Letter from the Chair
Donna Moro-Sutherland, MD, FACEP
Chair, Section of Pediatric Emergency Medicine
For most of us, summer vacation is here for our children. Professionally, that means the start of a new class of interns and/or fellows. As we attempt to balance our personal and professional lives, several of us call upon our friends for help and guidance. After 15 years as a pediatric emergency medicine physician instead of slowing down, I seem to take on more. Does this sound familiar to some of you? I do know that drawing from colleagues over the years has helped when needing guidance for a task at hand. For some of you, the “PEM Expert Profile” sheet has been completed. For others, it may be sitting in your in box as many of my projects do.....to get to when there is a break, which never seems to come! As we reach mid-year, I ask again that you take the time out of your busy schedule to download the “PEM Expert Profile” datasheet (acep.org/section of membership/pediatric emergency medicine) and forward it to me through the listserv (peds.section@elist.acep.org ). Since the last newsletter; we have secured a home for the profile. David Schnadower, MD, from the Division of Pediatric Emergency Medicine at Morgan Stanley Children's Hospital of New York Columbia University Medical Center and founder of http://www.pemfellows.com, is assisting us. This will allow many of us to communicate more easily when the stacks seem unbearable or the Chair wants the answer by tomorrow!!! Once launched, you will receive notification.
So, what’s next? Yes, you guessed it; a request from a friend. Many of us know the challenges of working our clinical load and spending that needed time with educational and administrative responsibilities. Oh, yes and that much more needed time with our families. As I flew to New Orleans in early March for CORD, Miami in late March for ACEP, San Diego in April for the Advance Pediatric Assembly, and finally to Hawaii for the Pediatric Academic Society in May, I returned to getting the girls through finals and at the same time preparing for my first class of pediatric emergency medicine fellows. Where does that leave me? Are these questions way too familiar to you? As many new graduates begin in the workforce, the questions and needs do not change. Balancing our personal and professional lives! New graduates are taking private practice jobs instead of remaining in academics. Some are even opting for part-time employment in order to get that needed personal lifestyle back. As we continue to negotiate for balance we pull from information gathered from friends. How much time is protected as the program director for a residency or fellowship? If I take on this new title, what time commitment will I need to truly get the job done? Are there enough hours in the day? So, by now have I caught your attention? Can you help and take 5 more minutes out of your day and go to the following link http://www.surveymonkey.com/s.aspx?sm=K7Tm6no_2b8BhqD0t4aV0QIA_3d_3d and help a friend answer some of these questions.
I hope that you find the time to navigate through our third newsletter. As promised, Chris Amato, MD, FAAP, continues with the “Picture of the Month.” Topics for this newsletter include the “Case of the Month” by Sabrina DeStefano, DO; “High-Fidelity Medical Simulation in the World of Pediatric Emergency Medicine” by Frank Overly, MD, FAAP; “International Pediatric Emergency Medicine: Trends, Challenges & Opportunities” by David Walker, MD; “International Child Health and the Emergency Physician: Residency-Based International Advocacy Experience” by Lina AbaJamra, MD; “Wound Management Update” by Annalise Sorrentino, MD, FAAP; “Literature Review” by Todd Wylie, MD; and an “Update on the ACEP Pediatric Emergency Medicine Committee” by Chair Kathleen Brown, MD, FACEP.
Finally, please mark your calendars for the upcoming PREP:EM An Intensive Review Course of Pediatric Emergency Medicine on August 16-20, 2008, at the Royal Sonesta Hotel in Cambridge, Mass. You will find complete details at the end of this newsletter and at www.pedialink.org/cmefinder.
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Secretary’s Corner
Michael Bachman, MD
Thank you to all of you who have contributed to our newsletters this year. Our section newsletter provides an opportunity for all of our members to get involved in the section. Please consider submitting an article, case, radiologic image, or picture. Please let me know if you are interested in submitting a contribution to a future newsletter or if there are any specific topics that you would like covered in future issues. Please contact me at peds.section@elist.acep.org. I look forward to your submissions!!
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Case of the Month
Sabrina DeStefano, DO
Pediatric Emergency Medicine Fellow
Morristown Memorial Hospital/Goreyb Children’s Hospital
Morristown, NJ
HPI: A 16-year-old female presents to the ED after she was exposed to an electric shock from an improperly wired light switch backstage during a school play. The patient states her left hand was stuck to the switch and she had to be pulled off the electrical source. The patient complains that her left thumb hurts. The patient and the mother deny any loss of consciousness (LOC), paresthesias, numbness, palpitations, chest pain, or any weakness.
PMH: No significant past medical history, no medications, no drug allergies, no surgical history, and no significant family history
Physical Exam:
HR: 93/minute BP: 141/81 RR: 28/minute T: 36.8°C, SO2: 98% on RA
General Appearance: The patient is alert and in no apparent distress.
HEENT: Atraumatic, PEERL, (-) hemotympanum, airway patent: (-) stridor, mucus membranes moist, (-) lymphadenopathy
Chest: (-) rales, (-) rhonchi, (-) wheezes; breath sounds equal bilaterally
Heart: (-) irregularity, (-) murmur
Abdomen: soft, (-) tenderness
Extremities: Left hand; distal pulses + 2 bilaterally, 3 small (3 mm) circular superficial partial thickness burns on the left thenar eminence, (2 mm) circular superficial partial thickness burn at the base of the 2nd and 3rd left digit on the palmar aspect of the hand, 2 small (2 mm) circular superficial partial thickness burns at the base of the 4th digit on the palmar aspect of the hand.
Skin: Burns as above, no exit wound noted, no other injuries
Neurologic: Left hand sensation and motor function of median, ulnar, and radial nerves intact, (-) focal deficits
Diagnostic Studies:
Basic Metabolic Profile: Na: 138 K: 4 CL: 101 CO2: 24 BUN: 10 CR: 0.7 Glucose: 74 Ca: 9.8
Mg: 2.1 mg/dL
Phosphorus: 3.7 mg/dL
CPK: 91 U/L
Troponin-I: < 0.3 ng/mL
Electrocardiogram (ECG): sinus rhythm at 93, (+) premature atrial contractions, (-) ST elevations
Urine Analysis (UA): (-) hemoglobin, all other parameters within normal limits
ED course and treatment:
Verification of the voltage and type of electricity was obtained. The father went to the school and noted it was 120 volts (V) AC. The burns were cleaned and dressed. The case was discussed with a hand surgeon who advised outpatient follow up in one day. Electrocardiography (ECG) changes were discussed with a pediatric cardiologist who advised outpatient follow up in two days.
Case Discussion: Low Voltage Electrical Injury in Children
Electrical injury can cause a burn of the skin and involve deeper tissue, such as muscle, nerves, and ligaments. Electrical injuries result in an estimated 1,000 deaths per year, 5,000 ED visits, and about 3,000 admissions to specialized burn centers per year.1,2 One third of electrical injuries occur in the household setting. The majority of the electrical injuries in children are from household sources and low voltage. However, low voltage may not correlate to less injury. Deaths have been documented with injuries from 50-60 V.3 Death following an electrical shock is usually secondary to cardiac complications, although respiratory arrest or multisystem complications can occur. Cardiac complications include sudden death secondary to ventricular fibrillation or asystole, myocardial injuries, and immediate or delayed arrhythmias.4
Electrical injuries are classified in the medical literature as either high voltage (>1000 V) or low voltage (<1000 V).3
Alternating Current (AC): Utilized in the United States and Canada for household appliances with current between 120-240 V. The flow of electrons changes rapidly in a cyclic fashion. This can cause tetanic muscle contraction and keep the victim in contact with the electrical source for a longer period.
Direct current (DC): Found in batteries, power lines, automotive, and medical equipment. Electrons flow constantly in one direction across the potential, causing a single muscle contraction that throws the victim away from the electrical source.
Dry skin is more resistant than wet skin causing burns that are more superficial. As opposed to a patient with wet skin, the resistance is lower causing the energy to be transmitted to the underlying structures. Joule’s law shows that thermal energy is equal to current2 x resistance x time. High resistance tissue, such as bone, skin, and fat, respond to electrical injury with coagulation necrosis due to their high resistance. Nerves and blood vessels have low resistance and are good conductors for electricity; therefore, they are more susceptible to injury.
Evaluation:
A thorough physical exam of the child who presents to the ED after any voltage electrical injury is necessary. Examine the patient for entry and exit wounds with special attention to the hands and bottom of the feet for an exit wound. Burns should be classified as partial thickness or full thickness. Despite the physical findings, remember that there may be underlying tissue damage. Between the entry and exit wound there may be anatomic damage and destruction not visible on the surface. It is imperative to do a thorough neurologic exam. Neurologic complications are the most common complications of electrical injury. Peripheral nerve injury may be involved by direct injury at the site of entrance or exit or in polyneuritic syndrome involving nerves far removed from the points of contact. Symptoms include numbness and paresthesias. Loss of function in a peripheral nerve is usually transient, and complete recovery may be expected if the nerve is not involved in local tissue injury.1 After electrical injury, tetanus prophylaxis must be verified and boosters given, if indicated.
Low voltage electrical injuries are the most common electrical injury to present to the pediatric ED. Management of these patients can include ECG, laboratory analysis, and urine analysis. Recent literature has debated the need and breadth for certain aspects of the ED evaluation in the asymptomatic child exposed to low voltage.
ELECTROCARDIOGRAPHY:
The practice guidelines for the management of electrical injuries published by the American Burn Association states that ECG should be performed in all patients with low voltage electrical injury. If the ECG is normal and the child is otherwise asymptomatic, the child may be discharged home.
In the literature, the necessity of the ECG has been debated. In a retrospective study of 151 children presenting to a pediatric ED, it was concluded that initial ECG is not necessary in household electrical injury (=240 V) in an otherwise asymptomatic child unless one of the following noted: loss of consciousness, tetany, wet skin, or the current flow crossed the heart region. 4 In another retrospective study of 70 children exposed to low voltage electrical injury, 53 had an ECG done as part of their ED evaluation. There were two abnormal EKG’s: one with premature ventricular contractions and one with a premature junctional contraction. Both of these arrhythmias are considered to be benign. It was concluded that if an asymptomatic child with a household low voltage electrical injury and small burn size presents to the ED, no further ECG is necessary. 6 In 2000, Bailey evaluated a set of guidelines implemented in a tertiary care pediatric ED for evaluation and management of electrical injuries in children. The guidelines stated low voltage electrical injury in a child who is asymptomatic should not receive an ECG unless the child had any of the following: cardiac history, loss of consciousness, voltage >240, lightning strike, unwitnessed event, humid conditions, tetany, or burns. None of the patients in the study who were sent home without an ECG evaluation had adverse effects.
MONITORING:
At one time it was standard practice to admit all electrical injuries to the hospital for 24-hour cardiac monitoring. The practice guidelines suggest that any patient with a history of LOC or documented dysrhythmia, either before or after admission to the ED, should be admitted for telemetry monitoring. Patients with ECG evidence of ischemia should be admitted and placed on cardiac monitors. 5 A review by Chen and Sareen looked at this question and presented a review of the recent literature. In the seven retrospective studies reviewed, no patient with a normal initial ECG developed late dysrhythmias, and those with nonfatal arrhythmias or nonspecific ECG abnormalities resolved spontaneously within 24 hours. 8
ORAL INJURY:
Low voltage electrical injury can damage the oral cavity and may leave a permanent scar. Most children, frequently between 1-2 years old, are injured by sucking or biting on an extension cord. The mechanism of injury can occur when an electric arc is formed between two wires of opposite polarity that pass external to the body surface of the child’s electrolyte-rich saliva. Heat generated may be greater than 1371°C, resulting in severe destruction of the mouth and contiguous tissue. This is why, although the injuries are from a low voltage source, the extent of the burn can be more significant than other types of low voltage injuries. Another mechanism of injury occurs when the current enters the mouth and passes through the body, exiting through a ground source, causing a contact burn. This is less common but more lethal. This mechanism has a high incidence of arrhythmias and sudden death.1
Management:
As always, the ABC’s (DE’s) apply. The immediate management of electrical burns of the mouth includes evaluating the extent of the burn and, if necessary, securing the airway prior to the onset of edema. 9 An ECG is recommended as per the practice guidelines from the ABA for all electrical injuries, but is again debated in the literature in an otherwise asymptomatic child. The same evidence from the literature regarding ECG and cardiac monitoring applies to low voltage oral burns as other low voltage electrical injuries and burns. Most management of low voltage oral burns can be done as an outpatient with close follow up and a reliable family. The goal of management is to prevent complications, such as scarring and contractures. Usually an oral surgeon or plastic surgeon will help to manage these injuries.
It is important to warn the parents of the potential of labial artery bleeding about one week after the injury. Usually five to 12 days after the injury, nonviable tissue separates from viable tissue. As devitalized tissue sloughs, bleeding from the labial artery may occur. 1 Most bleeding resolves with direct pressure.
CREATINE PHOSPHOKINASE
The practice guidelines from the ABA state that creatine phosphokinase (CPK) and the MB fraction are not reliable indicators of cardiac injury after electrical burns and should not be used in decisions regarding patient disposition.5 It appears that the elevation of CPK is correlated with the percentage of body surface burns, suggesting that it is more useful as a sign of extensive burns than of myocardial damage.7 In a retrospective study by Garcia, it was concluded that in patients with minor injuries, abnormal findings in the CPK did not precipitate changes in therapy.6 Another study by Zubair found that in patients with low voltage injury and elevated CPK values, the CPK elevation did not predict the need for immediate or reconstructive surgical care of the wound in terms of debridement, excision and grafting, or other operative procedures.3 In an asymptomatic child, it is generally not recommended to obtain a CPK or CK-MB after a low voltage electrical injury.
URINALYSIS
It is thought that an excessive release of myoglobin or hemoglobin into the circulation may produce renal damage from precipitation of these pigments in the kidneys. These tests have not shown to be helpful in the diagnostic evaluation of a child with a low voltage electrical injury. In a retrospective study of 106 children with low voltage electrical injury, none of the children had a positive urine myoglobinuria. 3 In another retrospective study by Wallace of the children with low voltage electrical injury, five had urine myoglobin measured and all five were negative. All of these children had a partial thickness burn =1% of the body surface area (BSA). In Garcia’s study of the 48 children with low voltage electrical injury, there was one abnormal urinalysis (UA) with microscopic hematuria and pyuria consistent with a urinary tract infection. All the other children in the low voltage group had a negative UA. In follow up, none of the patients developed renal failure and it was concluded that children with minor injuries related to low voltage electricity do not need an UA.
Summary:
Overall, the management of a child with a low voltage electrical injury who is otherwise asymptomatic can be done as an outpatient. In the ED, it is crucial to determine the extent of injury, if any, and prevent further complications. An ECG is recommended by the ABA as part of the ED management; however, recent literature does support that if a child has small burn (=% BSA) and is otherwise asymptomatic with no history of cardiac disease, no LOC, a witnessed event, without the involvement of water and no tetany, it is safe to discharge the patient without an ECG evaluation. If the patient does have an ECG with a ventricular arrhythmia or has a history of LOC, cardiac past history, or V >240, it is recommended to monitor the patient in the hospital on a telemetry unit for 24 hours.
In general, the literature does not support the use of other laboratory evaluations, such as CPK, CK-MB, urine myoglobin, or UA, to help determine management of patients with low voltage electrical injuries.
Prevention of electrical injuries in children is crucial. Pediatricians and government agencies should educate parents and caregivers of the potential hazards in and around the home. Also, preventative measures, such as the use of outlet covers and electrical wire covers, should be stressed along with adequate supervision at all times.
References
- Edlich R, Drake D, Lond W. Burns, Electrical. eMedicine 2007. Accessed 4/23/08.
- Mitchell E, Medzon R. Introduction to Emergency Medicine. New York: Lippincott, Williams, and Wilkins, 2005.
- Zubair M, Besner G. Pediatric electrical burns: management strategies. Burns 1997;23:413-420.
- Bailey B, Gaudreault P, Thivierge R, et al. Cardiac Monitoring of Children With Household Electrical Injury. Ann Emerg Med 1995;25: 612-617.
- Arnoldo B, Klein M, Gibran N. Practice Guidelines for the Management of Electrical Injuries. J Burn Care Res 2006;27:439-447.
- Garcia C, Smith G, Cohen D, et al. Electrical injuries in a pediatric emergency department. Ann Emerg Med 1995;26:604-608.
- Bailey B, Gaudreault P, Thivierge R. Experience With Guidelines for Cardiac Monitoring After Electrical Injury in Children. Am J Emerg Med 2000;18:671-675.
- Chen E, Sareen A. Do Children Require ECG Evaluation and Inpatient Telemetry After Household Electrical Exposure? Ann Emerg Med 2007;49:64-67.
- Thomas S. Electrical burns of the mouth: still searching for an answer. Burns 1996;22:137-140.
- Wallace B, Cone J, Vanderpool R, et al. Retrospective evaluation of admission criteria for paediatric electrical injuries. Burns 1995;21:590-593.
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Picture of the Month
Christopher S. Amato, MD, FAAP
Chair-Elect, Section of Pediatric Emergency Medicine
Morristown Memorial Hospital, Goryeb Children’s Hospital
Morristown, NJ
I recently cared for a 16-month-old male who presented with less than 24 hours of right eye swelling and redness that started with tearing and yellow discharge. The swelling became markedly worse after his afternoon nap prompting ED evaluation. He was awake, alert, playful, in no distress, and afebrile with normal vital signs. There was moderate right periorbital edema and erythema with non-painful extraocular movement and a normal eye exam, though visual acuities could not be performed. Due to the rapidity of its presentation, an orbital CT was obtained with the prime findings displayed for this month’s “Picture of the Month.” The findings made me go back to the books and figure out if I was missing something on the physical exam.
 |
 |
ORBITAL vs. PERIORBITAL CELLULITIS:
Orbital cellulitis is localized behind the orbital septum and is referred to as post-septal cellulitis. The infection may involve the fat and muscles contained within the orbit. The most common risk factor is sinusitis in both pediatric and adult patients.1 The complications of orbital cellulitis include vision loss in 3-11% and a mortality rate of up to 1-2%.2
Periorbital cellulitis (aka pre-septal cellulitis) is localized to the soft tissues anterior to the orbital septum. This is more common than orbital cellulitis. A retrospective study from Morocco notes that 9 of 33 cases had orbital cellulitis when looking at all children admitted for periorbital or orbital cellulitis admissions from 1994-2000.3 The study performed prior to this noted only 18 of 315 cases were orbital cellulitis.4
Microbiology:
Though Haemophilus influenzae is no longer a major player due to the prevalence of vaccinations, it was once believed to facilitate the invasion of other organisms that would cause orbital or periorbital cellulitis. Currently, typical organisms include Staphylococcus aureus, streptococci, non-spore forming anaerobes, and some non-typable Haemophilus. There are other more rare bacteria, including Eikenella corrodens, that have been associated with these infections and often they are difficult to isolate.5
| Symptoms |
Orbital |
Periorbital |
| Erythema |
v |
v |
| Edema |
v |
v |
| Pain with ocular movement |
v (more common) |
v |
| Chemosis |
v |
v (can occur) |
| Proptosis |
v |
|
| Globe displacement |
v |
|
| Limitation of ocular movement |
v |
|
| Double vision |
v |
|
| Vision loss |
v |
|
Blood cultures are suggested as a baseline prior to initiation of antibiotics; although, a retrospective review only noted 33% positive blood cultures in children <4years old and in only 5% of adults.6 Thus blood cultures are more likely to be positive with the younger patient. Other studies have noted variable rates of positive blood cultures from 0-33%.7
Culturing eye secretions or pharyngeal cultures are more likely to be contaminated with normal flora and yield little information. Culture of purulent material drained from an abscess or sinus contents should be sent for aerobic, anaerobic, and fungal analysis.
Clinical Exam:
The clinical manifestations of periorbital and orbital cellulitis have a significant amount of overlap. Painful ocular movement and chemosis can occur with moderate to severe periorbital cellulitis but are more common to the orbital infection. The clinical exam should include visual acuity in addition to ocular movement.
Radiologic Exams:
Computed tomography (CT) is the preferred method to view extension of inflammation into the orbit and to identify abscesses and any co-existing sinus disease. Other modalities include orbital sonography and MRI. There have been no controlled trials to date examining the utility of radiology studies in the diagnosis of orbital cellulitis or in distinguishing preseptal from orbital cellulitis.8 There is some controversy whether all patients with suspected orbital cellulitis require a CT.9-11 There are some experts that only suggest a CT in those patients that fail to respond to 24 hours of intravenous antibiotics. I suspect that this will soon become more popular due to increasing literature regarding the risks of radiation. In the United Kingdom, CT is recommended only if: 1) vision cannot be accurately assessed; 2) there are signs of gross proptosis, ophthalmoplegia, bilateral edema, or deteriorating visual acuity; 3) there has been no improvement after 24 hours of antibiotics; and 4) signs or symptoms of CNS involvement exist.
Treatment
There have been no randomized controlled trials to evaluate empiric antibiotics for the treatment of orbital cellulitis.8 The basis of treatment is to start broad spectrum antibiotic coverage with more specific concentration as any culture becomes positive.
- Nafcillin or Oxacillin (200mg/kg/day in four divided doses) or
- Vancomycin (40mg/kg/day in two to three divided doses) if methicillin-resistant Staphylococcus aureus (MRSA) is being considered as the causative organism.
With one of the following:
- Ampicillin-Sulbactam (300mg/kg/day in four divided doses)
- Ticarcillin-clavulanate (200-300mg/kg/day of Ticarcillin in four to six divided
doses in children <60kg)
- Piperacillin-tazobactam (240mg/kg/day in three divided doses)
- Ceftriaxone (80-100mg/kg/day in two divided doses)
- Cefotaxime (150-200mg/kg/day in three to four divided doses)
There have been no controlled trials to determine the length of antibiotic course nor are there any specific guidelines to indicate when to change to oral therapy. Surgical intervention is suggested in those patients that 1) fail to respond, 2) deteriorate clinically despite treatment, 3) have worsening visual acuity or papillary changes, 4) develop an abscess, except in selected pediatric cases of medial subperiosteal abscesses, which may be treated successfully medically.8 The treatment of a patient with orbital cellulitis often will involve consultation with ophthalmology and otolaryngology specialists.
Just a reminder to any and all who would like to submit a case or picture/video, please contact me at peds.section@elist.acep.org I look forward to your submissions!!
References
- Mills RP, Kartush JM, Orbital Wall Thickness and the spread of infection from the paranasal sinuses. Clin Otolaryngol 1985; 10:209.
- Osguthorpe, JD, Hochman M, Inflammatory sinus diseases affecting the orbit. Otolaryngol Clin North Am 1993; 26:657.
- Ailal F, Bousfiha A, Jouhadi Z, et al. Orbital Cellulitis in children: A retrospective study of 33. Med Trop (MARS) 2004; 64:359.
- Ambati BK, Ambati J, Azar N, et al. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthamology 2000; 107:1450.
- Hemady R, Zimmerman A, Katzen BW, Karesh JW. Orbital cellulitis caused by Eikenella corrodens. Am J Ophthalmol 1992; 114:584.
- Schramm VL Jr, Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope 1982; 92:732.
- Dudin A, Othman A. Acute periorbital swelling: evaluation of management protocol. Pediatr Emerg Care 1996; 12:16.
- Hunter DG, Trucksis M, Preseptal (periorbital) and orbital cellulitis. www.uptodate.com. Accessed 5/12/08.last updated: February 14, 2008.
- Howe, L, Jones, NS. Guidelines for the management of periorbital cellulitis/abscess. Clin Otolaryngol Allied Sci 2004; 29:725.
- Starkey CR, Steele RW. Medical management of orbital cellulitis. Pediatr Infect Dis J 2001; 20:1002.
- Mair MH, Geley T, Judmaier W, Gassner I. Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids. AJR Am J Roentgenol 2002; 179:1529.
- Uzcategui N, Warman R, Smith A, Howard CW. Clinical practice guidelines for the management of orbital cellulitis. J Pediatr Ophthalmol Strabismus 1998; 35:73.
- Chaudhry IA, Shamsi FA, Elzaridi E, et al. Outcome of treated cellulitis in a tertiary eye care center in the Middle East. Ophthalmology 2007; 114:345.
- Sobol SE, Marchand J, Tewfik TL, et al. Orbital complications of sinusitis in children. J Otolaryngol 2002; 31:131.
- Reynolds DJ, Kodsi SR, Rubin SE, Rodgers IR. Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient. J AAPOS 2003: 7:413.
- Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J 2002; 21:1157.
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High-Fidelity Medical Simulation in the World of Pediatric Emergency Medicine
Frank L. Overly MD, FAAP
Co-Director RIHMSC
Co-Director Pediatric Simulation
Assistant Professor Emergency Medicine and Pediatrics
Warren Alpert Medical School of Brown University
High fidelity medical simulation is the utilization of technology to create a lifelike situation where an individual can suspend disbelief and practice both procedural and decision making skills in an environment safe for both the trainee and the patient. Use of this technology as a training tool in medicine was pioneered by anesthesiologists during the 1980s and has become common in most areas of medical education. Whole body simulators are computer driven manikins, which are designed with features to encourage and require individuals to perform a physical exam and a variety of procedures. The manikins are verbally responsive and have palpable pulses. The chest wall rises with each breath and a monitor displays dynamic vital signs. Individuals can practice a variety of procedures on whole body simulators including IV/IO insertion, chest tube insertion, defibrillation, CPR, and intubation. Simulators can develop tongue edema, laryngospasm, trismus and require the participant to perform a surgical airway.
Traditional methods of teaching courses like PALS have limitations. A study by Nadel et al showed one year after PALS training, only 18% of residents in a control group could successfully perform ancillary airway maneuvers or endotracheal intubation.[1] Simulation has been integrated into courses like PALS and ACLS, and studies have shown simulation to be a more effective tool for skill acquisition under deliberate practice conditions which involve the following:
- Intense repetitive performance of cognitive or psychomotor skills
- Rigorous skills assessment
- Specific informative feedback
- Better skills performance in a controlled setting.[2] [3]
Medical simulation is currently being incorporated into medical education at all levels, medical school curricula, graduate medical education programs and continuing medical education courses. With the evolution of pediatric manikins over the past 5-10 years, pediatric focused programs are following this trend.
Using high fidelity medical simulation is ideal for recreating stressful situations that occur infrequently and are, therefore, at high risk for human error. A pediatric code is a prime example of a high stress situation that occurs infrequently where medical simulation can be used to allow learners the opportunity to practice acute care of critically ill pediatric patients. Eppich et al offer a review of the current literature as it relates to the use of simulation for training in acute pediatric emergencies. The review outlines why pediatric emergencies are ideal for simulation; they occur infrequently and the individuals required to manage these situations often have minimal pediatric acute care experience. The paper goes on to review basic simulation principles, its use as a training strategy, mastering advanced life support, improving airway skills, and improving non-technical skills (ie, teamwork, decision making, situational awareness). The review states that a majority of the studies supporting the benefit of medical simulation are not pediatric-based, but there is no reason to believe this evidence would not translate to the world of pediatric emergency care. [4]
Example of Pediatric Simulation Case Library:
Pediatric Emergency Airway Management Skills
Pediatric emergencies
- Issues unique to pediatric patients (ie, congenital
heart disease, ductal dependant lesions)
- Issues managed differently in pediatric patients (ie, asthma, DKA, trauma)
- Issues unique to office setting
Difficult conversations
- Pediatric death
- Child abuse or neglect
Pediatric procedures (ie, intraosseous access)
Pediatric procedural sedation
Team work training/Crisis resource management
Pediatric code team/Rapid response team training
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Pediatric medical simulation is currently being used to meet a wide variety of teaching goals. Scenarios are designed to encourage and require learners to practice decision making skills and procedural skills based on the specific case that is presented.
The scenario and the manikin are only part of the overall simulation. The environment is an equally important aspect to every simulation. Simulations can be “in-situ,” meaning run in an actual patient care space. Placing the manikin in the ED trauma bay or in a pediatric inpatient room and calling a code allows the actual ED team or code team to work together in the space they would be required to function in if it were an actual pediatric emergency. The simulations also can be staged in a simulation center. Most centers have simulation environments that can be mocked to look like a variety of different settings. It is important to make the environment realistic with the supplies, tools, and resources medical care providers would need to manage the scenarios in which they are immersed. Airway equipment, simulated medications, defibrillators, and other supplies are basic equipment most simulation centers have accessible. It is also imperative to have laboratory values, radiologic studies, ECGs, and other medical diagnostic tests that normally would be utilized in the management of the scenario being simulated.
Once the script is crafted, the stage is set, and personnel are prepped, the final aspect of simulation is the audiovisual recording of the event. Recording of the actual simulation is essential for the debriefing that follows. Individuals who participate in the simulation learn by doing, but most experts in medical simulation agree that the time spent after the simulation is when a majority of the learning takes place. By viewing select portions of the simulations video, it is useful to review what was done well and what could have been done more effectively.
A systematic review of 670 peer reviewed articles spanning 34 years identified 10 features of medical simulation that facilitate learning:
- Feedback is provided during the learning experience.
- Learners engage in repetitive practice.
- The simulator is integrated into the medical curriculum.
- Learners practice with increasing levels of difficulty.
- The simulator is adaptable to multiple learning strategies.
- The simulator captures clinical variation.
- The simulator is embedded in a controlled environment.
- The simulator permits individualized learning.
- Learning outcomes are clearly defined and measured.
- The simulator is a valid approximation of clinical practice.[5]
A subset of these articles was further analyzed and the collective data demonstrated a positive functional relationship between high-fidelity medical simulation and learning outcomes in medical education.[6]
Although simulation has proven to be an effective teaching tool, it is not an efficient teaching tool. Simulation enhanced educational programs require significant resources in personnel, equipment, and time. A high fidelity pediatric manikin can range in price from approximately $40,000 to over $200,000. An audiovisual system can be as simple as a handheld video camera and an LCD projector to a system that has hardwired cameras, overhead microphones, and software packaged to assist with the debriefing process.
Most centers start with a single manikin and gradually developed expertise in running the equipment. Overtime, centers can work to acquire more resources, including simulation and medical equipment, dedicated simulation space, and dedicated simulation staff. It is imperative to get institutional support to assist with both start up costs and ongoing operational expenses.
The time commitment to develop and run a medical simulation program is significant, and operational budgets can have a wide range. To run a program with the mission of training a group of PEM fellows could be as low as $15,000 a year, but if the scope of training is to include a 10,000 to 20,000 square foot simulation center, a simulation staff and training programs to service a healthcare system and region, the annual budget can easily surpass $1,000,000.
The Rhode Island Hospital Medical Simulation Center (RIHMSC) (www.rihsimctr.org ) falls between these two extremes. RIHMSC currently runs both adult and pediatric simulations. Their pediatric program runs pediatric sessions for EM residents monthly, pediatric emergency medicine fellows every other month, and pediatric residents quarterly. In addition to this, they have developed CME courses for simulation-enhanced PALS, pediatric office emergencies for pediatricians and family practitioners, and pediatric emergencies for EPs.
The Harvard Affiliated Emergency Medicine residency program at Brigham and Women’s Hospital has also successfully incorporated simulation into their training program (www.brighamandwomens.org/Stratus/ ). They published a manuscript titled, “A Comprehensive Medical Simulation Education Curriculum for Emergency Medicine.”[7] Although this is not pediatric specific, it offers a nice example of how one training program has chosen to integrate simulation-enhanced education into their standard curriculum.
For individuals interested in learning more about medical simulation, there is a Society for Simulation in Healthcare (www.ssih.org ), which publishes the journal Simulation in Healthcare and hosts an annual meeting (the International Meeting for Simulation in Healthcare). This society and the world of medical simulation continue to grow and, with that, pediatric simulation is also rapidly expanding. Whether you currently are involved in simulation, eventually teach with simulation, or participate in a simulation enhanced educational program, odds are this is a teaching modality that will benefit most medical professionals.
References
- Nadel, F.M., et al., Teaching resuscitation to pediatric residents: the effects of an intervention. Arch Pediatr Adolesc Med 2000;154(10):1049-54.
- Wayne, D.B., et al., Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med 2006;21(3): 251-6.
- Ericsson, K.A., Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79(10 Suppl):S70-81.
- Eppich, W.J., M.D. Adler, and W.C. McGaghie, Emergency and critical care pediatrics: use of medical simulation for training in acute pediatric emergencies. Curr Opin Pediatr 2006;18(3):266-271.
- Issenberg, S.B., et al., Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27(1):10-28.
- McGaghie, W.C., et al., Effect of practice on standardized learning outcomes in simulation-based medical education. Med Educ 2006;40(8):792-7.
- Binstadt, E.S., et al., A comprehensive medical simulation education curriculum for emergency medicine residents. Ann Emerg Med 2007;49(4):495-504, 504 e1-11.
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International Pediatric Emergency Medicine: Trends, Challenges,
and Opportunities
David Walker, MD
Attending Physician, Pediatric Emergency Department
Yale University School of Medicine
Yale-New Haven Hospital, New Haven, CT
International Pediatric Emergency Medicine (IPEM) is a developing field yet to find definable structure. It includes all global efforts to advance the care for acutely ill and injured children and is practiced by health care advocates and practitioners from a wide variety of specialties and training backgrounds. Due perhaps to trends in globalization, there is growing interest from those with PEM experience to participate in overseas projects. The following briefly summarizes some ongoing trends and challenges within IPEM and provides some resources for international participation.
The trends:
- Like the growth in this country, the field of PEM is developing recognition as a subspecialty practice worldwide, distinct from pediatrics and emergency medicine. Many practitioners who were trained initially in emergency medicine or pediatrics champion its cause. More fellowships in PEM are appearing both in the USA and around the globe.
- There are increasing numbers of PEM research collaboratives (Europe, Australia/New Zealand, Canada) and increasing numbers of PEM interest groups (Australia, New Zealand, Canada, France, Israel, Italy, Mexico, Spain, Turkey).
- Dissemination of the evidence base concerning PEM is occurring. Through vehicles, such as journals (ie, Clinical Pediatric Emergency Medicine, Pediatric Emergency Care, and an increasing numbers of articles on PEM topics in emergency medicine and pediatric journals), Web sites (www.pemdatabase.org ), and multiple free online listservs, topics in PEM are more readily accessible for caregivers around the world.
- Through the work of international groups like UNICEF and the International Red Cross and domestic groups like the Rainbow International Center for Child Health (www.uhhospitals.org/tabid/175/Default.aspx ), the overwhelming numbers of children who are victims of natural and manmade disasters are getting more much needed attention. Training courses and manuals now exist to give responders to natural and manmade disasters the pediatric know-how they need.
- Worldwide, practitioners, more than ever, desire pediatric-specific resuscitation and trauma knowledge. Practitioners from countries where PALS, APLS and ATLS are routinely taught (typically where emergency medicine is more mature) are sharing knowledge with colleagues in places where instruction on these topics is not widespread.
- In the United States and globally, more resources are being directed towards the creation of specialized departments with a focus on the care of acutely ill and injured children. Generalized emergency rooms are increasing stocks of pediatric equipment and recruiting pediatric providers.
- Many trained in PEM are moving toward careers based on improving care of children around the world. We see this in the proliferation of international electives for residents and PEM fellows. Increasingly, subsections of PEM academic departments are also developing specific international goals and objectives and are recruiting faculty with interests and expertise in international health.
The challenges:
- Medical care resources are often slim in the places that need them the most. That includes knowledge, access to knowledge, personnel, equipment, and currency.
- Obtaining funding for a teaching trip, research project or clinical intervention can be difficult. While anecdotally the “plight of children” makes a project more attractive to potential funders, one must be prepared to justify why resources should be allocated away from “problems at home,” especially in tough economic times.
- There is a general lack of information that describes how pediatric emergency care is delivered internationally. Sharing of lessons learned regarding regional challenges and triumphs would help inform and assist those in other parts of the world who may be facing similar obstacles.
- While coordination and cooperation of providers would be ideal, often times, multiple NGOs or universities or academic centers have projects established in the same locations with or without knowledge of one another. They may be competing for local health care dollars or staking claims with relationships to local medical centers. Unfortunately the desire to publish, market and brand name a group’s relationship with an international health care organization seemingly takes priority over the altruistic goal of increasing health care outcomes.
- Although programs, such as HINARI (www.who.int/hinari ), have forwarded access to publications for countries with developing style resources, it is still a challenge to provide international providers with the evidence base to practice medicine. Internet access is often unavailable or restricted to a few computers or to certain times during the day. Library resources are outdated and hard copy journals are expensive.
- Frequently, access to care internationally is limited severely. Prehospital transport is nonexistent in most developing countries. If it does exist, those who transport do not provide medical care. The expertise for pediatrics and certainly pediatric subspecialists is located in large urban centers at academic institutions and access to these care providers in many cases is financially and geographically impossible.
- There is not one “go-to” place where one can find information regarding PEM opportunities abroad. The information exists in individual academic medical centers, programs in international emergency medicine, programs in international pediatric health, NGOs, and perhaps upon Web sites which one may accidentally stumble. Many who want to do something “international” only have a semblance of an idea of what they want to do. They know an area they would like to visit or what kind of expertise they can provide. It is finding a match that is the problem. The process of finding an opportunity that matches one’s expertise and interests is a significant barrier to international involvement.
- A significant investment of time and resources is required to find and establish relationships with potential collaborators. Often, this requires trips to conferences, many phone calls (at odd hours to adjust for time zone differences), and even a site visit before a partnership is solidified.
The opportunities:
Where to begin? Let’s say you have a brief amount of time and want to volunteer your time teaching pediatric resuscitation or work a brief time clinically in a far away place. Or maybe you have started developing an idea for an international research project and don’t know how to further it.
The beginning practitioner needs exposure to the field. A good way would be to start small, perhaps by participating in an international elective or by volunteering to be a part of a larger group of seasoned practitioners traveling overseas. More advanced PEM physicians should tap into their professional networks to identify others with similar interests who can serve as collaborators or mentors for a new project.
Some tips to get you going:
- Start with your local academic department of emergency medicine. Many have more than one member with contacts to ongoing international projects. From my personal experience, EM guys and gals are always looking for one or more of us to help out plan/teach/install the pediatric portion of whatever they are up to.
- The international emergency medicine section of ACEP also has a list of international observerships in which you may have interest.
- If you have the desire to participate in a certain region or country, the ACEP international ambassador program (http://www.acep.org/acepmembership.aspx?id=25138 ) provides the names of US-boarded physicians who can provide advice and information on issues pertaining to the progress and status of emergency medicine in their assigned countries. They may have first-hand knowledge of ongoing projects.
- The fellow link on the SAEM website (www.saem.org ) is one way to find international emergency medicine programs with whom you may be able to link. These fellowships are for EM residency graduates who have an interest in international EM. Often times these programs have well-established links with international groups or sites.
- The Section on International Child Health of AAP hosts the CHILDisaster network registry for those with education and experience in humanitarian emergencies to volunteer their time when needed during the time of a disaster (www.aap.org/disaster ).
Some tips before and when you hit the ground:
- Do your research. Know the political climate, infrastructure, health care financing, and epidemiology of disease and injury. It is also important to be familiar with the culture of your destination country to prevent costly errors in communication that can result in costly mistakes and project failures.
- Know the players. Identify organizations already engaged in the country or region, and the projects currently in existence. Try to establish a connection with these organizations and the people involved. These folks can be your strongest allies or toughest competitors. Be familiar with the funders of existing projects. The Foundation Center (http://foundationcenter.org/ ) publishes a report that highlights key international grantmakers and presents trends in international giving. Also, the Global Health Council (http://www.globalhealth.org/ ) is a good source of information regarding health topics worldwide.
- When making the pitch for money, have a clear statement of purpose for your project. A geographic focus for your work is also important. Anticipate potential pitfalls and be prepared to address them. Show that there are collaborators that support your idea. Funders want to know that your idea is sustainable; your project will be run well; and their dollars will be spent wisely and make a difference. Most importantly, the project has to be a good fit with the donor’s funding priorities. Be aware that some donors are more likely to fund your project if they reap a benefit from your work (eg, brand naming, something tangible to market, a new geographical relationship, media exposure).
- Prepare to be creative. Sites where international work is performed are often under-resourced and lack the conveniences that developed-world physicians are accustomed. It can be challenging to apply and emphasize best practices in this setting. However, the ingenuity of those working in challenging circumstances is incredible and inspiring. Your challenge will be to customize existing practice models to your environment in a way that adjusts for local conditions, while preserving the integrity of the practice and ensuring positive health outcomes.
- Lastly, things happen on a different timetable. Flexibility and the ability to adapt to changing circumstances are important. This is especially true for those working in disaster relief.
In the future, an organization of those interested in international pediatric emergency medicine may be the ideal. The first step would be to identify those with PEM expertise who have an interest in international teaching, work, and/or research. A database of those interested in international opportunities and the opportunities themselves would be useful in reducing barriers to international participation.
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International Child Health and the Emergency Physician: Residency-Based International Advocacy Experience
Lina AbuJamra, MD
Assistant Professor of Pediatrics
Northwestern University’s Feinberg School of Medicine
Attending Physician, Emergency Department
Children's Memorial Hospital
Despite advances in modern medicine, eleven million children worldwide younger than five years of age die each year— most from preventable disease and almost all in developing countries. The gaps in child mortality between the rich and poor countries are wide and are becoming wider. The United States is home to only 3% of the world’s two billion children. Of the $70 billion in funds spent globally on health research, only 10% addresses the illnesses that cause 90% of the world burden of disease— an imbalance subsequently captured by the term “the 10/90 gap.”
The World Health Organization (WHO) estimates that there is a global shortage of more than four million health workers. Healthcare workers in most resource-poor countries are overburdened, underpaid, and unsupported. The need is undeniable and the profits are tangible.
There are many ways to get involved. Short-term work is available through volunteer organizations. Lengthier medical commitments can be arranged via national government organizations, universities, or non-profit groups. Some healthcare professionals prefer remote settings where a complete lack of medical resources exists and supplies are brought in by the medical team. Others select more urban sites where infrastructure already exists. In these locales, arranging work in conjunction with a local medical school affords the opportunity to focus on teaching future healthcare providers.
For the physician who is unable to leave the United States, there are multiple ways to get involved from the comfort of home. Physicians can participate in donation programs and recycle medical supplies for international use. They can also volunteer at clinics that primarily serve immigrant populations, as well as incorporate ways to care for these patients within the scope of their daily practice.
Spending time caring for children in need is rewarding professionally and personally. However, this type of advocacy cannot meet all of the challenges facing the advancement of global child health. Long-term vision and planning is needed. EPs can aid progress by working with training programs both in the United States and throughout the developing world, in sharing resources between industrialized and developing nations, and in creating networks to establish treatment programs and monitoring success of treatment over time. The program we describe next is a relatively new program that will hopefully grow into a long-standing and mutually-beneficial program between two institutions.
A RESIDENCY-BASED INTERNATIONAL ADVOCACY EXPERIENCE
Two years ago, a group of residents from Children’s Memorial Hospital recognized their common interest in participating in an international elective experience and joined together to create a collective international advocacy experience. The goal behind the program was to bridge the gap of inequalities in healthcare delivery to underserved children, while exposing residents to medical care in developing countries. This would be accomplished by having a continued presence at a hosting institution. Over time, residents would better understand the needs of children and healthcare workers dedicated to improving child health and well-being. They would not only gain valuable lessons as individuals, but as a group they would have the ability to make a collective contribution to the community’s needs and give back to their hosts. The residents went through the usual process of combing the internet, seeking out mentors with international experience, and making contacts with physicians abroad. With the support of the residency program and a faculty mentor, the residents entered into a partnership with a referral hospital in Tanzania.
In August 2006, the first two residents participated in the elective rotation. By the end of this academic year, twenty four pediatric residents and one pediatric intensive care fellow have completed the rotation, and another twelve are planning on participating in the upcoming academic year. During their rotation, residents work side-by-side with their Tanzanian counterparts to provide direct patient care to children. The opportunity for trainees from two distinctly different systems to learn from each other’s experience has proven invaluable.
The experience has had a profound professional and personal impact on each participating resident. In the absence of the wealth of resources they had become accustomed to during their training in the United States, they had become more astute clinicians— using their hands and their stethoscopes rather than laboratory studies and computerized tomography (CT) scanners. Their mindfulness of cost-effective medicine and ordering tests only when necessary quickly became apparent in morning report discussions. Residents developed a new level of understanding of the effect that global disparities have on child health. They described feeling inspired, invigorated, and increasingly invested in advocating for children both on a local and international level. In the words of one participant, the experience “lit a fire” and reminded him why he aspired to become a physician.
In the years to come, we anticipate that the program will continue to grow. Through this shared learning experience, residents from the United States and Tanzania will act as vehicles for change through continued efforts in advocacy, education, and patient care. At the center of patient care, they are well-equipped to provide ongoing needs assessment to determine how to most effectively improve community health outcomes.
Although the idea of tackling the issues on the forefront of global child health can at first be overwhelming, physicians, including residents in training, can improve the health of children in developing countries. There is still much to be done, and many ways to do the work that lies ahead. Every physician can contribute toward the goal of improving the health of children worldwide. The combination of education and resources provides great potential for many lives to be saved and for all children to benefit from the advances that have been made in medicine. What role will you play in this effort to promote child health?
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Wound Management Update 2008
Annalise Sorrentino, MD, FAAP
Assistant Professor of Pediatrics, Division of Emergency Medicine
University of Alabama-Birmingham
Summer is almost here…and with that comes plenty of bumps, bruises, cuts, and scrapes. I can only speak for myself, but I know a reminder of the basics is always welcome…especially before the new interns start!
The goals of wound management are hemostasis, cosmesis, and avoidance of infection.
| Wound Healing Stages |
- Immediately following the injury, there is coagulation and vasospasm.
- Within 48 hours of suturing, epithelialization occurs in the epidermis (the only layer capable of regeneration).
- Four days after the injury marks the peak in new vessel formation.
- Collagen formation begins within 48 hours, and peaks in the first week following an injury. This can continue for up to one year and is necessary to restore strength to the wound.
- For reasons that are not completely understood, wound contraction occurs 3-4 days following the injury, sometimes causing an inversion of wound margins.
|
Wound Assessment
TIME
The optimal time-to-repair has not been truly defined. Some studies have shown that repair of simple lacerations (not grossly contaminated or involving deep structures) had a better outcome if they were closed within 19 hours of the injury.5 An exception to this are wounds found on the head, as their outcome was comparable to wounds on other parts of the body, even if closed up to 24 hours after injury.
MECHANISM
This can range from simple laceration from a sharp object to a crush wound to a mammalian bite wound. This can lend information on potential foreign body retention or injury to deep structures. Certain mechanisms also have better rates of healing and less chance of infection (ie, simple cut with sharp margins has a low risk for significant infection or scarring, while crush injuries or stellate lacerations carry a higher risk of infection). If the injury was caused by a bite, potential for infection by mouth pathogens should be addressed.
FOREIGN BODY/ DEEP STRUCTURE
Retained foreign body is a common cause of delayed healing and wound infection (and of emergency department litigation!), so careful evaluation for foreign material is important. Direct wound visualization is helpful if the floor of the wound can be seen. Any foreign material that is easily seen should be removed. If needed, the wound may be slightly enlarged to achieve this. If there is a non-irritant foreign body (ie, glass, metal) in a non-critical area (away from joint or other vital structure), it may be left in place. Irritant foreign bodies, such as wood or splinters, should be removed. Plain radiographs may be helpful in detecting radio-opaque material, such as metal, and can pick up a percentage of glass fragments. Glass has been shown to be more commonly found in puncture wounds in the foot (by stepping on) or in the head (from motor vehicle collisions). They are more likely to be seen if they are >15mm. If your suspicion is high, ultrasound may also be helpful if plain films are unrevealing.
Careful inspection of the location of the injury and proximate function can shed light on the possibility of involvement of deeper structures. Lacerations to the distal extremities carry a risk of tendon, ligament, or nerve involvement. Deeper lacerations or punctures can involve arterial bleeding. Lacerations involving a joint will require extensive irrigation and possibly a trip to the operating room.
TETANUS PROPHYLAXIS
Characteristics that make a wound at higher risk for tetanus infection include wounds contaminated with dirt/soil, saliva, or feces; puncture wounds; avulsions; crush wounds; burns; and frostbite.
The following are current recommendations for tetanus prophylaxis:
- If baseline tetanus status is unknown, or if they have not received their primary series of 3 immunizations, they should receive the tetanus toxoid for a clean wound, and tetanus toxoid with TIG for a “dirty” wound as described above.
- If the patient has received their primary series of tetanus immunizations, they should be updated for a clean wound if it has been =10 years, and for a dirty wound if it has been =5 years.
- DTaP should be administered for those <7 years of age and for those >11 years of age who have not previously received the acellular pertussis component.
Type of Closure
After assessing the age of the wound, mechanism of injury, and degree of contamination, the next decision is what type of closure, if any, that you will use.
Primary closure: Performed on clean wounds 12-18 hours old (up to 24 hours on the face)
Delayed primary closure: Can be considered if presentation for repair is after the above time frame; this involves cleaning and debridement of the area followed by a 4-5 day waiting period. This allows the host to decrease the bacterial load prior to closure.
Secondary intention: Considered for deep puncture wounds that cannot be adequately irrigated, contaminated wounds, non-cosmetic animal bites, abscesses, or those that present in a delayed fashion that are not a candidate for delayed primary closure
Wound Preparation
Wound preparation is a very important step in preventing subsequent infection. In our ED, the wounds are most often anesthetized prior to irrigation and debridement. L.E.T. (Lidocaine/Epinephrine/Tetracaine) is most commonly used, with avoidance of certain body parts (ie, fingers, toes, penis, nose). Lidocaine (1%) can be infiltrated directly into the wound. To diminish the discomfort of local infiltration with lidocaine, buffering with sodium bicarbonate in a 1:9 ratio can be done; warming of the lidocaine mixture; slow injection; and injection directly into the wound margins rather than into healthy intact skin parallel to the wound.
Lidocaine with epinephrine can be helpful for highly vascular wounds, but should be avoided in wounds with limited blood supply. Two percent lidocaine is helpful for digital blocks and should be used without epinephrine. Viscous lidocaine can be used on mucous membranes or deep abrasions, such as in “road rash,” to minimize discomfort prior to cleansing.
For disinfection of the surrounding skin, povidone-iodine is used most often. This can be diluted in a 1:10 mixture with saline. Betadine® surgical scrub should not be placed directly into the wound, as it may be toxic to the tissue. Agents, such as ShurClens® (surfactant cleaners), do not have any antibacterial activity, but can help minimize the scrubbing trauma while reducing bacterial load.
Debridement is felt by some to be even more important than irrigation, as devitalized tissue possesses the capacity to enhance infection. Sometimes, debridement will aid in approximating wound edges in a more aesthetically pleasing way. Careful attention should be paid to the orientation of the wound in relation to the natural skin tension lines to minimize further scarring. Rarely, if ever, should an area around the wound be shaved, as this can lead to a higher risk of infection. Using a lubricant to direct hair away from the cut is usually sufficient.
Irrigation is important in wound preparation to aid in removal of smaller foreign bodies or contaminants. However, low-risk wounds in highly vascularized areas have been shown to have good outcomes without any irrigation.2 Normal saline is most typically used, although a study evaluating the use of tap water in the irrigation of simple lacerations showed no higher infection risk.11 Optimal irrigation pressures are felt to be 5-8 pounds per square inch. This can be attained using a 19-gauge catheter on a 60 cc syringe. High pressure irrigation (>25 PSI) should be reserved for highly contaminated wounds, although pressures this high may cause further tissue damage and infection by dissection through tissue. The amount of irrigation used depends on the type and contamination of the wound.2
Along the same lines as sterile saline vs tap water, another study looked at the potential effect using nonsterile gloves while repairing simple lacerations. This prospective, randomized trial found that in more than 800 patients, use of nonsterile gloves did not change the subsequent infection rate.1
Wound Closure
There are several methods that can be used to approximate wound edges and each carry with them their own risks and benefits.
Tissue Adhesives
Tissue adhesives were approved for use in the United States in 1998, with the most commonly used adhesive being octyl-2-cyanoacrylate (Dermabond™). Use of tissue adhesives has many advantages including the following: 1)less potentially painful, 2 )rapid application, and 3) no need for removal. There have been several studies showing no long term difference with healing or cosmesis in wounds repaired with sutures vs tissue adhesives, and some suggest a better cosmetic outcome with the use of adhesives. One study showed a statistically significant increased rate of wound dehiscence in wounds closed with tissue adhesives, but the clinical significance of this is unclear.1,6
| Wound Adhesive Application |
| 1. |
Clean wound as per routine.
|
| 2. |
Ensure wound edges are dry with complete hemostasis prior to approximating the wound edges. |
| 3. |
Using forceps or fingers, the wound edges should be approximated or lightly everted. Often a second assistant is crucial in this step. |
| 4. |
A thin layer of adhesive should then be placed over the edges, being careful not to exert any pressure onto the wound. (This first layer will achieve full strength in 2 minutes.) |
| 5. |
If there is a need to remove the adhesive, all attempts should be done to do so within 10 seconds. If that is not possible, antibiotic ointment or petroleum jelly can be placed on the wound for 30 minutes to aid in polymer removal. |
| 6. |
Most complications from use of tissue adhesives are not related to the wound itself, but rather to leakage of the adhesive to other areas. |
| 7. |
Caution with wound care around the eye should be taken to avoid gluing the lid or lashes closed. |
The wound that is an ideal candidate for tissue adhesives is the clean, linear laceration under minimal tension. Occasionally, deep sutures are placed prior to edge approximation with tissue adhesives to relieve some of the tension on the wound. Tissue adhesives are not recommended for grossly contaminated wounds, wounds on the hands or feet, wounds over joints, wounds in the hairline or crossing the vermilion border, puncture wounds, or in patients at risk for delayed wound healing. Stellate lesions or crush injuries are also not good candidates. In terms of keloid formation, there is no data supporting that tissue adhesives either promote or prevent this from happening.
Another study chose to look at the cosmetic outcomes of simple facial lacerations closed with Dermabond™ vs Steri Strips™.12 This prospective, randomized controlled trial evaluated almost 100 children ages 1-18 years with simple facial lacerations (<2.5 cm in length; <12 hours old; clean; not in areas of high tension or mobility, such as nose, ears, or mouth). At two months post-repair, the cosmetic outcomes were rated by two plastic surgeons, which were blinded to the method used for wound closure. They found, using the mean cosmesis visual analogue score, that the Steri Strips™ group had slightly better outcomes. The advantage of Steri Strips™ over Dermabond™ includes speed of closure and cost.12
Staples/Other
In the pediatric ED, staples are used on an occasional basis, especially on scalp wounds. The advantage of speed of closure, with the wound still adequately anesthetized, cleansed, and approximated, must be balanced by the occasional disadvantage of their removal. After an episode of a child returning to the ED to get his staples removed after the primary care physician could not remove them with the provided staple remover, I am convinced of the discomfort associated with staple removal.
While we are on the subject of scalp lacerations, another technique that has been proposed is the hair apposition technique (HAT). One study randomized patients into two groups: one repaired by standard suturing and the other by the HAT.8
These same investigators then performed another study and showed that this technique can be performed equally well by trained physicians or nurses. This may be something that can be started at the time of triage.9
Hair Apposition Technique (HAT)
|
| 1. |
The wound is cleansed normally (Local anesthesia is not needed.).
|
| 2. |
Four to five strands of hair on either side of the laceration are bundled (should be at least 3 cm in length) and crossed over the wound.
|
| 3. |
A single twist is made to approximate the wound edges, and then it is secured with a drop of tissue adhesive (No knot is made.).
|
| 4. |
The patient is asked not to wash the wound for 2 days.
|
Sutures
Probably the most common method used to close lacerations in the ED is sutures. The biggest question is usually, “What suture should I use?” For me, it’s easiest to divide sutures first into absorbable and non-absorbable, and then decide which suture would be best for the particular laceration.
| |
Knot Security |
Retention of 50% of tensile strength (days) |
Site |
| Absorbable Sutures |
| Fast absorbing gut |
Poor |
4-6 |
Face |
| Vicryl Rapide |
Good |
5-7 |
Face, scalp, under casts/splints |
| Monocryl |
Good
|
7-10 |
Face, deep sutures in contaminated wounds |
| Chromic gut |
Fair |
10-14 |
Mouth, tongue, nailbed |
| Vicryl |
Good |
30 |
Deep sutures, mouth, nailbed |
| Nonabsorbable Sutures |
| Nylon |
Good |
|
Anywhere |
| Prolene |
Least |
Anywhere (blue in color, good for hard to see areas) |
| Silk |
Best |
Rarely used |
One topic that has been of interest is the cosmetic outcomes of lacerations sewn with absorbable vs nonabsorbable suture. Absorbable suture has the advantage of reducing need for follow up as well as eliminating the need for suture removal, which can be as traumatic as placement of sutures, especially in the younger child. However, it also causes significant tissue reactivity, which could potentially lead to more visible scarring. Two studies were performed comparing the cosmetic outcomes of these 2 suture types.
One study looked at all non-contaminated, new (<12 hours) wounds in children 1-18 years of age. The usual suspects were excluded (bites, grossly contaminated wounds, crush injuries, wounds over joints, those at risk for poor healing, and scalp lacerations), and those enrolled were randomized into one of two groups: 1) repair with absorbable plain gut or 2) repair with nonabsorbable nylon. The wounds were reassessed at 10 days and then again at 4-5 months. Their findings were that there were no differences in the rates of infection or wound dehiscence between the two groups. It was felt that the long term cosmetic outcomes were equal in the groups.4
More recently, another study was done looking at the cosmetic outcomes of absorbable vs nonabsorbable sutures in pediatric facial lacerations. The anatomic site of the laceration was limited to the face, and the patients were again randomized into one of two groups: absorbable or nonabsorbable. They were followed up at 5-7 days, and again at three months. Similar to the previous study, they found no differences in cosmesis, infection, or dehiscence between the two groups. One limitation the investigators found was the number of absorbable sutures that required removal.7 Part two of their study is going to investigate the time frame for complete self-resorption of these sutures. In our ED, fast-absorbing gut is routinely used on the face and, although rare, there are times when the suture remnants should be removed before self-resorption takes place to minimize tissue reactivity. It is important to remind families of the possibility of retained suture and follow-up if that is a concern.
I hope this review was helpful. I know it was a good refresher for me. Good luck this summer!!
References:
- Beam JW. Tissue Adhesives for Simple Traumatic Lacerations. J Athl Train 2008; 43(2):222-224.
- Brancato JC. Minor Wound Preparation and Irrigation. www.uptodate.com. Accessed 3/8/08.
- deLemos D. Closure of Skin Wounds with Sutures. www.uptodate.com. Accessed 3/23/08.
- Karounis H. et al. A Randomized, Controlled Trial Comparing Long-term Cosmetic Outcomes of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut versus Nonabsorbable Nylon Sutures. Acad Emerg Med 2004;11(7):730-735.
- Kronfol R. Closure of Minor Skin Wounds with Staples. www.uptodate.com. Accessed 3/23/08.
- Kronfol R. Tissue Adhesives. www.uptodate.com. Accessed 3/23/08.
- Luck RP, et al. Cosmetic Outcomes of Absorbable Versus Nonabsorbable Sutures in Pediatric Facial Lacerations. Pediatr Emerg Care 2008; 24(3):137-142.
- Ong MEH, et al. A Randomized Controlled Trial Comparing the Hair Apposition Technique With Tissue Glue to Standard Suturing in Scalp Lacerations (HAT Study). Ann Emerg Med 2002; 40(1):19-26.
- Ong MEH, et al. Hair Apposition Technique for Scalp Laceration Repair: a Randomized Controlled Trial Comparing Physicians and Nurses (HAT 2 Study). Am J Emerg Med 2008; 26:433-438.
- Perelman VS, et al. Sterile Versus Nonsterile Gloves for Repair of Uncomplicated Lacerations in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2004; 43(3):362-370.
- Valente JH, et al. Wound Irrigation in Children: Saline Solution or Tap Water? Ann Emerg Med 2003; 41(5):609-616.
- Zempsky WT, et al. Randomized Controlled Comparison of Cosmetic Outcomes of Simple Facial Lacerations Closed with Steri Strip™ Skin Closures or Dermabond™ Tissue Adhesive. Pediatr Emerg Care 2004; 20(8):519-524.
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Update on the ACEP Pediatric Emergency Medicine Committee
Kathleen Brown, MD FACEP
Chair, Pediatric Emergency Medicine Committee
The ACEP Pediatric Emergency Medicine Committee continues to work on their objectives for 2008. Thanks to all of the members who have contributed to our progress outlined below. Any section member who would like to help out with any of the objectives is welcome to contact Dr. Brown at pedsem.ctte@elist.acep.org.
2008 Objectives:
- Work with Federal Government Affairs Committee as needed to improve EMSC funding and ensure its reauthorization
Members:
James M. Callahan, MD, FACEP (Lead)
Isabel A. Barata, MD, FACEP
Kathleen Brown, MD, FACEP, Chair
Status: The House of Representatives has approved the Wakefield Act. The Wakefield Act now goes to the Senate for approval. Dr. Callahan spoke with James Eadie, MD, FACEP, and Mary Jo Wagner, MD, FACEP, co-Chairs of the Federal Government Affairs Committee. The Government Affairs Committee is looking for new ideas/flashier ways of approaching funding on the Hill. The Pediatric Committee will try to think about ideas for a new approach to ensuring funding for the EMSC Program. Dr. Callahan will listen in on upcoming Government Affairs Committee conference calls.
- Work with the Public Relations Committee to improve public image of emergency physicians and reinforce their role regarding pediatric emergencies
Members:
Lee S. Benjamin, MD, FACEP (Lead)
Randolph J. Cordle, MD, FACEP
Richard M. Cantor, MD, FACEP
Lisa Bundy, MD
Douglas K. Holtzman, MD
Madeline Joseph, MD, FACEP
Status: The group is working with the ACEP Public Relations Committee on developing a web-based product to be used as a tool for general emergency medicine physicians.
- Work with AAP Committee on Pediatric Emergency Medicine (AAP/COPEM) to create a compilation of best practices, first nurse and triage guidelines, and benchmarking data for improving ED wait times and ED flow for pediatric patients. Expand resources available to College members in practical ways including development of a policy statement and PREP.
Members:
Kathleen Brown, MD, FACEP, Chair (Lead)
Ann Marie Dietrich, MD, FACEP
Lee S. Benjamin, MD, FACEP
Mark A. Hostetler, MD, FACEP
Aderonke Ojo, MD, MBBS
James M. Callahan, MD, FACEP
Status: The group has developed an extensive reference list. Plans are to recruit authors from AAP/COPEM to help contribute to the paper.
- Work with the Disaster Preparedness and Response Committee to establish ACEP as the primary organization for pediatric disaster medicine expertise by disseminating guidelines and developing educational materials for disaster preparedness unique to the pediatric patient.
Members:
David S. Markenson, MD (Lead)
Lisa Bundy, MD
Lee S. Benjamin, MD, FACEP
Sanjay Mehta, MD
Mark A. Hostetler, MD, FACEP
Antonio E. Muniz, MD, FACEP
Constance Doyle, MD, FACEP (Liaison)
Status: The group continues to work on the development of pediatric disaster preparedness educational materials.
- Work with the Quality and Performance Committee to conduct a literature search and identify and compile recommendations on pediatric EM quality indicators
Members:
Kathleen Brown, MD, FACEP (Lead)
Isabel A. Barata, MD, FACEP
Ann Marie Dietrich, MD, FACEP
Mark A. Hostetler, MD, FACEP
Paul Ishimine, MD, FACEP
Aderonke Ojo, MD, MBBS
Status: The committee is collecting a list of indicators already available and will consider compiling the list as a resource.
- Develop a series of clinical scenarios for publication in ACEP News with CME credit
Members:
Richard M. Cantor, MD, FACEP (Lead)
Isabel A. Barata, MD, FACEP
Lisa Bundy, MD
Ann Marie Dietrich, MD, FACEP
Malford T. Pillow, MD
Gerald R. Schwartz, MD, FACEP
Lee S. Benjamin, MD, FACEP
Status: Dr. Cantor has worked with the editor of ACEP News to develop a forum for PEM clinical scenarios. Three clinical scenarios are in the pipeline for publication in ACEP News. Anyone on the committee is welcome to write a scenario. Interested members can contact Dr. Cantor for more information.
- Work with the AAP and EMSC to disseminate and publicize the Guidelines for Preparedness for pediatric emergency care and the pediatric equipment list
Members:
Ghazala Q. Sharieff, MD, FACEP (Lead)
Ann Marie Dietrich, MD, FACEP
Douglas K. Holtzman, MD
Paul Ishimine, MD, FACEP
David S. Markenson, MD
Malford T. Pillow, MD
Sanjay Mehta, MD
Status: Dr. Krug of AAP/COPEM is working on final revisions. Once revisions are complete, the guidelines will be sent to the committee for final review.
- Revise the following policy as part of the policy sunset review process: Use of Pediatric Sedation and
Analgesia
Members:
Isabel A. Barata, MD, FACEP (Lead)
Ghazala Q. Sharieff, MD, FACEP
Randolph J. Cordle, MD, FACEP
Malford T. Pillow, MD
Status: The revised document is being submitted to the ACEP board for approval.
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Pediatric Literature Review
Todd Wylie, MD
Assistant Professor of Emergency Medicine and Pediatrics
Department of Emergency Medicine
University of Florida Health Science Center, Jacksonville
Article #1: Title: Cosmetic Outcomes of Absorbable Versus Nonabsorbable Sutures in Pediatric Facial Lacerations
Authors: Luck RP, Flood R, Eyal D, Saludades J, Hayes C, Gaughan J.
Journal: Pediatr Emerg Care 2008; 24: 137-142.
Summary:
The objective of this prospective, randomized clinical trial was to demonstrate comparable cosmetic outcome in traumatic facial lacerations repaired with absorbable sutures versus those repaired with nonabsorbable sutures. The authors also wanted to demonstrate that there was no significant difference in the rate of complications (infection, wound dehiscence, and keloid formation) and parental and patient satisfaction. All patients between 1-18 years of age with a linear facial laceration were eligible for inclusion in the study. Lacerations had to be 1-5 cm in length and repairable with one- or two-layered repair to be included. Exclusion criteria included the following: lacerations with irregular borders, contaminated lacerations, lacerations >8 hours old, lacerations amenable to repair with topical adhesives, mammalian bites, immunodeficiency, bleeding disorders, clotting disorders, pregnancy, diabetes, and renal deficiencies. Either 5-0 or 6-0 fast-absorbing surgical gut sutures were used to close the lacerations in patients randomized to the absorbable suture group. Nylon suture was used for those patients randomized to the nonabsorbable suture group.
Patients from both groups had follow-up visits within 5-7 days after laceration repair. The lacerations were evaluated for complications, including wound infection and/or dehiscence, during the visit. In addition, any visualized sutures were removed during this initial visit. Patients also had a three month follow-up visit, at which time the healed lacerations were evaluated by three pediatric EM physicians that were blinded to the original treatment group assignment. The wound healing was evaluated using a visual analog scale (VAS) of cosmesis (range of 0-100, 0 representing “worst scar,” 100 representing “best scar”). The minimal clinically important difference on the VAS scale was defined as 15 or greater. The evaluators also noted the presence or absence of keloid formation at the three month visit. Parents also were asked to evaluate wound healing at three months, including a VAS score, perceived complications, and convenience.
Six hundred and seventy four patients with lacerations were seen between June 2005 and November 2005. Of these, 125 patients were eligible for inclusion in the study. Eighty-eight patients were enrolled in the study. Forty-nine patients were randomized to the absorbable suture group, and 39 patients were randomized to the nonabsorbable suture group. Thirty-nine (80%) patients from the absorbable suture group returned for the 5-7 day follow-up visit. Thirty-five (90%) patients from the nonabsorbable suture group returned for the 5-7 day follow-up. Twenty-three patients from the absorbable suture group returned for the three month evaluation, and 24 patients from the nonabsorbable suture group returned. There were no significant differences reported in the patient demographics or laceration characteristics between the two groups of patients that finished the study.
The mean VAS for the absorbable suture group was 92.3. The mean VAS for the nonabsorbable suture group was 93.7. The difference of the means was 1.4 (95% CI = -5.31 to 8.15). Since the difference of the means was less than 15, the two were considered equivalent. The mean parental VAS scores for the absorbable and nonabsorbable suture groups were 86.3 and 91.2, respectively (difference of the means = 4.9; CI 2.41 – 7.41). Two patients in the absorbable suture group suffered wound dehiscence. No patients in the nonabsorbable suture group experienced wound dehiscence. No patient in either group developed a wound infection. Only one patient developed a keloid, and that patient was in the nonabsorbable suture group. Parents rated the absorbable sutures as more convenient (91 % vs. 75 % for the nonabsorbable suture group), although there was not a statistical difference between the two. Complications were noted by three parents from the absorbable suture group and none from the nonabsorbable suture group. This difference was not found to be statistically significant.
Comments:
The results of this study support the idea that absorbable sutures provide comparable cosmetic outcome and similar complication rates as nonabsorbable sutures when used for closing traumatic wounds. Despite the limitation of this study, it does add to the growing body of literature that supports the use of absorbable sutures for wound closure in certain clinical scenarios (see references below).
References
- Karounis H, et al. A Randomized, Controlled Trial Comparing Long-term Cosmetic Outcomes of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut versus Nonabsorbable Nylon Sutures. Acad Emerg Med 2004; 11: 730-735.
- Parell GJ, Becker GD. Comparison of Absorbable With Nonabsorbable Sutures in Closure of Facial Skin Wounds. Arch Facial Plast Surg. 2003; 5: 488-490.
- Shetty PC, Dicksheet S, Scalea TM. Emergency Department repair of hand lacerations using absorbable Vicryl sutures. J Emerg Med 1997; 15: 673-674.
- Guyuron B, Vaugahn C. A comparison of absorbable and non-absorbable suture materials for skin repair. Plast Reconstr Surg 1992; 89: 234-236.
- Start NJ, Armstrong AM, Robson NJ. The use of chromic catgut in the primary closure of scalp wounds in children. Arch Emerg Med 1989; 6: 216-219.
Article #2: Title: The Pediatric Respiratory Assessment Measure: A Valid Clinical Score for Assessing Acute Asthma Severity from Toddlers to Teenagers
Authors: Ducharme FM, Chalut D, Plotnick L, et al.
Journal : J Pediatr 2008;152(4):476-80.
Summary:
As the authors state in the first paragraph of this article, obtaining standard lung function tests (eg, peak expiratory flow rate or spirometry) for young children with an acute asthmatic exacerbation is tough and often impossible. In the absence of standard lung function tests, it is desirable to have some other means to measure asthma severity and treatment response in the acute care setting; such as a clinical scoring system. The Preschool Respiratory Assessment Measure (PRAM) is a clinical scoring system that has been validated in small children. The stated objectives of the authors were to evaluate the PRAM in terms of validity, responsiveness to change, and reliability in children ages 2-17 years that present with acute asthma exacerbations.
A prospective, observational cohort study designed to evaluate the PRAM was conducted between March and May 2003, and September and November 2003. The eligibility criteria included: ages 2-17 years, history of asthma as defined by two or more episodes of wheezing responsive to inhaled beta-agonists, and requiring at least one nebulized albuterol treatment for the index exacerbation. Patients with known chronic lung disease were excluded from the study.
All children in the study were subjected to the same initial evaluation and treatment as defined by an existing clinical care pathway. A triage nurse assessed the patient, recorded an initial PRAM, and then initiated treatment with bronchodilators. Next, the treating physician or nurse recorded a second PRAM (generally within 60 minutes of initial treatment), and an additional PRAM every 1-2 hours thereafter until disposition. A decision to admit or discharge the patient was made within 6 hours of triage for each patient.
The predictive validity and responsiveness were assessed using disposition as the outcome. Responsiveness was defined as the ability of the PRAM to detect clinically important changes over time. In addition, the internal consistency of the PRAM was evaluated using triage scores to identify the degree to which each individual item contributed to the PRAM score. The inter-rater agreement (degree to which a physician and nurse obtained similar PRAM scores on the same patient) also was assessed.
Nine hundred and sixty-four patients were eligible for the study of which 782 (81%) had a PRAM recorded at triage. The median age of these patients was 5.8 years. Sixty-three percent of the patients were male. A second PRAM was recorded for 554 (57%) patients between 15 and 75 minutes after initial treatment. The predictive validity (association between the PRAM and the rate of admission) was reported as strong for the PRAM at triage (r = 0.4, P < .0001) and at the second recording (r = 0.5, P < .0001). No significant difference was reported for the PRAM between preschool and older children at either the initial or subsequent measurement. A combination of the triage PRAM and the change in the PRAM after initial treatment represented the best predictor of admission. The PRAM was reported to show a “good ability” to identify change between triage and disposition. Good internal consistency was reported for the triage PRAM across the entire age spectrum and across different age groups. Inter-rater reliability between the physician and nurse measuring the PRAM in the same patient was found to be high (k = 0.78). This was reported as true across all age groups and for each component of the PRAM.
Comments:
The PRAM demonstrated good inter-rater reliability, responsiveness, and predictive validity across the entire spectrum of ages evaluated. In the discussion, the authors suggest the following categories for children at low, moderate, and high risk of hospital admission based on the PRAM: 0-3 represents low risk (< 10%), 4-7 represents moderate risk (10-50 %), and 8-12 represents high risk (> 50%). For the 12-point PRAM, readers are referred to the following article: Chalut DS, Ducharme FM, Davis GM. The preschool respiratory assessment measure (PRAM): A responsive index of acute asthma severity. J Pediatr 2000; 137: 762-768.
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Upcoming Scientific Meetings in Pediatric Emergency Medicine
Summer 2008
EMSC Grantees Meeting
June 25-27, 2008
Bethesda, MD
PREP:EM An Intensive Review Course of Pediatric Emergency Medicine
August 16-20, 2008
Cambridge, MA
Royal Sonesta Hotel
Register online at www.pedialink.org/cmefinder or call 866-THE-AAP1 (866-843-2271) toll-free; Sponsored by AAP Section on Emergency Medicine and the American Academy of Pediatrics
AAP Section on Emergency Medicine Meeting
Oct 10-12, 2008
Boston, MA
ACEP Scientific Assembly
Oct 27-30, 2008
Chicago, IL
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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.
