a systematic review

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Schneider KJ, Leddy JJ, Guskiewicz KM, Seifert T, McCrea M, Silverberg ND, Fe...

The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC).

Systematic Review: Psychosocial consequences of mild traumatic brain injury in children: results of a systematic review by the International Collaboration on Mild Traumatic Brain Injury Prognosis

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Keightley ML, Ct P, Rumney P, Hung R, Carroll LJ, Cancelliere C, Cassidy JD

Objective: To synthesize the best available evidence regarding psychosocial consequences of mild traumatic brain injury (MTBI) in children.

Systematic Review: Prognosticators of persistent symptoms following pediatric concussion: a systematic review

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Zemek RL, Farion KJ, Sampson M, McGahern C

Objective: To identify predictors of persistent concussion symptoms (PCS) in children following concussion.

Systematic Review: Interventions provided in the acute phase for mild traumatic brain injury: a systematic review

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Gravel J, D'Angelo A, Carrire B, Crevier L, Beauchamp MH, Chauny JM, Wassef M...

This systematic review investigated the effectiveness of interventions initiated in acute settings for patients who experience mild traumatic brain injury.

Systematic Review: Clinical decision rules for children with minor head injury: a systematic review

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Pickering A, Harnan S, Fitzgerald P, Pandor A, Goodacre S

This study aimed to identify clinical decision rules for children with minor head injury and compare their diagnostic accuracy for detection of intracranial injury (ICI) and injury requiring neurosurgical intervention (NSI).

Systematic Review: Which symptom assessments and approaches are uniquely appropriate for paediatric concussion?

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Gioia GA, Schneider JC, Vaughan CG, Isquith PK

Objectives: To (a) identify post-concussion symptom scales appropriate for children and adolescents in sports; (b) review evidence for reliability and validity; and (c) recommend future directions for scale development.

Concussion  Key studies

Key Study: Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department

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Osmond MH, Klassen TP, Wells GA, Davidson J, Correll R, Boutis K, Joubert G, ...

Methods: This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Physicians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule.

Key Study: Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED

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Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, Aglipay M,...

Objective: To derive and validate a clinical risk score for persistent postconcussion symptoms among children presenting to the emergency department.

Key Study: Effect of cognitive activity level on duration of post-concussion symptoms

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Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP III

Objective: To determine the effect of cognitive activity level on duration of post-concussion symptoms.

Key Study: Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study

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Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS

Objective: To evaluate the diagnostic accuracy of clinical decision rules and physician judgment for identifying clinically important traumatic brain injuries in children with minor head injuries presenting to the emergency department.

Key Study: Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department

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Babcock L, Byczkowski T, Wade SL, Ho M, Mookerjee S, Bazarian JJ

Objective: To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury.

Key Study: Time interval between concussions and symptom duration

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Eisenberg MA, Andrea J, Meehan W, Mannix R

Objective: To test the hypothesis that children with a previous history of concussion have a longer duration of symptoms after a repeat concussion than those without such a history.

Key Study: Mild traumatic brain injury: a description of how children and youths between 16 and 18 years of age perform leisure activities after 1 year

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Jonsson C, Andersson EE

Objective: To describe how children and youths perform leisure activities, 1 year after a mild traumatic brain injury (MTBI).

Key Study: Identifying neurocognitive deficits in adolescents following concussion

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Thomas DG, Collins MW, Saladino RA, Frank V, Raab J, Zuckerbraun NS

This study of concussed adolescents sought to determine if a computer-based neurocognitive assessment (Immediate Postconcussion Assessment and Cognitive Test [ImPACT]) performed on patients who present to the emergency department (ED) immediately following head injury would correlate with assessments performed 3 to 10 days postinjury and if ED neurocognitive testing would detect differences in concussion severity that clinical grading scales could not.

Key Study: Identifying the specific needs of adolescents after a mild traumatic brain injury: a service provider perspective

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Swaine BR, Gagnon I, Champagne F, Lefebvre H, Friedman D, Atkinson J, Feldman D

Objectives: To identify the specific service needs of adolescents with mild traumatic brain injury (MTBI) and those of their parents through the perspective of expert service providers as well as to compare it to the perspective of adolescents and their parents obtained in a prior study.

Key Study: Visuomotor response time in children with a mild traumatic brain injury

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Gagnon I, Swaine B, Friedman D, Forget R

Objective: To compare the visuomotor response times of children after a mild traumatic brain injury (mTBI) with those of noninjured children matched for age, sex, and premorbid level of physical activity.

Congenital Heart Defect
Congenital Heart Defect  Bottom Line Recommendations

Bottom Line: Approach to cyanotic congenital heart disease in the newborn

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Cheung C

This document summarizes causes, symptoms, and management of cyanosis in newborns.

Congenital Heart Defect  Clinical guidelines

Clinical Practice Guideline: Duct dependant congenital heart disease

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Brierley J, National Health Service Children's Acute Transport Service

Objective: To standardise the initial management of neonates with duct dependent congenital heart disease.

Clinical Practice Guideline: Resuscitation of blue baby and the use of prostaglandins

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Linney M, Gnapragassam J, Wilson P, Rodd I

This document relates to the acute management of infants presenting acutely with collapse and/or cyanosis suggestive of congenital heart defect.

Congenital Heart Defect  Systematic reviews

Systematic Review: Pulse oximetry screening for critical congenital heart defects in asymptomatic newborn babies: a systematic review and meta-analysis

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Thangaratinam S, Brown K, Zamora J, Khan KS, Ewer AK

Objective: To assess the performance of pulse oximetry as a screening method for the detection of critical congenital heart defects in asymptomatic newborn babies.

Congenital Heart Defect  Key studies

Overview of studies: Congenital Heart Disease In Pediatric Patients: Recognizing The Undiagnosed And Managing Complications In The Emergency Department

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Judge P, Meckler G

Objective: This review focuses on the recognition and initial management of patients with undiagnosed congenital heart disease presenting to the ED and touches on considerations for postoperative infants and children with complex congenital heart disease.

Key Study: The Critically Ill Infant with Congenital Heart Disease

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Strobel, AM & Lu, N.

Objective: This article presents an approach for identification of infants with congenital heart disorders.

Key Study: Reappraisal of the prostaglandin E1 dose for early newborns with patent ductus arteriosus-dependent pulmonary circulation

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Huang FK, Lin CC, Huang TC, Weng KP, Liu PY, Chen YY, Wang HP, Ger LP, Hsieh KS

Objective: To review our experience of a low initial dose of PGE1 treatment in early newborns with congenital heart disease and patent ductus arteriosus (PDA)-dependent pulmonary flow.

Key Study: Congenital heart disease

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Dolbec K, Mick NW

This publication provides an overview of the presentations of congenital heart defects, and makes diagnosis and management recommendations for emergency physicians.

Key Study: Impact of oxygen saturation targets and oxygen therapy during the transport of neonates with clinically suspected congenital heart disease

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Shivananda S, Kirsh J, Whyte HE, Muthalally K, McNamara PJ

Objective: To determine the effect of average SpO(2) range and oxygen administration during neonatal transport on clinical markers of cardiovascular instability.

Key Study: Approach to diagnosing congenital cardiac disorders

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Hartas GA, Tsounias E, Gupta-Malhotra M

Objective: To give a general picture of the diagnostic approach to a multitude of heart defects.

Key Study: To intubate or not to intubate? Transporting infants on prostaglandin E1

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Meckler GD, Lowe C

This document describes the pretransport and transport management of infants receiving prostaglandin E(1) infusion for congenital heart disease and compares transport complications among unintubated and electively intubated infants.

Overview of studies: Emergency presentation of congenital heart disease in children

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EB Medicine

Objective: To address the evaluation and management of pediatric patients with congenital heart defects in the context of the evidence available from the medical literature.

Key Study: Lessons from transporting newborn infants with known or suspected congenital heart disease

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Bouchut JC, Teyssedre S

This study presents the results of an evaluation of transporting, by a nonspecialized emergency medical service, neonates with known or suspected cardiac abnormalities.

Key Study: Evaluation and management of the cyanotic neonate

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Steinhorn RH

This document discusses the potential challenges in recognizing cyanosis, including the presence of higher concentrations of fetal hemoglobin, and its oxygen binding characteristics.

Key Study: Transporting newborn infants with suspected duct dependent congenital heart disease on low-dose prostaglandin E1 without routine mechanical ventilation

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Browning Carmo KA, Barr P, West M, Hopper NW, White JP, Badawi N

Objective: To evaluate the safety of transporting newborn infants with suspected duct dependent congenital heart disease (CHD) treated with prostaglandin E1 (PGE1) without routine mechanical ventilation.

Key Study: Cardiac emergencies in the first year of life

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Yee L

This document discusses the most common causes of cyanotic and acyanotic heart disease in infants.

Key Study: ABC of clinical electrocardiography: Paediatric electrocardiography

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Goodacre S, McLeod K

General clinicians and junior paediatricians may have little experience of interpreting paediatric electrocardiograms. Although the basic principles of cardiac conduction and depolarisation are the same as for adults, age related changes in the anatomy and physiology of infants and children produce normal ranges for electrocardiographic features that differ from adults and vary with age. Awareness of these differences is the key to correct interpretation of paediatric electrocardiograms.

Key Study: Management of the neonate with symptomatic congenital heart disease

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Penny DJ, Shekerdemian LS

This document addresses some of the principles on which resuscitation and stabilisation of the symptomatic neonate with congenital heart disease may be based.

Key Study: Prevalence and clinical significance of cardiac murmurs in neonates

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Ainsworth S, Wyllie JP, Wren C

Objective: To determine the prevalence and clinical significance of murmurs detected during routine neonatal examination.

Key Study: Differentiation of systemic infection and congenital obstructive left heart disease in the very young infant

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Pickert CB, Moss MM, Fiser DH

This retrospective review of critically ill infants 0 to 28 days of age presenting with either bacterial sepsis or meningitis or a congenital obstructive left heart syndrome (COLHS), identifies historical, physical, or laboratory findings which might differentiate the two groups at presentation.

Key Study: Evaluation of low dose prostaglandin E1 treatment for ductus dependent congenital heart disease

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Kramer HH, Sommer M, Rammos S, Krogmann O

This study reports experience with low-dose prostaglandin E1 (PGE1) treatment of 91 newborns with ductus dependent congenital heart disease (CHD).

Constipation
Constipation  Bottom Line Recommendations

Bottom Line: Flowchart of evaluation and management of functional constipation in children

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Koppen IJ, Lammers LA, Benninga MA, Tabbers MM

Flowchart of evaluation and management of functional constipation in children.

Constipation  Clinical guidelines

Guidelines: Constipation in Children and Young People: Diagnosis and Management

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National Institute for Health and Care Excellence

This guideline covers diagnosing and managing constipation in children and young people up to 18. It provides strategies to support the early identification and timely, effective treatment of constipation which will help improve outcomes for patients. It does not cover constipation caused by a specific condition.

Guidelines: Constipation

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Royal Children's Hospital Melbourne

These clinical practice guidelines cover the description, etiology, diagnosis and management of constipation in children.

Guidelines: Childhood Functional Gastrointestinal Disorders: Neonate/Toddler

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Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S

This article provides a description, assessment, and analysis of each functional gastrointestinal intestinal disorder that affects the neonate/toddler age group.

Guidelines: Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV

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Drossman DA

This summary article about the Rome IV diagnostic criteria describes the the field of functional gastrointestinal disorders, distinguishes them from motility and structural disorders, discusses the changes from the Rome III criteria, reviews the Rome committee process, provides a biopsychological pathophysiological conceptualization of functional gastrointestinal disorders, and offers an approach to patient care.

Guidelines: Functional Disorders: Children and Adolescents

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Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M

The Rome criteria provide symptom-based guidelines by which child and adolescent functional gastrointestinal disorders (FGID) can be diagnosed.

Guidelines: Constipation

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Kids Health WA

These emergency department guidelines cover the background, assessment and management of constipation in children.

Guidelines: Management of Functional Constipation

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SickKids

This pathway is for use with children aged 1-18 years old with no underlying disease or cormorbidity who have been diagnosed with functional constipation.

Guidelines: Evaluation and treatment of constipation in children and adolescents

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Nurko S, Zimmerman LA

These clinical practice guidelines cover the definition, etiology and pathophysiology, diagnosis, differential diagnosis and treatment of constipation in infants younger than six months, and also in children six months and older.

Guidelines: Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN

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Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A...

This evidence-based guideline provides recommendations for the evaluation and treatment of children withfunctionalconstipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants under 6 months of age and the other for older infants and children.

Guidelines: Managing functional constipation in children

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Rowan-Legg A; Canadian Paediatric Society, Community Paediatrics Committee

These guidelines are published in English and French, and cover the description, etiology, diagnosis and management, including long-term treatments and behavioural modifications and education, for functional constipation in children.

Constipation  Overviews of systematic reviews

Cochrane Summary: Laxatives for the management of childhood constipation

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Gordon M, MacDonald JK, Parker CE, Akobeng AK, Thomas AG

This summary addresses the questions: What are the effectiveness and side effects of osmotic and stimulant laxatives used for the treatment of functional childhood constipation?

Guideline Summary: Idiopathic constipation in children clinical practice guidelines

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Paul SP, Broad SR, Spray C

This is a review of current guidelines for diagnosing and managing idiopathic constipation in children.

Constipation  Systematic reviews

Cochrane Systematic Review: Osmotic and stimulant laxatives for the management of childhood constipation

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Gordon M, MacDonald JK, Parker CE, Akobeng AK, Thomas AG

The objective of this systematic review was to evaluate the efficacy and safety of osmotic and stimulant laxatives used to treat functional childhood constipation.

Systematic Review: Is There A Role for Pre-, Pro- and Synbiotics in the Treatment of Functional Constipation in Children?

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Koppen IJ, Benninga MA, Tabbers MM

The objective of this systematic review was to investigate the efficacy and safety of pre-, pro- and synbiotics in the treatment of pediatric functional constipation.

Review: Management of Functional Constipation in Children: Therapy in Practice

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Koppen IJ, Lammers LA, Benninga MA, Tabbers MM

This review discusses the evaluation and management of functional constipation in the pediatric population and provides a summary of drug treatment options.

Systematic Review: Constipation in children: fibre and probiotics

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Tabbers MM, Benninga MA

This systematic review aimed to answer the following clinical questions: What are the effects of fibre for children with chronic constipation? What are the effects of probiotics for children with chronic constipation?

Review: Irritable bowel syndrome in children: pathogenesis, diagnosis and evidence-based treatment

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Sandhu BK, Paul SP

This review covers the description, etiology, diagnosis and management of irritable bowel syndrome in children.

Cochrane Systematic Review: Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

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Brazzelli M, Griffiths PV, Cody JD, Tappin D

The objective of this systematic review was to assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.

Systematic Review: Nonpharmacologic treatments for childhood constipation: systematic review

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Tabbers MM, Boluyt N, Berger MY, Benninga MA

The objectives of this systematic review were to summarize the evidence and assess the reported quality of studies concerning nonpharmacologic treatments for childhood constipation, including fiber, fluid, physical movement, prebiotics, probiotics, behavioral therapy, multidisciplinary treatment, and forms of alternative medicine.

Systematic Review: Constipation in children

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Tabbers MM, Boluyt N, Berger MY, Benninga MA

This systematic review aimed to answer the following clinical questions: What are the effects of treatments for children with chronic constipation? What are the effects of treatments for clearing the bowel in children with faecal impaction?

Review: Clinical practice guidelines for pediatric constipation

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Greenwald BJ

The purpose of this review was to discuss the diagnosis and management of pediatric constipation by nurse practitioners in primary care.

Systematic Review: Currently recommended treatments of childhood constipation are not evidence based: a systematic literature review on the effect of laxative treatment and dietary measures

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Pijpers MA, Tabbers MM, Benninga MA, Berger MY

The objective of this systematic review was to investigate and summarise the quantity and quality of the current evidence for the effect of laxatives and dietary measures on functional childhood constipation.

Constipation  Key studies

Key Study: Delayed Diagnoses in Children with Constipation: Multicenter Retrospective Cohort Study

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Freedman SB, Rodean J, Hall M, Alpern ER, Aronson PL, Simon HK, Shah SS, Mari...

The objective of this study was to evaluate the association between abdominal radiograph performance and emergency department (ED) revisits with important alternate diagnosis among children with constipation.

Key Study: Effectiveness of Pelvic Physiotherapy in Children With Functional Constipation Compared With Standard Medical Care

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van Engelenburg-van Lonkhuyzen ML, Bols EM, Benninga MA, Verwijs WA, de Bie RA

This study aimed to compare the effectiveness of pelvic physiotherapy (PPT) vs standard medical care (SMC) in children with functional constipation.

Key Study: Using the Bristol Stool Scale and Parental Report of Stool Consistency as Part of the Rome III Criteria for Functional Constipation in Infants and Toddlers

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Koppen IJ, Velasco-Benitez CA, Benninga MA, Di Lorenzo C, Saps M

The objectives of this study were to evaluate among parents of infants and toddlers the agreement between parental report and the Bristol Stool Scale (BSS) in assessing stool consistency and the effect of both methods on determining the prevalence of functional constipation (FC) according to the Rome III criteria.

Key Study: Follow-up in Childhood Functional Constipation: A Randomized, Controlled Clinical Trial

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Modin L, Walsted AM, Rittig CS, Hansen AV, Jakobsen MS

The objective of this study was to evaluate whether follow-up by phone or self-management through Web-based information improved treatment outcomes for childhood functional constipation.

Key Study: Free fatty acid suppositories are as effective as docusate sodium and sorbitol enemas in treating constipation in children

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Ormarsson OT, Asgrimsdottir GM, Loftsson T, Stefansson E, Lund SH, Bjornsson ES

This phase two clinical trial evaluated the efficacy of suppositories containing free fatty acids (FFA) compared with Klyx docusate sodium and sorbitol enemas for treating constipation in children.

Key Study: Recurrent Urinary Tract Infections in Children With Bladder and Bowel Dysfunction

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Shaikh N, Hoberman A, Keren R, Gotman N, Docimo SG, Mathews R, Bhatnagar S, I...

The objectives of this longitudinal study were to describe the clinical characteristics of children with bowel dysfunction and to examine the effects of bowel dysfunction on patient outcomes in children with and without vesicoureteral reflux.

Key Study: Comparison of Polyethylene Glycol-Electrolyte Solution vs Polyethylene Glycol-3350 for the Treatment of Fecal Impaction in Pediatric Patients

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Boles EE, Gaines CL, Tillman EM

The objective of this study was to evaluate the safety and efficacy of polyethylene glycol-electrolyte solution vs polyethylene glycol-3350 for the treatment of fecal impaction in pediatric patients.

Key Study: Polyethylene glycol 4000 for treatment of functional constipation in children

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Dziechciarz P, Horvath A, Szajewska H

The aim of the study was to evaluate the effectiveness and safety of 2 different polyethylene glycol (PEG) doses for the maintenance treatment of functional constipation in children.

Key Study: Disimpaction of children with severe constipation in 3-4 days in a suburban clinic using polyethylene glycol with electrolytes and sodium picosulphate

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Jordan-Ely J, Hutson JM, Southwell BR

The aim of this study was to assess the effectiveness of a high-dose oral protocol using polyethylene glycol with electrolytes (PEG + E) (Movicol Rx) combined with sodium picosulphate (SP) (Dulcolax SP Rx) in faecal impaction in children presenting to a suburban clinic.

Key Study: PedsQL Gastrointestinal Symptoms Scales and Gastrointestinal Worry Scales in pediatric patients with functional and organic gastrointestinal diseases in comparison to healthy controls

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Varni JW, Bendo CB, Denham J, Shulman RJ, Self MM, Neigut DA, Nurko S, Patel ...

The primary objective of this study was to compare the gastrointestinal (GI) symptoms and worry of pediatric patients with functional GI disorders (FGIDs) and organic GI diseases to healthy controls utilizing the Pediatric Quality of Life Inventor (PedsQL) Gastrointestinal Symptoms and Worry Scales for patient self-reports ages 5-18 years and parent proxy-reports for ages 2-18 years. The secondary objective was to compare FGIDs and organic GI diseases to each other.

Key Study: Safety and efficacy of milk and molasses enemas in the emergency department

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Vilke GM, DeMers G, Patel N, Castillo EM

The objective of this study was to evaluate the success and complication rates of administering milk and molasses enemas in the ED.

Key Study: Pediatric abdominal radiograph use, constipation, and significant misdiagnoses

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Freedman SB, Thull-Freedman J, Manson D, Rowe MF, Rumantir M, Eltorki M, Schuh S

The objectives of this study were to determine the proportion of children diagnosed with constipation assigned a significant alternative diagnosis within 7 days (misdiagnosis), if there was an association between abdominal radiograph (AXR) performance and misdiagnosis, and if there were features that might identify children with misdiagnoses.

Key Study: Pediatric constipation in the emergency department: evaluation, treatment, and outcomes

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Freedman SB, Thull-Freedman J, Rumantir M, Eltorki M, Schuh S

The primary objective of this study was to determine whether enema administration is associated with 7-day emergency department (ED) revisits for persistent symptoms of pediatric constipation. Secondary objectives focused on assessing other predictors of ED revisits.

Key Study: Prucalopride is no more effective than placebo for children with functional constipation

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Mugie SM, Korczowski B, Bodi P, Green A, Kerstens R, Ausma J, Ruth M, Levine ...

This multicenter, randomized, placebo-controlled, double-blind, phase 3 trial aimed to evaluate the efficacy and safety of prucalopride in children (6 months to 18 years old) with functional constipation.

Key Study: A randomized trial of enemaversus polyethylene glycol 3350 for fecal disimpaction in children presenting to an emergency department

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Miller MK, Dowd MD, Friesen CA, Walsh-Kelly CM

This study aimed to compare efficacy of enema versus polyethylene glycol (PEG) 3350 for pediatric fecal impaction treatment.

Key Study: Safety and efficacy of milk and molasses enemas compared with sodium phosphate enemas for the treatment of constipation in a pediatric emergency department

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Hansen SE, Whitehill JL, Goto CS, Quintero CA, Darling BE, Davis J

The purpose of this study was to determine the safety and efficacy of routine milk and molasses enemas (MME) compared with sodium phosphate enemas for the treatment of constipation in the pediatric emergency department (ED). A secondary objective included the identification of factors associated with enema selection in the pediatric ED.

Key Study: Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG

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Bekkali NL, van den Berg MM, Dijkgraaf MG, van Wijk MP, Bongers ME, Liem O, B...

This study tested the hypothesis that enemas and polyethylene glycol (PEG) would be equally effective in treating rectal fecal impaction (RFI) but enemas would be less well tolerated and colonic transit time (CTT) would improve during disimpaction.

Key Study: A randomized controlled trial of enemas in combination with oral laxative therapy for children with chronic constipation

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Bongers ME, van den Berg MM, Reitsma JB, Voskuijl WP, Benninga MA

This randomized controlled trial compared the effects of additional treatment with rectal enemas (intervention) with conventional treatment alone (oral laxatives, control) in severely constipated children.

Key Study: PEG3350 in the treatment of childhood constipation: a multicenter, double-blinded, placebo-controlled trial

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Nurko S, Youssef NN, Sabri M, Langseder A, McGowan J, Cleveland M, Di Lorenzo C

This study aimed to establish the efficacy and best starting dose of polyethylene glycol (PEG)3350 in the short-term treatment of children with functional constipation.

Key Study: Behavioral therapy for childhood constipation: a randomized, controlled trial

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van Dijk M, Bongers ME, de Vries GJ, Grootenhuis MA, Last BF, Benninga MA

The aim of this study was to evaluate the clinical effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood.

Key Study: Functional defecation disorders in children: PACCT criteria versus Rome II criteria

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Boccia G, Manguso F, Coccorullo P, Masi P, Pensabene L, Staiano A

The aim of this study was to evaluate the clinical validity and applicability of the Paris Consensus on Childhood Constipation Terminology (PACCT) versus the Rome II criteria for pediatric functional defecation disorders (FDDs).

Key Study: Emergency department management and short-term outcome of children with constipation

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Miller MK, Dowd MD, Fraker M

The objective of this study was to describe variation in emergency department evaluation and treatment of children with constipation and characteristics and treatments associated with improvement.

Key Study: Polyethylene glycol 3350 plus electrolytes for chronic constipation in children: a double blind, placebo controlled, crossover study

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Thomson MA, Jenkins HR, Bisset WM, Heuschkel R, Kalra DS, Green MR, Wilson DC...

The objective of this study were to assess the efficacy and safety of polyethylene glycol 3350 plus electrolytes (PEG+E) for the treatment of chronic constipation in children.

Key Study: A randomized, prospective, comparison study of polyethylene glycol 3350 without electrolytes and milk of magnesia for children with constipation and fecal incontinence

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Loening-Baucke V, Pashankar DS

The aim of this study was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes.

Key Study: Predictive factors for short-term symptom persistence in children after emergency department evaluation for constipation

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Patel H, Law A, Gouin S

The objectives of this study were to describe the clinical characteristics of children presenting to the ED with constipation and the ED interventions; to measure short-term symptom resolution at 48 hours and 7 days after the ED visit; and to identify predictive factors associated with poor symptom resolution at 48 hours and 7 days after the ED visit.

Critically Ill Neonate
Critically Ill Neonate  Bottom Line Recommendations

Critically Ill Neonate Pre-Printed Order Set

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TREKK Critically Ill Neonate PedsPac

This pre-printed order (PPO) set is for management of the critically ill neonate in the ED. PPO document is adaptable to your hospitals form policy. This PPO is intended for use on patients ~ 28 days of age (corrected age). Published: December 2018, Version 1.0.

Critically Ill Neonate Algorithm

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TREKK Critically Ill Neonate PedsPac

This point of care algorithm is to guide initial management of critically ill neonates in the Emergency Department. This algorithm is intended for use on patients ~ 28 days of age (corrected age). Published: December 2018, Version 1.0.

Croup
Croup  Bottom Line Recommendations

Bottom Line Recommendations: Croup

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Johnson, DW. & TREKK Network

Bottom line recommendations for the treatment and management of croup. Published online: October 2016.

UNDER REVIEW: Recommendations de Base: Laryngite Aigu

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Johnson, DW. & TREKK Network

Bottom line recommendations for the treatment and management of croup- French. Published online: October 2014.

Croup  Clinical guidelines

Clinical Practice Guideline: Summary: Diagnosis and Management of Croup

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Albera Medical Association,

Summary of Alberta Clinical Practice Guideline document. Published: 2003; Last revised; 2008.

Clinical Practice Guideline: Guideline for the Diagnosis and Management of Croup

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Alberta Medical Association,

Developed by Alberta Clinical Practice Guideline Working Group. Published: 2003; Last revised: 2008.

Croup  Summaries of systematic reviews

Cochrane Summary: Glucocorticoids for croup

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Russell, K, Liang, Y, O'Gorman, K, Johnson, DW, Klassen, TP,

Objective: To provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research. Published online: January 2012; Evidence current to: July 2010.

Cochrane Summary: Nebulized epinephrine for croup in children

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Bjornson, C, Russell, K, Vandermeer, B, Klassen, TP, Johnson, DW,

Objective: To assess the efficacy (measured by croup scores, rate of intubation and health care utilization such as rate of hospitalization) and safety (frequency and severity of side effects) of nebulized epinephrine versus placebo in children with croup, evaluated in an emergency department (ED) or hospital setting. Published online: October 2013; Evidence current to: July 2013.

Croup  Overviews of systematic reviews

Cochrane Overview: The Cochrane Library and the treatment of croup in children: an overview of reviews (2010)

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Bjornson, C, Russell, K, Foisy, M, Johnson, D,

Objective: To synthesize the evidence currently in the Cochrane Database of Systematic Reviews (CDSR) related to the clinical effectiveness and applicability of four treatments for croup - glucocorticoids, epinephrine, heliox and humidified air. Published: December 2010.

Cochrane Overview: Evidence Summary: Croup

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Alberta Research Centre for Health Evidence (ARCHE),

The purpose of this document is to describe the effectiveness of four treatment options, based on a 2012 Overview of Reviews. Published online: 2014.

Croup  Systematic reviews

Cochrane Systematic Review: Heliox for croup in children (2010)

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Vorwerk, C, Coats, T,

Objective: To examine the effect of heliox on relieving symptoms and distress, determined by a croup score (a tool for measuring the severity of croup) or clinical assessment variables, through comparisons with placebo or active treatment(s) in children with croup. Published: February 2010; Evidence current to: June 2009.

Cochrane Systematic Review: Nebulized epinephrine for croup in children (2013)

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Bjornson, C, Russell, K, Vandermeer, B, Klassen, TP, Johnson, DW,

Objective: To assess the efficacy (measured by croup scores, rate of intubation and health care utilization such as rate of hospitalization) and safety (frequency and severity of side effects) of nebulized epinephrine versus placebo in children with croup, evaluated in an emergency department (ED) or hospital setting. Published: October 2013; Evidence current to: July 2013.

Cochrane Systematic Review: Humidified air inhalation for treating croup (2006)

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Moore, M, Little, P,

Objective: To assess the efficacy of humidified air in the treatment of croup. Published: January 2006; Evidence current to: January 2006.

Cochrane Systematic Review: Glucocorticoids for croup (2011)

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Russell, K, Liang, Y, O'Gorman, K, Johnson, DW, Klassen, TP,

Objective: To provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research. Published: January 2011; Evidence current to: July 2010.

Review: Croup in children

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Candice L. Bjornson, David W. Johnson

Objective: This review will address the diagnosis and management of croup in children, specifically focusing on clinical assessment of disease severity to guide management decisions.

Croup  Key studies

Key Study: Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial (2006)

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Scolnik, D, Coates, AL, Stephens, D, Da Silva, Z, Lavine, E, Schuh, S,

Objective: To determine whether a significant difference in the clinical Westley croup score exists in children with moderate to severe croup who were admitted to the emergency department and who received either 100% humidity or 40% humidity via nebulizer or blow-by humidity. Published: 2006.

Key Study: A randomized trial of a single dose of oral dexamethasone for mild croup (2004)

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Bjornson, CL, Klassen, TP, Williamson, J, Brant, R, Mitton, C, Plint, A, Bull...

Objective: The primary outcome was a return to a medical care provider for croup within seven days after treatment. The secondary outcome was the presence of ongoing symptoms of croup on days 1, 2, and 3 after treatment. Other outcomes included economic costs, hours of sleep lost by the child, and stress on the part of the parent in relation to the child's illness. Published: 2004.

Key Study: Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing (2000)

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Rittichier, KK, Ledwith, CA,

Objective: Steroid use for the treatment of croup has been supported by several studies, although few have addressed the use of oral dexamethasone for outpatient management. The efficacy of oral (PO) versus intramuscular (IM) dosing of dexamethasone in the outpatient treatment of moderate croup are compared in this study. Published: 2000.

Key Study: A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup (1998)

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Johnson, DW, Jacobson, S, Edney, PC, Hadfield, P, Mundy, ME, Schuh, S,

Objective: To study how budesonide compares with dexamethasone, the conventional therapy for croup, and whether either reduces the rate of hospitalization. Published: 1998.

Key Study: Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial (1998)

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Klassen, TP, Craig, WR, Moher, D, Osmond, MH, Pasterkamp, H, Sutcliffe, T, Wa...

Objective: To determine the effectiveness of 3 glucocorticoid regimens in patients with croup. Published: 1998.

Key Study: Oral and inhaled steroids in croup - A randomized, placebo-controlled trial (1995)

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Geelhoed, GC, Macdonald, WB,

Objective: To compare the efficacy of oral dexamethasone and inhaled budesonide in children hospitalized with croup, using a three-way, double blind, randomized, placebo-controlled clinical trial design. Published: 1995.

Key Study: Placebo-controlled trial of prednisolone in children intubated for croup (1992)

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Tibballs, J, Shann, FA, Landau, LI,

Objective: To study the effect of prednisolone on two clinical endpoints--the duration of intubation and the need for reintubation. Published: 1992.

Key Study: Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study (1978)

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Westley, CR, Cotton, EK, Brooks, JG,

Objective: To test the effectiveness of racemic epinephrine for the treatment of croup in comparison to saline. Published: 1978.

Diabetic ketoacidosis
Diabetic ketoacidosis  Bottom Line Recommendations

Diabetic Ketoacidosis References and Development Team

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TREKK Diabetic Ketoacidosis PedsPac

This document outlines the references used and team involved in the development of the diabetic ketoacidosis PedsPac. Published online: January 2019.

Diabetic Ketoacidosis Algorithm

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TREKK Diabetic Ketoacidosis PedsPac

This point of care algorithm is to guide initial management of pediatric diabetic ketoacidosis in the Emergency Department. Published online: January 2019, Version 1.0.

Diabetic Ketoacidosis Pocket Card

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TREKK Diabetic Ketoacidosis PedsPac

This pocket card contains tips to manage pediatric patients with diabetic ketoacidosis. Published online: January 2019, Version 1.0.

Diabetic Ketoacidosis Pre-Printed Order Set

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TREKK Diabetic Ketoacidosis PedsPac

This pre-printed order (PPO) set is for management of pediatric diabetic ketoacidosis in the ED. PPO document is adaptable to your hospitals form policy. Published online: January 2019, Version 1.0.

Bottom Line Recommendations: Diabetic Ketoacidosis

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Reid, S and TREKK Network

Bottom line recommendations for the treatment and management of diabetic ketoacidosis (DKA).

Bottom Line: Diabetic Ketoacidosis Protocol: For Children up to Age 19 Years

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BC Children's Hospital

This protocol is designed as an algorithm for treating the majority of cases of diabetic ketoacidosis in infants, children and adolescents.

Bottom Line: Immediate Assessment and Magement of Diabetic Ketoacidosis (DKA) in Children

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Wherrett, D, Huot, C, Mitchell, B, & Pacaud, D

Figure from Canadian Diabetes Association Clincial Practice Guidelines on Type 1 Diabetes in Children and Adolescents.

Diabetic ketoacidosis  Clinical guidelines

Clinical Practice Guideline: ISPAD Clinical Practice Consensus Guidelines 2014 Compendium: Diabetic ketoacidosis and hyperglycemic hyperosmolar state

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Wolfsdorf, J, Allgrove, J, Craig, M, Edge, J, Glaser, N, Jain, V, Lee, W, Mun...

The following recommendations are based on currently available evidence and are intended only as a general guide to DKA management. Because there is considerable individual variability in presentation of DKA (ranging from mild with only minimal dehydration to severe with profound dehydration),some patients may require specific treatment that, in the judgment of the treating physician, may be within or, occasionally, outside the range of options presented here.

Clinical Practice Guideline: Type 1 Diabetes in Children and Adolescents

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Wherrett, D, Huot, C, Mitchell, B, & Pacaud, D

This section addresses those areas of type 1 diabetes management that are specific to children. Key Messages: 1) Suspicion of diabetes in a child should lead to immediate confirmation of the diagnosis and initiation of treatment to reduce the likelihood of diabetic ketoacidosis (DKA). 2) Management of pediatric DKA differs from DKA in adults because of the increased risk for cerebral edema. Pediatric protocols should be used. 3) Children should be referred for diabetes education, ongoing care and psychosocial support to a diabetes team with pediatric expertise.

Clinical Practice Guideline: Diabetic ketoacidosis in children and adolescents: An update and revised treatment protocol

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Metzger, D

The protocol assists the medical practitioner in calculating fluid and electrolyte replacement needs for individual patients and outlines a plan for initial assessment and ongoing monitoring.

Diabetic ketoacidosis  Systematic reviews

Systematic Review: Bicarbonate in diabetic ketoacidosis

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Chua, HR, Schneider, A, & Bellomo, R

Objective: This study was designed to examine the efficacy and risk of bicarbonate administration in the emergent treatment of severe acidemia in diabetic ketoacidosis (DKA).

Systematic Review: Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults

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Usher-Smith, JA, Thompson, MJ, Sharp, SJ, & Walter, FM

Objective: To identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults.

Critically Appraised Topic: Evidence-based emergency medicine/critically appraised topic. Is fluid therapy associated with cerebral edema in children with diabetic ketoacidosis?

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Hom, J, & Sinert, R

Diabetic ketoacidosis is the most common cause of morbidity and mortality in children with type I diabetes mellitus, and cerebral edema is the leading cause of pediatric diabetic ketoacidosis death. Excessive intravenous fluid administration has been implicated as a cause of cerebral edema. We perform an evidence-based emergency medicine review assessing the association of intravenous fluid hydration and cerebral edema.

Systematic Review: Cerebral edema in diabetic ketoacidosis

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Levin, DL

Objective: To review the causes of cerebral edema in diabetic ketoacidosis (CEDKA), including pathophysiology, risk factors, and proposed mechanisms, to review the diagnosis, treatment, and prognosis of CEDKA and the treatment of diabetic ketoacidosis as it pertains to prevention of cerebral edema.

Diabetic ketoacidosis  Key studies

Key Study: Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis

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Kuppermann, N., Ghetti S.,Schunk J.E., et al.

Background: Diabetic ketoacidosis in children may cause brain injuries ranging from mild to severe. Whether intravenous fluids contribute to these injuries has been debated for decades.

Methods: This 13-center, randomized, controlled trial examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis.

Key Study: How can cerebral edema during treatment of diabetic ketoacidosis be avoided?

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Watts, W, & Edge, JA

This article discusses how DKA might be prevented from occurring in the first instance, known risk factors for cerebral edema, fluid and insulin management, the importance of careful monitoring during DKA treatment, and the importance of recognizing and acting on the earliest symptoms to prevent long-term harm.

Key Study: Subclinical cerebral edema in children with diabetic ketoacidosis randomized to 2 different rehydration protocols

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Glaser, NS, Wootton-Gorges, SL, Buonocore, MH, Tancredi, DJ, Marcin, JP, Calt...

Previous studies show that vasogenic cerebral edema (CE) occurs during diabetic ketoacidosis (DKA) treatment in children, but the role of intravenous fluids in contributing to CE is unclear. We used magnetic resonance diffusion weighted imaging to quantify subclinical CE in children with DKA randomized to 2 intravenous fluid regimens.

Key Study: Dehydration in children with diabetic ketoacidosis: A prospective study

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Sottosanti, M, Morrison, GC, Singh, RN, Sharma, AP, Fraser, DD, Alawi, K, Sea...

Objective: To investigate the association between the degree of patient dehydration on presentation with diabetic ketoacidosis (DKA) and clinical and laboratory parameters obtained on admission.

Key Study: Measured degree of dehydration in children and adolescents with type 1 diabetic ketoacidosis

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Ugale, J, Mata, A, Meert, KL, & Sarnaik, AP

Objectives: 1) measure the degree of dehydration in children with type 1 diabetes mellitus and diabetic ketoacidosis based on change in body weight; and 2) investigate the relationships between measured degree of dehydration and clinically assessed degree of dehydration, severity of diabetic ketoacidosis, and routine serum laboratory values.

Key Study: Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry are they?

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Fagan, MJ, Avner, J, & Khine, H

A prospective consecutive case series of patients aged 5 to 20 years who presented to a pediatric emergency department with diabetic ketoacidosis (DKA) was studied to determine the actual percent loss of body weight during an episode of DKA to determine the degree of dehydration and thereby provide a guide for hydration therapy during such an episode.

Key Study: Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration

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Edge, JA, Roy, Y, Bergomi, A, Murphy, NP, Ford-Adams, ME, Ong, KK, & Dung...

Objective: To ascertain whether initial depression of conscious level in children with diabetic ketoacidosis (DKA) is related to hyperosmolality, acidosis or other factors.

Key Study: The UK case-control study of cerebral oedema complicating diabetic ketoacidosis in children

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Edge, JA, Jakes, RW, Roy, Y, Hawkins, M, Winter, D, Ford-Adams, ME, Murphy, N...

Cerebral oedema complicating diabetic ketoacidosis (DKA) remains the major cause of morbidity and mortality in children with type 1 diabetes, but its aetiology remains unknown. Our objective was to determine the impact of baseline biochemical factors and of treatment-related variables on risk of the development of cerebral oedema in children with DKA.

Key Study: Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis

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Lawrence, SE, Cummings, EA, Gaboury, I, & Daneman, D

Objectives: To determine incidence, outcomes, and risk factors for pediatric cerebral edema with diabetic ketoacidosis (CEDKA) in Canada.

Key Study: Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics

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Glaser, N, Barnett, P, McCaslin, I, Nelson, D, Trainor, J, Louie, J, Kaufman,...

Cerebral edema is an uncommon but devastating complication of diabetic ketoacidosis in children. Risk factors for this complication are defined in this multicenter study.

Febrile Status Epilepticus
Febrile Status Epilepticus  Bottom Line Recommendations

Emergency Medicine Cases Podcast: Emergency management of pediatric seizures - Guidance and podcast

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Helman A

With the help of two of Canadas Pediatric Emergency Medicine seizure experts hand picked by TREKK, Dr. Lawrence Richer and Dr. Angelo Mikrogianakis, well give you the all the tools you need to approach the child who presents to the ED with seizure with the utmost confidence.

Bottom Line: Managing febrile seizures infographic

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Stahl-Timmins W

This infographic provides general information on managing febrile seizures.

Bottom Line: Emergency management of febrile seizure in children

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Guidelines & Protocols Advisory Committee

This pathway from the clinical practice guideline presents a decision tree for emergency management of febrile seizures in children

Febrile Status Epilepticus  Clinical guidelines

Clinical Practice Guideline: Emergency management of the paediatric patient with generalized convulsive status epilepticus

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