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C.L.A.P.P.E.D.CLinically Applied Pearls from the PediatricEmergency Department

Stephen Noseworthy, MD

• No conflict of interest to declare

Practice Changes

• 1. Obtaining Urine Samples

• 2. Role of Probenecid in Soft tissue infections

• 3. Using Allerject over Epipen…until recently• 4. Using more online resources to assess and manage

concussion

• 5. Using more Ventolin MDI with a spacer overnebulizer for acute asthma management

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Objectives

By the end of our talk today you should be able to:

1. use a new technique for obtaining a clean urine sample ina child < 90 days of age.

2. recognize and know where to find the new BCCHtreatment algorithm for diagnosing and treating febrileUTI’s in children

3. assess and manage pediatric concussions

4. access online and community resources for concussion

Arch Dis Child 2013;98:27-9

3 Steps

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New Research

Accuracy of a new clean-catch technique for diagnosis ofurinary tract infection in infantsyounger than 90 days of ageMaría Luisa Herreros MD PhD1,2, Alfredo Tagarro MD

PhD1,2, Araceli García-Pose MD1, Aida Sánchez MD3,

Alfonso Cañete MD PhD1,2, Pablo Gili MD PhD2

Pediatrics & Child Health 2015, 20(6);e30-3

Culture result –Catheterization

Positive Negative Total

Cultureresult – cleancatch

Positive 32 2 34

Negative 1 17 18

Total 33 19 52

Cultures obtained from bothclean catch and catheterization

Sensitivity 97% (CI 82% to 100%)Specificity 89% (CI 65% to 98%)

Urinalysis Results

Collection technique; culture result LeukocyteEsterase Positive(n)

Nitrite Positive (n)

Catheter; positive (n=34) 30 8

Catheter; negative (n=21) 0 1

Clean-catch; positive (n=37) 32 9

Clean-catch; negative (n=20) 4 0

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Study Limitations

1. Catheter gold standard vs. Suprapubic aspiration

2. More males than females

3. Small sample size

4. Included only infants with high likelihood of having aSBI

Conclusion

• It appears that this new technique for clean catch urine isas sensitive and specific as catheter collection in thisparticular study, but more research is needed

• In the meantime:• This is not a harmful procedure

• Is as good as other clean catch techniques (ie waiting forbaby to void)

• May be faster than just waiting and even catheterization

• Can easily be carried out by parents and an office staffmember

www.childhealthbc.ca

BC Children’s HospitalEmergency DepartmentGuidelines

Urinary Tract Infections

Febrile UTI

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• Movie Trailer - Concussion

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Complications

• Second Impact syndrome

• Post-concussion syndrome

• Post-traumatic epilepsy

• Post-traumatic vertigo

• Cranial nerve injuries

• Chronic Traumatic Encephalopathy

Symptoms

• Headache

• Amnesia

• Dizziness

• Nausea

• Vomiting

• Confusion

• Loss of Consciousness is not required,and often absent

Identify Patients withworrisome Features

1. CATCH: a clinical decision rule for the use ofcomputed tomography in children with minor headinjuryMartin Osmond, et al. for the Pediatric EmergencyResearch Group of Canada, 2010

2. Identification of children at very low risk of clinically-important brain injuries after head trauma: aprospective cohort studyNathan Kuppermann, et al, for the Pediatric EmergencyCare Applied Research Network (PECARN), 2009

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CATCH Study

PECARN study

DiagnosticTool

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Treatment Strategies

http://onf.org/system/attachments/266/original/GUIDELINES_for_Diagnosing_and_Managing_Pediatric_Concussion_Recommendations_for_HCPs__v1.1.pdf

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www.Parachutecanada.org

http://www.injuryresearch.bc.ca/education/concussion-awareness-training-tool/

http://www.injuryresearch.bc.ca/wp-content/uploads/2014/09/return-to-learn.pdf

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http://www.injuryresearch.bc.ca/wp-content/uploads/2014/09/return-to-play.pdf

Other Resources

• Online:• ChildHealth BC

• CPS Position Statement – Sport RelatedConcussion: Evaluation and Management,2014

Other Resources

• Community:• BC Centre for Ability (0-19yrs)

• Fraser Health Concussion Clinic (16 and older)

• GF Strong Early Response Concussion Service forAdolescents (12-15 yrs)

• Sports Medicine Clinics – acute symptoms

• Pediatricians with special interest

• Role of School – counselling, IEP’s, adjustment ofacademic expectations

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Summary

1. Obtaining a urine sample from an infant is often anecessary and time consuming investigation.

2. With just 3 easy steps - feeding, tapping the abdomen,and rubbing the lumbar spine – you can have your veryown sample in less than a minute!

3. This technique does not require more manpower thancatheterization and can be done in your office.

4. More research and dissemination will make this aneveryday practice

Summary

1. The complications of concussions can be fatal (SecondImpact Syndrome), or can be long and drawn outaffecting a person socially, emotionally, intellectually,and physically.

2. There are more resources available to us now than everbefore for evaluating and treating concussions - SCAT3and Parachutecanada.org and injuryresearch.bc.ca -excellent online resources for physicians, parents,patients and coaches

3. Return to Learn should take priority over Return to Playin all pediatric concussions

Useful Websites

1. www.aap.org

2. www.childhealthbc.ca

3. www.cma.ca

4. www.cps.ca

5. www.fraserhealth.ca

6. www.parachutecanada.org

7. www.injuryresearch.bc.ca

8. www.onf.org

9. www.TREKK.ca

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References

1. Herreros Fernandez ML, Gonzalez Merino N, Tagarro Garcia A, et al. A new techniquefor fast and safe collection of urine in newborns. Arch Dis Child 2013;98:27-9

2. Herreros Fernandez ML, Tagarro Garcia A, Garcia-Pose A, et al. Accuracy of a newclean-catch technique for diagnosis of urinary tract infection in infants younger than 90days of age. Pediatrics & Child Health 2015, 20(6);e30-3

3. Kuppermann N, Holmes JF, Dayan PS et al. Identification of children at very low riskof clinically-important brain injuries after head trauma: a prospective cohort study.Lancet. 374 (9696): 1160-1170 (2009).

4. McCrory P, Meeuwisse WH, Aubrey M et al. Consensus statement on concussion insport: the 4th International Conference on Concussion in Sport held in Zurich, November2012. Br J Sports Med. 47 (5): 250-258 (2013).

5. Osmond Martin H, Klassen Terry P, Wells George A, et al. CATCH: a clinical decisionrule for the use of computed tomography in children with minor head injury. CMAJMarch 9, 2010 182(4), First published February 8, 2010.

6. Purcell, Laura K, Canadian Pediatric Society Healthy Active Living and SportsMedicine. Sport-related Concussion:evaluation and management March 2014. PaediatrChild Health 2014;19(3);153-8

7. Zemek R, Duval S, DeMatteo C et al. Guidelines for Diagnosing and ManagingPediatric Concussion [Internet]. Toronto, ON: Ontario neurotrauma Foundation; 2014June [accessed 2014 Nov 28]. Available from:http://onf.org/system/attachments/265/original/

Thank-you

Brain101.orcasinc.com