Little Big Med

Episode 35: Pediatric Sedation Trends Feb 18, 2021

In this episode host Jason Woods talks with Corrie Chumpitazi and Pradip Kamat about the general trends in pediatric sedation (outside of the operating room) over the last decade, centered on a paper they co-authored. The discussion focuses on changing distribution of WHO is doing sedations, medications used, and safety measures.

Highlighted paper: Kamat PP, McCracken CE, Simon HK, et al. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020;145(5):e20193559. doi:10.1542/peds.2019-3559

DISCLOSURE: We will be discussing sedation medications, which are commonly used but not FDA approved for children for this indication.

Guests

Corrie E. Chumpitazi MD, MS, Associate Professor of Pediatrics, Baylor College of Medicine/Texas Children’s Hospital

Director of Sedation, Associate Chief of Research, Sedation Oversight Committee Chair, Section of Emergency Medicine, Baylor College of Medicine/Texas Children’s Hospital

Site Principal Investigator, National EMS for Children Innovation and Improvement Center

Society for Pediatric Sedation Provider Course Chair

Pradip P. Kamat MD, MBA Associate Professor of Pediatrics/Pediatric Critical Care Medicine Children’s Heathcare of Atlanta/Emory University School of Medicine

Director Children’s Sedation Services At Egleston, Children’s Healthcare of Atlanta/Emory University School of Medicine

Society for Pediatric Sedation, Chair of Membership Committee, President-Elect

Additional Resources

Texas Children’s Hospital Procedural Sedation Evidence Based Guideline

Bibliography

Kamat PP, McCracken CE, Simon HK, et al. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020;145(5):e20193559. doi:10.1542/peds.2019-3559
Bhatt M, Kennedy RM, Osmond MH, Krauss B, McAllister JD, Ansermino JM, Evered LM, Roback MG; Consensus Panel on Sedation Research of Pediatric Emergency Research Canada (PERC) and the Pediatric Emergency Care Applied Research Network (PECARN). Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med. 2009 Apr;53(4):426-435.e4. doi: 10.1016/j.annemergmed.2008.09.030. Epub 2008 Nov 20. PMID: 19026467.
Roback MG, Green SM, Andolfatto G, Leroy PL, Mason KP. Tracking and Reporting Outcomes Of Procedural Sedation (TROOPS): Standardized Quality Improvement and Research Tools from the International Committee for the Advancement of Procedural Sedation. Br J Anaesth. 2018 Jan;120(1):164-172. doi: 10.1016/j.bja.2017.08.004. Epub 2017 Nov 23. PMID: 29397125.
Grunwell JR, Travers C, McCracken CE, Scherrer PD, Stormorken AG, Chumpitazi CE, Roback MG, Stockwell JA, Kamat PP. Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Crit Care Med. 2016 Dec;17(12):1109-1116. doi: 10.1097/PCC.0000000000000920.
Mallory MD, Baxter AL, Yanosky DJ, Cravero JP; Pediatric Sedation Research Consortium. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011;57(5):462-8.e1.
Jenkins E, Hebbar KB, Karaga KK, et al. Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age. Pediatr Radiol. 2017;47(8):974-983. doi:10.1007/s00247-017-3844-7
Biber JL, Allareddy V, Allareddy V, et al. Prevalence and Predictors of Adverse Events during Procedural Sedation Anesthesia-Outside the Operating Room for Esophagogastroduodenoscopy and Colonoscopy in Children: Age Is an Independent Predictor of Outcomes. Pediatr Crit Care Med. 2015;16(8):e251-e259. doi:10.1097/PCC.0000000000000504
Grunwell JR, Travers C, Stormorken AG, Scherrer PD, Chumpitazi CE, Stockwell JA, Roback MG, Cravero J, Kamat PP.Pediatric Procedural Sedation Using the Combination of Ketamine and Propofol Outside of the Emergency Department: A Report From the Pediatric Sedation Research Consortium. Pediatr Crit Care Med. 2017 Aug;18(8):e356-e363. doi: 10.1097/PCC.0000000000001246.PMID: 28650904

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Episode 34: Taking a Device From Concept to Commercial Production with Mark Piehl Jan 05, 2021

In this episode of Little Big Med, host Jason Woods talked with Mark Piehl, pediatric intensivist and founder and CMO of 410 Medical Innovation, about his journey with taking an idea for a medical innovation from concept the entire way to commercial production. Mark is co-inventor of the LifeFlow device and has specific interest in improving resuscitation in pediatric shock, sepsis, and trauma.

Key Points:

Guest: Mark Piehl MD, MPH – Founder and CMO of 410 Medical Innovation, Medical Director WakeMed Mobile Pediatric Critical Care Transport Team, pediatric intensivist at WakeMed in Raleigh, NC

Twitter – @markpiehl

Audio Editor – Kellen Vu

Additional Resources:

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Episode 33: Pediatric Readiness with Stefanie Ames Dec 02, 2020

In this episode of Little Big Med, host Jason Woods talks with Dr. Stefanie Ames about the paper she first-authored titled “Emergency Department Pediatric Readiness and Mortality in Critically Ill Children”.

Key Points

Retrospective study, data from Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project, 2013
Included 20483 patients from 426 hospitals in Florida, Iowa, Massachusetts, Nebraska, and New York
Mortality decreased with increasing readiness score
Adjusted OR also showed that the highest “readiness” hospitals had the lowest mortality in this cohort
Some concern remains that the difference is at least partially related to case definition – ICU admission was included as an inclusion criteria, which may have falsely lowered the overall level of illness of patients admitted to an institution with a PICU. HOWEVER –
- Cases were also followed through time – so patients that were transferred to a hospital with an ICU from a hospital without one had their data linked together.
- In that case the presence or absence of an ICU at the index hospital would not have “counted against” the index hospital, unless that hospital were inappropriately admitting critical ill patients to a general ward instead of transferring to a facility with a PICU
- The authors feel they addressed this by also considering PECARN illness severity scores, most of which were 4 or 5 (most severe illness)
- Most deaths in this cohort occurred in the ED rather than in the ICU/floor, arguing that the ICU admission criteria itself did not drive mortality rates.
Another analysis of this article from EMA exists but comes to a different conclusion about the impact of this article. I’m linking here so you can listen to the differing viewpoints.

Guest

Stefanie Ames, Assistant Professor, Pediatric Critical Care Medicine, University of Utah

Audio Editor – Kellen Vu

References

The post Episode 33: Pediatric Readiness with Stefanie Ames appeared first on Little Big Med.

Episode 32 Part 2 Nov 13, 2020

This is part 2 of a 2 part episode. Please see part 1 for full show notes, guest information, and references.

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Episode 32 Part 1: Pain in the Pediatric ED – an Interprofessional Approach Nov 13, 2020

This is part 1 of a 2 part series. Please be sure to listen to part 2!

In this episode, host Jason Woods speaks with Dr. Daniel Tsze and Child Life Specialist Hilary Woodward about how to approach pain in the pediatric patient. This could be pain from the presenting complaint or from the procedure being performed. The discussion focusses primarily on the non-pharmacologic techniques that have been shown to improve the experience for patients, caregivers, and care providers.

Dan and Hilary are both part of the PECARN (Pediatric Emergency Care Applied Research Network) and this episode is published in partnership with the PECARN Dissemination Working Group.

Guests

Hilary Woodward MS, CCLS -New York-Presbyterian Morgan Stanley Children’s Hospital at Columbia University Medical Center

Daniel Tsze MD, MPH – Associate Professor of Pediatrics (Emergency Medicine), New York-Presbyterian Morgan Stanley Children’s Hospital at Columbia University Medical Center

Show Notes

Techniques – non pharmacologic
1. Environment – Remember that the environment can have a huge impact not he patient! (I.e. colors on the walls, pictures/posters, cartoons). The attitude and approach from the caregivers and clinical providers also contributes.
2. Before procedure
  1. Opportunities for patient to interact (safely) with procedure materials. Can use either (or both) of the techniques below:
    1. Medical play – free play with safe procedure materials, possibly with some child-centered narration as patient manipulates what is provided (i.e. “you’re putting that on the doll’s arm”); helps with desensitization & child-directed understanding (figuring out organically how the materials work) and increases patient’s opportunities for control.
    2. Developmentally appropriate teaching – practice procedure on stuffed animal/doll etc., while explaining what will happen and clarifying patient’s questions/misconceptions as needed. May consider hand-over-hand techniques to give patients some knowledge/experience with sharps (if caregiver consent provided, safety guidelines in place, patient assessed by clinician to be an appropriate candidate developmentally and in regards to temperament)
  2. Explanation of what you are going to do. How much do you tell a child and how does this change based on
    1. Can start with “small spoonfuls” of info, focusing on what the patient’s sensory experience will likely be (i.e. how will it feel, what will they see/smell/taste; “some kids say it’s like _______”). Monitor verbal/non-verbal cues to guide when/if/how to share more
    2. Patient and caregiver input is vital – ask what they would like to know more about, and offer choices of coping techniques (consider needs of self-identified “attenders” vs. “distractors”)
  3. Don’t forget the basis like splinting, ice packs, which also have analgesic effects
  4. Positioning for comfort
    1. Chest to chest in a chair for scalp lacs, procedures on extremities
      1. Parent sitting in a chair works well – make sure that patient’s feet are dangling so that they don’t have leverage to push up
      2. Make sure to brace the extremity you are working with (rest extremity on the bed or on a bedside table, ideally at close to a 90 degree angle)
      3. Consider asking a “helper” to hold head or extremity steady
    2. Patient’s back against parent’s chest for facial lacs, procedures on extremities
      1. Have parent lay on stretcher with their whole body (feet included) on the bed; child lays or sits between parent’s legs, with their bottom on the stretcher (NOT on parent’s lap) – then parent can cross their legs over child’s legs
      2. As with chest-to-chest, make sure to use appropriate bracing and a “helper” as needed for steadying
  5. Do you talk with parents about their role in comforting their child, not showing distress etc?
    1. Strengths-based approach: Reinforce helpful caregiver behaviors, while validating the stress of the situation. “The way you let your child know you will be there for him, and the way you engaged him in telling his favorite story – that was so helpful! It really makes a positive difference when parents show calm and help engage their child. I know you might not be feeling as calm on the inside, but you’re really helping us create a better experience for your son. Thank you!”
    2. If it’s a more challenging scenario, and you are having difficulty identifying a strength, step into the conversation piece by piece. Start with validating: “I can see how upsetting this is for you, and it makes complete sense to feel upset in this situation.” Then read the verbal & non-verbal cues – are you building effective rapport? If so, you might be able to very gently make your big ask (and it can help to label it as such): “I’ve been thinking about how we can help make this experience as smooth as possible for your daughter. I have some ideas, and I know this might be a big ask, but I’m hoping you can help me?” If receptive: “I’m noticing that your daughter seems more tearful & distressed when she sees you get upset. Maybe you could help us distract her? Sometimes, helping distract their child helps parents feel a little better, too.” And when the procedure is over, make sure to validate the parent’s effort and be specific about what went well to both parent & child.
3. During Procedure
  1. Distraction
    1. Both “techy” (iPad, virtual reality) and “non-techy” (toys, games, songs, conversation, deep breathing, etc.)
  2. “Blinder” and other visual barriers
    1. Any specific dos and dont’s with these?
      1. Generally not worthwhile for kids who become more agitated by the blinder/barrier itself (may include toddlers, patients with sensory challengers, patients who are “attenders” and better able to cope/feel in control when they can see everything that is going on). Patient choice & caregiver input are key.
  3. Parent/family presence? Helpful or harmful?
    1. From Hilary – I would say 98% of the time helpful, but it can be important to give parents the choice whether to be present and/or involved. (This discussion might connect well with the point above about whether or not to talk with parents/caregivers about their role in comforting their child.)

References

Additional resources

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Episode 31: Pediatric Drowning – Prevention and Management Sep 15, 2020

In this episode, host Jason Woods speaks with Emma Harding and Laura Bricklin about drowning in children. The discussion covers prevention (specifically parental and patient education) and management, as well as the current terminology and existing data.

This episode is produced in conjunction with Drs. Emma Harding and Laura Bricklin as part of their worth on an AAP CATCH grant.

The following show notes were authored by Drs. Bricklin and Harding and provide a fantastic review.

Take-Home Points

Drowning is the #1 cause of preventable death in children age 1-4
You can’t drown-proof a child – multiple layers of protection help prevent drowning
Providers are a major source of water-safety education for most families

Major Data Points

Drowning claimed the lives of nearly 1,000 children (under 20 years old) in 2017, and an estimated 8,700 children visited a hospital emergency department for a drowning.

Two age groups have the highest risk of drowning – toddlers, and teens. Teens of color are at especially high risk.

The highest rate of drowning is among children under age 4, with children 12 to 36 months of age being at the highest risk.

Most infants drown in bathtubs and buckets.
Most preschool-aged children drown in swimming pools.
CPSC found that 69% of children under 5 who drowned were not expected to be at or near a pool when the drowned.

Teens ages 15-19 years have the second-highest fatal drowning rate. Every year, about 370 children ages 10-19 drown.

Among teens, half of all drownings occur in natural water settings like lakes, rivers or oceans.
Among teens, drowning is due to a variety of factors, but alcohol is often involved.

Layers of Protection

All children and adults should learn to swim. If swim lessons are suspended in your area due to coronavirus, it is important to add other layers of protection until your child can access lessons.

Close, constant, attentive supervision around water is important. Assign an adult ‘water watcher,’ who should not be distracted by work, socializing, or chores.

Around the house, empty all buckets, bathtubs, and wading pools immediately after use. If you have young children, keep the bathroom door closed, and use toilet locks to prevent access.

Pools should be surrounded by a four-sided fence, with a self-closing and self-latching gate. Research shows pool fencing can reduce drowning risk by 50%. Additional barriers can include door locks, window locks, pool covers, and pool alarms.

Adults and older children should learn CPR.

Everyone, children and adults, should wear US Coast Guard-approved life jackets whenever they are in open water, or on watercraft.

Parents and teens should understand how using alcohol and drugs increase the risk of drowning while swimming or boating.

Pathophysiology

Fatal and nonfatal drowning typically begins with a period of panic, loss of the normal breathing pattern, breath-holding, air hunger, and a struggle by the victim to stay above the water.

Reflex inspiratory efforts eventually occur, leading to hypoxemia by means of either aspiration or reflex laryngospasm that occurs when water contacts the lower respiratory tract

Results in decreased lung compliance, ventilation-perfusion mismatching, and intrapulmonary shunting, leading to hypoxemia that causes diffuse organ dysfunction

Management

Prehospital
- Rescue and immediate resuscitation by bystanders improves the outcome of drowning victims

Ventilation is generally considered the most important initial treatment for victims of submersion injury. Rescue breathing should begin as soon as the rescuer reaches shallow water or a stable surface. Note that the priorities of CPR in the drowning victim differ from those in the typical adult cardiac arrest patient, which emphasizes immediate uninterrupted chest compressions. If the patient does not respond to the delivery of two rescue breaths that make the chest rise, the rescuer should immediately begin performing high-quality chest compressions.
- In a large, population-based, observational study using a Japanese government registry, no significant difference in neurologic outcome at one month was found between drowning victims treated initially with compression-only CPR and conventional CPR with rescue breathing

According to the AHA Guidelines for Advanced Cardiac Life Support (ACLS), routine cervical spine immobilization can interfere with essential airway management and is not recommended
- unless there are clinical signs of injury or a concerning mechanism (eg, dive into shallow water)

Pulses may be very weak and difficult to palpate in the hypothermic patient with sinus bradycardia or atrial fibrillation; a careful search for pulses should be performed for at least one minute before initiating chest compressions in the hypothermic patient because these arrhythmias require no immediate treatment.

Attempts at rewarming hypothermic patients with a core temperature <33ºC should be initiated, either by passive or active means as available.
ED
- If tracheal intubation is performed, an orogastric tube should be placed to relieve gastric distension, which occurs from passive passage of fluid and is common in nonfatal drowning patients.

A bedside glucose measurement should be obtained soon upon arrival.

Wet clothing should be removed and rewarming initiated in hypothermic patients.
- Methods include passive and active external rewarming (eg, application of warm blankets, plumbed garments, heating pads, radiant heat, forced warm air), and active internal core rewarming (eg, warmed humidified oxygen via tracheal tube, heated irrigation of peritoneal and pleural cavities).
- In addition, endovascular and several extracorporeal rewarming options are available in some centers.

Possibly because of the neuroprotective effects of hypothermia, complete recovery of some patients with accidental hypothermia and cardiac arrest, despite prolonged resuscitation, has been well documented
- Therefore, prolonged resuscitative efforts may be effective (in rare instances, even if continued for several hours) and should be continued until the patient’s core temperature reaches 32 to 35ºC (90 to 95ºF)

Most non-fatal drowning victims are hospitalized because of the severity of illness or concern for clinical deterioration.
- However, a review of 75 pediatric patients found that all who ultimately developed symptoms did so within seven hours of immersion

Asymptomatic patients should be closely observed for approximately eight hours and admitted if any deterioration occurs.
- If vital signs, pulse oximetry, and all studies, including a chest radiograph obtained close to the end of the observation period, are normal and no clinical deterioration develops during this period, the patient may be discharged with appropriate follow-up.
- Clear verbal and written instructions to return to the emergency department immediately for any respiratory or other problems must be given, and the patient must be accompanied by a responsible adult.

References:

Brenner, R. A., Taneja, G. S., Haynie, D. L., Trumble, A. C., Qian, C., Klinger, R. M., & Klebanoff, M. A. (2009). Association Between Swimming Lessons and Drowning in Childhood. Archives of Pediatrics & Adolescent Medicine, 163(3), 203. doi:10.1001/archpediatrics.2008.563

Causey, A. L., Tilelli, J. A., & Swanson, M. E. (2000). Predicting discharge in uncomplicated near-drowning. The American Journal of Emergency Medicine, 18(1), 9-11. doi:10.1016/s0735-6757(00)90039-1

Chandy, D., MD, & Weinhouse, G. L., MD. (2020). Drowning (submersion injuries). Retrieved August 01, 2020, from https://www.uptodate.com/contents/drowning-submersion-injuries

Denny, S. A., Quan, L., Gilchrist, J., Mccallin, T., Shenoi, R., Yusuf, S., . . . Weiss, J. (2019). Prevention of Drowning. Pediatrics, 143(5). doi:10.1542/peds.2019-0850

Hoek, T. L., Morrison, L. J., Shuster, M., Donnino, M., Sinz, E., Lavonas, E. J., . . . Gabrielli, A. (2010). Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(18_suppl_3). doi:10.1161/circulationaha.110.971069

Lavonas, E. J., Drennan, I. R., Gabrielli, A., Heffner, A. C., Hoyte, C. O., Orkin, A. M., . . . Donnino, M. W. (2015). Part 10: Special Circumstances of Resuscitation. Circulation, 132(18 suppl 2). doi:10.1161/cir.0000000000000264

Pratt, F. D., & Haynes, B. E. (1986). Incidence of “Secondary Drowning” after saltwater submersion. Annals of Emergency Medicine, 15(9), 1084-1087. doi:10.1016/s0196-0644(86)80133-0

Schmidt, A. C., Sempsrott, J. R., Hawkins, S. C., Arastu, A. S., Cushing, T. A., & Auerbach, P. S. (2016). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness & Environmental Medicine, 27(2), 236-251. doi:10.1016/j.wem.2015.12.019

Tobin, J. M., Ramos, W. D., Pu, Y., Wernicki, P. G., Quan, L., & Rossano, J. W. (2017). Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning. Resuscitation, 115, 39-43. doi:10.1016/j.resuscitation.2017.04.004

Venema, A. M., Groothoff, J. W., & Bierens, J. J. (2010). The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation, 81(4), 434-439. doi:10.1016/j.resuscitation.2010.01.005

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Episode 30: Pediatric Stroke – A Primer with Dr. Megan Barry Aug 17, 2020

On this episode, host Jason Woods talks with Dr. Megan Barry, pediatric neurologist and stroke specialist, about pediatric stroke. This episode serves as a primer to pediatric stroke and a foundation for future discussion. We talk about diagnosis and initial management, risk factors, and places that can trip you if you aren’t careful

Of note, since recording, the International Pediatric Stroke Organization has been founded and has a number of great resources.
Guests

Megan Barry, DO. Assistant professor, Pediatric Neurohospitalist, Adult Vascular Neurologist, University of Colorado and Children’s Hospital Colorado

References

Additional Resources

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Episode 29: AHA Pediatric Post Cardiac Arrest Scientific Statement with Alexis Topjian Jul 10, 2020

On this episode, host Jason Woods talks with Alexis Topjian about the 2019 “AHA Pediatric Post–Cardiac Arrest Care Scientific Statement.” Dr. Topjian is the first author on the statement, which is the first pediatric post arrest care statement from the AHA (previously children had primarily been discussed as a special population within a primarily adult guideline). The document itself is long, but contains a large amount of useful information for bedside providers, health care administrators, and researchers.

Guests

Alexis Topjian MD, Associate Professor of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children’s Hospital of Philadelphia

References

Topjian AA, de Caen A, Wainwright MS, et al. Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation. 2019;140(6):e194-e233. doi:10.1161/CIR.0000000000000697

Additional Resources

Previous Little Big Med podcast with Dr. Topjian on post arrest hypotension in children

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Episode 28: Online Professionalism and Social Media in Medicine with Sarah Mojarad – Repost Jul 01, 2020

On this episode, host Jason Woods speaks with Sarah Mojarad, lecturer at USC with appoints in the schools of Medicine and Engineering. Professor Mojarad is an expert in online professionalism, social media use in STEMM (science, technology, engineering, mathematics, medicine), and science communication. This episode is all about how and why social media can be used in medicine (also the how not and why not!), strategies for successful communication to colleagues and patients, and mistakes to avoid.

Sarah has a number of online resources on these topics (listed below) and is a fantastic person to follow on social media. Her insights, topic highlights, and approach are invaluable to any health care practitioner looking to be involved on social media.

Guest

Sarah Mojarad, Lecturer of Engineering Writing, Viterbi School of Engineering and Keck School of Medicine, University of Southern California

Where to find Sarah:

Faculty bio

Twitter – @Sarah_Mojarad

Medium page

YouTube

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Episode 27, Part 1: Gender Equity in Medicine with Nancy Spector May 12, 2020

On this episode, host Jason Woods speaks with Dr. Nancy Spector, Professor of Pediatrics at Drexel University College of Medicine, and Executive Director of the Executive Leadership in Academic Medicine program, about gender equity issues in medicine. Dr. Spector is a frequent speaker on this issue and was the lead author on an article last year outlining the progress, barriers, and opportunities for women in pediatrics (see reference below).

This is part one of a two-part discussion. In part one, Dr. Spector focuses on outlining the scope of the issues and provides strategies for decreasing the equity gap and increasing opportunities for women at all levels of academic medicine.

I want to send out a big thanks to Kellen Vu, who serve as audio producer for this episode!

Guest

Nancy Spector MD, Professor of Pediatrics, Associated Dean for Faculty Development, Drexel University College of Medicine

References

Additional Resources – Things Dr. Spector mentioned for additional information

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Episode 27, Part 2: Cross-gender Mentoring in Medicine with Nancy Spector May 12, 2020

On this episode, host Jason Woods speaks with Dr. Nancy Spector, Professor of Pediatrics at Drexel University College of Medicine, and Executive Director of the Executive Leadership in Academic Medicine program, about gender equity issues in medicine. Dr. Spector is a frequent speaker on this issue and is the lead author on an article published last year outlining the progress, barriers, and opportunities for women in pediatrics (see reference below).

This is part two of a two-part discussion. In part two, Dr. Spector focuses on mentoring across different genders. She provides strategies for successful mentorship, guidance on being a genuine ally without appropriating, and how to help your mentee seek out additional mentorship in areas where you may not have sufficient skill.

I want to send out a big thanks to Kellen Vu, who serve as audio producer for this episode!

Guest

Nancy Spector MD, Professor of Pediatrics, Associated Dean for Faculty Development, Drexel University College of Medicine

References

Additional Resources – Things Dr. Spector mentioned for additional information

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Episode 26: EVALI Mar 09, 2020

On this episode, host Jason Woods speaks with Dr Heather Hoch DeKeyser, pediatric pulmonologist, about EVALI (e-cigarette or vaping product use-associated lung injury). This recently recognized condition has caused numerous people to suffer severe lung disease. We discuss the definition, current approach, remaining mysteries, and potential causes.

All treatment discussed is based on the most recent CDC EVALI guideline at the time of recording – available here

Guest:

Heather Hoch DeKeyser MD – Assistant Professor, Dept. of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado

Additional Resources:

References:

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Episode 25: Sticky Education Feb 03, 2020

On this episode, host Jason Woods speaks with Dr. Janet Corral, medical education expert, about some high yield tips to improve the success of your education! We also discuss the state of medical education as a whole and how to adjust the delivery for the needs of the current learners.

Guests

Janet Corral, Associate Professor, University of Colorado School of Medicine, PhD Educational Technology

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Episode 24: Metabolic Resuscitation for Pediatric Septic Shock Jan 19, 2020

On this episode, host Jason Woods speaks with Dr Nelson Sanchez-Pinto, pediatric intensivist, about an article he co-authored that was just e-published in the last week! The article concerns a retrospective analysis of the use of HAT therapy (hydrocortisone, ascorbic acid, thiamine) at a single center PICU for the treatment of pediatric septic shock. The e-pub link is below and this post will update when it is published in print. This topic has caused significant controversy and strong emotions for the last several years, and I expect that to continue. Please take a look at the additional resources below, as well as Dr. Sanchez-Pinto’s twitter feed (@nelsonspinto), for even more information.

E-publication link: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1543LE

The highlights:

Study details
- Single center, retrospective, propensity score matched
- 557 septic shock patients in the PICU
- 43 received HAT, 181 hydrocortisone alone, 333 neither
- HAT patients matched 1:1 with the other groups
Results
- HAT patients had lower mortality at 30-days (9 vs 28%, P=0.03) and 90-days (14 vs 37%, P=0.01) compared to no HAT or hydrocortisone
- Similar results comparing mortality in HAT to those with hydrocortisone alone – 30-day (9 vs 30%, p=0.01) and 90 day (14 vs 37%, p=0.01)
- No difference at 30 days in vasoactive free days or hospital free days

Guests

Nelson Sanchez-Pinto MD, Assistant Professor of Pediatrics and Preventative Medicine, Northwestern University, Feinburg School of Medicine

Pediatric Intensivist, Anne and Robert H. Lurie Children’s Hospital of Chicago

References

1. Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238.

2. Wilson JX. Mechanism of action of vitamin C in sepsis: ascorbate modulates redox signaling in endothelium. Biofactors. 2009;35(1):5-13.

3. Fowler AA, 3rd, Syed AA, Knowlson S, Sculthorpe R, Farthing D, DeWilde C, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.

4. Spoelstra-de Man AME, Elbers PWG, Oudemans-van Straaten HM. Making sense of early high-dose intravenous vitamin C in ischemia/reperfusion injury. Crit Care. 2018;22(1):70.

5. Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.

6. Wald EL, Sanchez-Pinto LN, Smith CM, Moran T, Badke CM, Barhight MF, Malakooti MR. Hydrocortisone-Ascorbic Acid-Thiamine Use Associated with Lower Mortality in Pediatric Septic Shock. Am Journal Respr and Crit Care Med. E-pub ahead of print. PMID: 31916841. DOI: https://doi.org/10.1164/rccm.201908-1543LE

7. Fowler AA, Trust JD, Hite RD. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure – The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322(13):1261-1270. doi:10.1011/jama.2019.11825

Additional Resources

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Episode 23: Nephritis Dec 02, 2019

What is it and why are there so many names?

On this episode, host Jason Woods speaks with Dr. Danielle Soranno, pediatric nephrologist, about nephritis in children. What is it, why are the terms so confusing, how do we diagnosis it, and when should we involve a nephrologist? Did the nephrologists invent terminology just to confuse us?

Guests

Danielle Soranno MD, Assistant Professor, Pediatrics, Bioengineering & Medicine
University of Colorado and Children’s Hospital Colorado

References

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Episode 22: Risk Factors for Bronchiolitis Care Escalation Nov 12, 2019

On this episode, host Jason Woods speaks with Dr. Gabrielle Freire about her work with PERN (Pediatric Emergency Research Network) and evaluation of predictive risk factors for escalation of care in bronchiolitis.

THE BOTTOM LINE:

Multiple risk factors were found that predicted escalated care in infants. Infants aged < 12 months old with bronchiolitis but without predictors have a low risk of receiving escalated care (<1%) and may be candidates for outpatient management. Infants with increasing numbers of predictors are at a increasing risk of requiring escalated care and need consideration for in patient care with expertise in paediatric airway support.

The highlights:

Background
- Bronchiolitis is responsible for ~ 16% of all hospitalizations in the first year of life
- The cost incurred from bronchiolitis admissions is thought to be ~ $1.78 billion every year in the US and Canada
Study methods
- Retrospective cohort study of a previously collected database of infants aged < 12 months with clinical diagnosis of bronchiolitis
- Inclusion
  - Bronchiolitis defined as viral respiratory infection with respiratory distress
  - Age 12 months or younger
  - Visits from Jan – Dec 2013 collected as part of PERN
  - First episode of bronchiolitis only
- Exclusion
  - Comorbidities such as chronic lung disease, congenital heart disease, immunodeficiency, renal or liver insufficiency, neuromuscular disorders
  - Prior episode of diagnosed bronchiolitis
Results
- 2722 patients included
- 261 (9.6%) required escalated care
- Predictors included in the final model
  - O2 sats < 90 (OR 8.9)
  - Nasal flaring/grunting (OR 3.76)
  - Apnea (OR 3.01)
  - Retractions (OR 3.02)
  - Age < 2 months (OR 2.1)
  - Concomitant dehydration (OR 2.13)
  - Poor feeding (OR 1.85)
Discussion points (detailed in the audio)
- Respiratory rate and retractions were co-linear, so RR was not included in the final model
- The risk score “points” were assigned by diving the OR by 2 to give a total score of 14
- Duration of illness was not found to be a significant predictor – this may be due to the lack of granularity of the data (only available in days rather than hours)
- Oxygen saturation had the highest OR by a substantial margin

Guests

Gabrielle Freire MD, Paediatric Emergency Physician, The Hospital for Sick Children, Department of Paediatrics University of Toronto, Toronto, Ontario, CA.

Important Resources

PERN website

References

Freire G et. al. for the Pediatric Emergency Research Networks (PERN). Predicting Escalated CAre in Infants with Bronchiolitis. Pediatrics. 2018 Sept 142;3. PMID: 30126934.

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Little Big Little: What is Vaping? Oct 16, 2019

This is the first segment in a series of “shorts” – smaller quick hit episodes on a focused topic. I’m going to affectionately call them “Little Big Littles”.

On this Little Big Little, host Jason Woods speaks with Dr. Heather Hoch about what we might need to know about vaping to take care of our patients.

Guests

Heather Hoch MD – Assistant Professor, Dept. of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado

Important Resources

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Episode 21: HIV Screening in the Pediatric ED Aug 19, 2019

On this episode, host Jason Woods speaks with Dr. Amy Grover about HIV screening in the pediatric emergency department. Dr. Grover works in both the section of emergency medicine and hospital medicine and has an interest in HIV screening.

The highlights:

An estimated 50% of adolescents with HIV do not know they have contracted HIV
Acute retroviral syndrome has many non specific symptoms and can be difficult to diagnosis but includes the following
- Fever
- Fatigue
- Myalgias
- Nausea, vomiting, and/or diarrhea
- Rash that can involve the hands and feed
- Pharyngitis is typically not as exudative as EBV
CDC guidelines recommend that EVERY person ages 13-64 who is sexually active be screened for HIV at least once in their lives, and yearly if ongoing risk for exposure
One of the difficult aspects of setting up a screening program is deciding who is responsible for follow up of the results. Each institution will have to discuss what is appropriate for their setting
Do not forget to evaluate for risk of other STI, including Syphilis (prevalence is rising in the US)
Most rapid screening tests that do not use whole blood can not detect HIV infection until there is an antibody response (3 weeks – 3 months)
The 4th generation HIV test can detect infection starting as early as 15 days after infection. Note that there is still a latent period when detection is not possible.
One of the important reasons to screen patients is that there is evidence that knowledge of HIV infection decreases high-risk behavior.
The benefit and effect of HIV screening may depend on the regional HIV rates

Guests

Amy Grover MD – University of Colorado School of Medicine, Sections of Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado

Important Resources

CDC HIV Resource Library

References

The post Episode 21: HIV Screening in the Pediatric ED appeared first on Little Big Med.

Episode 20: HIV Pre-exposure Prophylaxis (PrEP) Jul 16, 2019

On this episode, host Jason Woods speaks with Martin Walker (Director of HIV Programs for Planned Parenthood of the Rocky Mountains) and Moises Munoz (Prevention Services Manager Children’s Hospital Immunodeficiency Program, Children’s Hospital Colorado) about pre-exposure prophylaxis for HIV (PrEP).

The highlights:

The only FDA approved PrEP regimen the combination product of emtricitabine/tenofovir (brand name Truvada)
It was approved in 2012 for PrEP
Typical dosing is one pill (200/300) once per day, for patients > 35 kg (regardless of age)
Prior to the start of PrEP, counseling and labs are suggested
- Labs required before the start of PrEP include baseline creatinine and UA, negative studies for HIV and Hepatitis, pregnancy if applicable, and other STIs (all of these are included in ongoing monitoring as well)
- Counseling should include discussion of risk factors, compliance, required testing, need for continued protection from other STIs
- Generally not recommended to use in patients with GFR < 60
From the start of use, different tissues require different amounts of time to reach effective concentrations. There is not clear data on this but Martin suggests 7 days for receptive anal intercourse and 21 days for receptive vaginal intercourse.
Some studies suggest that for penile-anal intercourse, as few as 4 doses per week may be effective.
See below for training resources

Guests

Martin Walker – Director of HIV Programs for Planned Parenthood of the Rocky Mountains

Moises Munoz – Prevention Services Manager Children’s Hospital Immunodeficiency Program, Children’s Hospital Colorado

Important Resources

References

Hosek S, Rudy B, Landovitz R, et. al. “An HIV Pre-Exposure Prophylaxis (PrEP) Demonstration Project and Safety Study for Young MSM”. J Acquir Immune Defic Syndr. 2017 Jan 1; 74(1): 21–29. PMID: 27632233
Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis 2014; 14:820. PMID: 25065857.
Krakower DS, Mayer KH. Pre-exposure prophylaxis to prevent HIV infection: current status, future opportunities and challenges. Drugs 2015; 75:243. PMID: 25673022.
Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med 2012; 4:151. PMID: 22972843.
Seifert SM, Glidden DV, Meditz AL, et al. Dose response for starting and stopping HIV preexposure prophylaxis for men who have sex with men. Clin Infect Dis 2015; 60:804. PMID: 25409469
Anderson PL, Meditz A, Zheng JH. Cellular pharmacology of TFV and FTC in blood, rectal, and cervical cells from HIV- volunteers. Presented at the Conference on Retroviruses and Opportunistic Infections 2012.

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**Episode 19: In-flight Emergencies** May 02, 2019

On this episode, host Jason Woods speaks with Dr. TJ Doyle, medical director of the communicaton center at the University of Pittsburgh Medical Center (UPMC) and medical director for STAT-MD, a ground based consulting group for airlines. The discussions encompasses that frequency and types of in-flight medical emergencies (IME), what is in the medical kit on airplanes, what resources are available in-flight, and the legal ramifications for medical vounteers.

The highlights:

Worldwide ~ 2.75 billion persons fly annually.
IME occur in roughly 1 per 604 US flights, or 24-130 IME per 1 million passengers.
69% had EMS requested, 25% transported to hospital, 8.6% admitted, 0.3% died.
Aircrafts divert in about 4$ of IME
Airplane cabins are pressurized to between 5000 and 8000 ft altitude
Minimum equipment in the US (see graphic)

AED
Hemorrhage control
IV line
Gloves
Medications to treat “basic conditions”
Pain
Allergic reactions
Bronchoconstriction
Hypoglycemia
Dehydration
“Some” cardiac conditions
Equipment for initial assessment
Most common IME
Syncope or near 32.7%
GI 14.8%
Resp 10.1%
CV 7.0 %
Medical volunteer role
Individual airline policies may have different guidance
Not generally required to carry proof of medical license
Primary role is to gather info, provide assessment, and communicate with ground support. May need to admin medicines or perform procedures but direction of care is by ground medical.
Legal and ethical issues
US Aviation Medical Assistance Act
Protects passengers who provide medical assistance from liability except in cases of negligence or willful misconduct.
Medical volunteers who seek compensation for this service may jeopardize their protections under this law, though now lawsuit of such has been filed
Duty to respond
In US, Canada, England, Singapore, no legal duty
In Australia, many European countries, physicians are required to render assistance.
Other countries may have different protections or no protections at all

**Guests**

Thomas J. Doyle, Clinical Assistant Professor of Emergency Medicine, University of Pittsburgh Medical Center; Associate Medical Director, STAT MedEvac; Medical Director, Command Center, STAT-MD.

**References**

Christian Martin-Gill, MD, MPH; Thomas J. Doyle, MD, MPH; Donald M. Yealy, MD. In-Flight Medical Emergencies: A Review. JAMA. 2018;320(24):2580-2590. doi:10.1001/jama.2018.19842
Peterson DC, Martin-Gill C, Guyette FX, et all. Outcomes of Medical Emergencies on Commercial Airline Flights. NEJM. 2013:368(22):2075-2083. doi:10.1056/NEJMoa1212052

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Episode 18b: Anti-trafficking and the role of the ED Mar 18, 2019

On this episode, host Jason Woods speaks with Dr. Makini Chisolm-Straker, an ED physician in New York who is also a founder of HEAL Trafficking, an organization that works to fight human traffickingi n all forms. This is part 2 of a 2 part discussion. The highlights:

Definition of trafficking
1. recruitment, harboring, transportation, provision, and/or obtaining of a person
2. By the use of force, fraud, and/or coercion
3. For purposes of labor and/or sexual exploitation
Numbers and general info
1. Overall labor trafficking is most common
2. Under age 18 “survival” sex considered victim of trafficking
3. US reports 15-50k brought to US each year for trafficking, but tn 2014, US DOS reported 21,000 calls to its trafficking hotline, so it is likely far under-reported in the official numbers.
4. On a 2016 survey of victims of trafficking, 55% had seen an ED/UC while trafficked
There is no comprehensive trafficking screening tool in existence
1. The Greenbaum tool is only for use in english speaking patients ages 13-17 and evaluates for risk of sex trafficking
Quotes from Makini’s published work that I loved
1. It is important NOT to employ the Greenbaum Tool until the clinician has had a frank conversation about mandated reporting with the patient. Too often clinicians envision trafficking as a crime from which which victims must be rescued or saved. That is not our job. And it does not work. Victims that are unwillingly rescued often end up back in exploitation circumstances. Many young people in trafficking situations do not identify as victims and some feel a strong sense of agency: others expect to be criminalized by authority figures because that has been their experience.
2. We must apply the principles learned from because of IPV work. Survivors know more about their situation and needs than we do. Our rescue actions, intended with love, often have untoward unintended consequences for those we seek to serve.

Guests

Makini Chisolm-Straker MD, Assistant Professor of Emergendy Medicine, Mount Sinai Health System

Other Resources

HEAL Trafficking
Training for providers that Dr. Chisolm-Straker mentioned
Human trafficking hotline:
1. Phone: 1-888-373-7888
2. SMS:233733 text HELP or INFO
3. Humantraffickinghotline.org
HumantraffickingED.com

References

1. Greenbaum VJ, Livings MS, Lai BS et al. Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings. Journal of Adolescent Health 2018;63(6):745–52.

2. Greenbaum VJ, Dodd M, McCracken C. A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting. Pediatric Emergency Care 2018;34(1):33–7.

3. Chisolm Straker M, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. Journal of Health Care for the Poor and Underserved 2016;27(3):1220–33.

4. Shandro J, Chilsom-Straker M, Duber HC et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. YMEM 2016;68(4):501–1.

5. Chisolm Straker M. Measured steps: evidence‐based anti‐trafficking efforts in the E.D. Acad Emerg Med 2018. doi: 10.1111/acem.13552

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Episode 18a: Anti-trafficking and the role of the ED Mar 18, 2019

On this episode, host Jason Woods speaks with Dr. Makini Chisolm-Straker, an ED physician in New York who is also a founder of HEAL Trafficking, an organization that works to fight human traffickingi n all forms. This is part 1 of a 2 part discussion. The highlights:

Definition of trafficking
1. recruitment, harboring, transportation, provision, and/or obtaining of a person
2. By the use of force, fraud, and/or coercion
3. For purposes of labor and/or sexual exploitation
Numbers and general info
1. Overall labor trafficking is most common
2. Under age 18 “survival” sex considered victim of trafficking
3. US reports 15-50k brought to US each year for trafficking, but tn 2014, US DOS reported 21,000 calls to its trafficking hotline, so it is likely far under-reported in the official numbers.
4. On a 2016 survey of victims of trafficking, 55% had seen an ED/UC while trafficked
There is no comprehensive trafficking screening tool in existence
1. The Greenbaum tool is only for use in english speaking patients ages 13-17 and evaluates for risk of sex trafficking
Quotes from Makini’s published work that I loved
1. It is important NOT to employ the Greenbaum Tool until the clinician has had a frank conversation about mandated reporting with the patient. Too often clinicians envision trafficking as a crime from which which victims must be rescued or saved. That is not our job. And it does not work. Victims that are unwillingly rescued often end up back in exploitation circumstances. Many young people in trafficking situations do not identify as victims and some feel a strong sense of agency: others expect to be criminalized by authority figures because that has been their experience.
2. We must apply the principles learned from because of IPV work. Survivors know more about their situation and needs than we do. Our rescue actions, intended with love, often have untoward unintended consequences for those we seek to serve.

Guests

Makini Chisolm-Straker MD, Assistant Professor of Emergendy Medicine, Mount Sinai Health System

Other Resources

HEAL Trafficking
Training for providers that Dr. Chisolm-Straker mentioned
Human trafficking hotline:
1. Phone: 1-888-373-7888
2. SMS:233733 text HELP or INFO
3. Humantraffickinghotline.org
HumantraffickingED.com

References

1. Greenbaum VJ, Livings MS, Lai BS et al. Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings. Journal of Adolescent Health 2018;63(6):745–52.

2. Greenbaum VJ, Dodd M, McCracken C. A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting. Pediatric Emergency Care 2018;34(1):33–7.

3. Chisolm Straker M, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. Journal of Health Care for the Poor and Underserved 2016;27(3):1220–33.

4. Shandro J, Chilsom-Straker M, Duber HC et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. YMEM 2016;68(4):501–1.

5. Chisolm Straker M. Measured steps: evidence‐based anti‐trafficking efforts in the E.D. Acad Emerg Med 2018. doi: 10.1111/acem.13552

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Episode 17: Teeny Weeny Problems – Pediatric Urology Feb 04, 2019

On this episode, host Jason Woods speaks with Dr. Tanya Davis, pediatric urologist and all around superstar, about common pediatric urology problems that present to the emergency department. The highlights:

Testicular torsion is an emergency, and ultrasound should be performed when this is suspected. If the symptoms are highly suggestive call urology even with a normal ultrasound
It is suggested that urology is contacted before performing any repair of a laceration that is more than superficial.
Pediatric patients that develop epididymitis in the absence of sexual activity should be referred to urology, as this is unusual and may indicate an anatomic abnormality.
Dr. Davis feels that any patient with complex urogenital anatomy, indwelling catheters, or a surgically created catheterizable tract should NOT have antibiotics started for UTI without contacting their primary urologist.

Guests

Tanya Davis MD, Clinical Instructor, Department of Urology, Children’s National Health System

Pediatric Urologist, Mid-Atlantic Permanente Medical Group

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Episode 16: Transgender Health Care Dec 31, 2018

First, apologies for the delay in this episode! We’ve got a 2-month-old at home and it turns out, those little amazing terrorists take a lot of time!

On this episode, host Jason Woods speaks to Dr. Natalie Nokoff, a pediatric endocrinologist who works with transgender patients. The discussion centers on the health care needs of these patients, preferred language, safety, and how to approach the discussion of gender in our population.

Important Links

References

Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet 2016; 388:401.
Turban J, Ferraiolo T, Martin A, Olezeski C. Ten Things Transgender and Gender Nonconforming Youth Want Their Doctors to Know. J Am Acad Child Adolesc Psychiatry 2017; 56:275.
Olson-Kennedy J and Forcier M. Management of transgender and gender-diverse children and adolescents. UpToDate. Last Update Nov 2018. Accessed Nov 2018.
Olson-Kennedy J and Forcier M. Gender development and clinical presentation of gender diversity in children and adolescents. Last Update Nov 2018. Accessed Nov 2018.

Guests

Natalie Nokoff MD, Assistant Professor of Pediatrics, Section of Endocrinology, Children’s Hospital Colorado and the University of Colorado

The post Episode 16: Transgender Health Care appeared first on Little Big Med.

Episode 15b: Specific Renal Issues Nov 08, 2018

This is part 2 of a discussion with Dr. Danielle Soranno, on specific renal issues in the ED. She discusses hyperkalemia, end-stage renal disease, and HUS among others. If you haven’t listened to Part 1 yet, got back an episode in the feed.

Guests

Danielle Soranno MD, Assistant Professor, Pediatrics, Bioengineering & Medicine
University of Colorado and Children’s Hospital Colorado

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Episode 15a: Nephrology Overview with Danielle Sorrano Nov 05, 2018

On this episode, host Jason Woods tries to tackle all things renal. This is part 1 of a discussion with Dr. Danielle Soranno, who gives an overview of how she approaches the kidney and what things we need to know in general. She talks about common renal issues in the emergency department and what information she wants to hear when called for a consult

Part 2 will post later this week and digs into some specific illnesses such as HUS, hyperkalemia, and end-stage renal disease.

Guests

Danielle Soranno MD, Assistant Professor, Pediatrics, Bioengineering & Medicine
University of Colorado and Children’s Hospital Colorado

Important Information

Fab Four – FABU
1. Function
2. Anatomy
3. Blood Pressure
4. Urine

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Episode 14: UTICalc with Nader Shaikh Sep 05, 2018

On this episode, host Jason Woods speaks to Dr. Nader Shaikh about his recent paper on the development of a calculator (UTICalc) to estimate the probability of UTI in pediatric patients. The calculator itself is fantastic and easy to use (see link below) but the discussion centers on the methods behind the calculator. We dig into how these calculators are developed, how to determine if they are accurate/useful, and how to use them in clinical practice.

Important Links

UTI Calculator link – UTICalc
AAP UTI Guidelines, 2016 Reaffirmation of 2011 Guidelines
AAP 2011 UTI Guidelines Update

References

Shaikh N et al. “Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children”. JAMA Pediatr. 2018 Jun 1;172(6):550-556. doi: 10.1001/jamapediatrics.2018.0217.
Roberts KB; Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610.Lavelle JM, Blackstone MM, Funari MK, et al. Two-step process for ED UTI screening in febrile young children: reducing catheterization rates. Pediatrics. 2016;138(1):e20153023.
Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27(4):302-308.
Hoberman A, Wald ER, Reynolds EA, Penchansky L, Charron M. Pyuria and bacteriuria in urine specimens obtained by catheter from young children with fever. J Pediatr. 1994;124(4):513-519.
Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in febrile infants. J Pediatr. 1993;123(1):17-23.

Guests

Nader Shaikh MD, Associate Professor, General Academic Pediatrics, Children’s Hospital of Pittsburgh

The post Episode 14: UTICalc with Nader Shaikh appeared first on Little Big Med.

Episode 13: Adolescent Sexual Health and Education Aug 14, 2018

On this episode, host Jason Woods speaks to Daniela Fellman and Alison Macklin, leaders from the Responsible Sex Education Institute, about a topic that can sometimes be difficult for patients, parents, and care providers…sex! Sexual and reproductive health education is hugely important and frequently politicized. Both interviewees are leading the way when it comes to education and outreach programs in the field of sex education. We talk about a variety of resources which are listed below, as well as get a sneak peek at two books which are being published soon.

Important Links

Responsible Sex Education Institute
ICYC Instagram
ICYC – In Case You’re Curious
Making Sense of “It” by Alison Macklin (available for pre-order now!)

Additional Resources

Guests

Alison Macklin – Vice President of Education and Innovation, Responsive Sex Education, Planned Parenthood of the Rocky Mountains

Daniela Fellman – Program Manager of Texting Initiatives, Planned Parenthood of the Rocky Mountains

The post Episode 13: Adolescent Sexual Health and Education appeared first on Little Big Med.

Episode 12: High Altitude Illness with Elaine Reno Jul 17, 2018

On this episode, host Jason Woods speaks with Dr. Elaine Reno, an emergency medicine physician who is also a wilderness medicine expert, about high altitude illness in pediatrics. We focus on risk factors, identification of illness, and recommendations for initial treatment.

Important points

Significant altitude illness is rare below 8000 feet
Pre-verbal children DO experience high altitude illness but can be more difficult to diagnose given the difficulty in communication.
Dr. Reno strongly prefers slow acclimatization for children, rather than prophylactic medication.

Point of Care Resources

Guests

Elaine Reno MD – Assistant Professor of Emergency Medicine, University of Colorado School of Medicine, Department of Emergency Medicine, Section of Wilderness and Environmental Medicine

The post Episode 12: High Altitude Illness with Elaine Reno appeared first on Little Big Med.

Episode 11b: Acute Illness and Known Metabolic Disease with Austin Larson Jun 07, 2018

On this episode, host Jason Woods speaks with Dr. Austin Larson, a specialist in pediatric inherited metabolic disorders (and also someone way smarter than I), about what do do with the crashing neonate if there are concerns for a metabolic disorder. We review the diagnostic approach, emergent treatment, and what resources are available to read/consult in this situation.

Important points

Most children with known inherited metabolic disorder will have a letter with them, from their metabolic doc, about what to do if they show up to the with a new illness. If they do not, then the New England Consortium website is a great resource.
Most protocols recommend starting D10 fluids at 1.5 x maintenance is generally the recommendation, unless there is a reason why glucose/fluids will otherwise harm the patient.
Be careful with patients who are on a ketogenic diet as treatment for their seizures, as giving them glucose can cause refractory status epilepticus. In those patients, the preferred calorie support would be lipids.

Point of Care Resources

New England Consortium for treatment protocols
Vademecum Metabolicum handbook in book form
App version of Vademecum Metabolicum – eVM

Guests

Austin Larson, MD – Assistant Professor of Pediatrics and Metabolic and Clinical Genetics, University of Colorado School of Medicine and Children’s Hospital Colorado

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Episode 11a: Crashing Neonate and Metabolic Disorders with Austin Larson Jun 07, 2018

On this episode, host Jason Woods speaks with Dr. Austin Larson, a specialist in pediatric inherited metabolic disorders (and also someone way smarter than I), about what do do with the crashing neonate if there are concerns for a metabolic disorder. We review the diagnostic approach, emergent treatment, and what resources are available to read/consult in this situation.

Important points

If an ill neonate presents and there is any concern for inherited metabolic disorder, starting D10 fluids at 1.5 x maintenance is generally the recommendation, unless there is a reason why glucose/fluids will otherwise harm the patient.
If there are concerns for inherited metabolic disorder, in addition to glucose, checking ketones (urine or serum, though serum preferred), ammonia, and lactate can be very helpful.
If the ammonia level is >200 micromols/L and rising, dialysis will likely be needed and you need to start making plans for this.
Neonates generally can not generate a significant ketosis, even if fasting or ill, without an inherited metabolic disorder.
Other labs to consider obtaining in an ill child with hypoglycemia or concern for metabolic disorder
1. Cortisol
2. Serum Amino Acids
3. Urine Organic Acids
4. Serum ketones
5. Free fatty acids
6. Growth Hormone
7. Insulin
8. Acylcarnitine profile

Point of Care Resources

New England Consortium for treatment protocols
Vademecum Metabolicum handbook in book form
App version of Vademecum Metabolicum – eVM

Guests

Austin Larson, MD – Assistant Professor of Pediatrics and Metabolic and Clinical Genetics, University of Colorado School of Medicine and Children’s Hospital Colorado

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Episode 10: Post-resuscitation Hypotension After Cardiac Arrest with Alexis Topjian May 04, 2018

On this episode we discuss the rates and risks of post-resuscitation hypotension after cardiac arrest. Host Jason Woods MD talks with Dr. Alexis Topjian, a critical care doc from Children’s Hospital of Philadelphia with special interests in neuro-critical care and post-arrest care, about her recent article on post arrest hypotension. This article was published in JAMA in 2018 (see references below) and evaluated outcomes based on presence of hypotension, and hypotensive burden, after out-of-hospital cardiac.

Guests

Alexis Topjian MD, Associate Professor of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children’s Hospital of Philadelphia

References

Topjian AA, Telford R, Holubkov R, et al. Association of Early Postresuscitation Hypotension With Survival to Discharge After Targeted Temperature Management for Pediatric Out-of-Hospital Cardiac Arrest. JAMA Pediatr. 2018;172(2):143–11. doi:10.1001/jamapediatrics.2017.4043.
Topjian AA, French B, Sutton RM, et al. Early Postresuscitation Hypotension Is Associated With Increased Mortality Following Pediatric Cardiac Arrest*. Critical Care Medicine. 2014;42(6):1518-1523. doi:10.1097/CCM.0000000000000216.
Bhanji F, Topjian AA, Nadkarni VM, et al. Survival Rates Following Pediatric In-Hospital Cardiac Arrests During Nights and Weekends. JAMA Pediatr. 2017;171(1):39–7. doi:10.1001/jamapediatrics.2016.2535.
Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children. N Engl J Med. 2017;376(4):318-329. doi:10.1056/NEJMoa1610493.

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Episode 9: Suicide Prevention and Firearms Apr 25, 2018

The last in our current series on firearm violence looks at suicide prevention and the relation of firearms to suicide. Host Jason Woods MD talks with Dr. Emmy Betz, a researcher in suicide prevention, about what is currently know, strategies for harm reduction, and her efforts as the co-founder of the Colorado Coalition for Firearm Safety, which works to bring the medical community together with firearm owners, gun shops, and shooting ranges to improve safety.

Guests

Emmy Betz MD, MPH – Assistant Professor, Department of Emergency Medicine, University of Colorado School of Medicine.

Resources

National Suicide Prevention Lifeline – 1-800-273-8255
Dr. Betz’s TED Talk
Colorado Firearm Safety Coalition
Giffords Law Center – access state by state listing of firearm laws
Joint program between the American Society for Suicide Prevention and the National Shooting Sports Foundation

References

Betz ME, Kautzman M, Segal DL, et al. Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen. Psychiatry Research 2018;260:30–5.
Betz ME, Wintersteen M, emergency EBAO, 2016. Reducing suicide risk: challenges and opportunities in the emergency department. annemergmedcom
Pierpoint LA, Tung GJ, Brooks-Russell A, Brandspigel S, Betz M, Runyan CW. Gun retailers as storage partners for suicide prevention: what barriers need to be overcome? Inj Prev 2018;:injuryprev–2017–042700–5.
McCourt AD, Vernick JS, Betz ME, Brandspigel S, Runyan CW. Temporary Transfer of Firearms From the Home to Prevent Suicide. JAMA Intern Med 2017;177(1):96–6.
Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med 2016;165(3):205–10.

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Episode 8: Firearm and Youth Violence in Canada Mar 19, 2018

We continue our look at firearm and violent injury in the youth population by examing the issue outside of the United States. Host Jason Woods MD gathered Canadian physicians Carolyn Snider and Natasha Saunders, both researchers on violent injury (and specifically firearm-related injury), to discuss the scope of violent youth injury in Canada, ED-based intervention programs, risk factors, and the rising rates of injury due to air guns and BB guns.

Guests

Carolyn Snider MD, MPH – Associate Professor, Department of Emergency Medicine, University of Toronto, Staff Physician Winnipeg Health Sciences Center, founder of the Emergency Department Violent Injury Prevention program (EDVIP)

Natasha Saunders MD – Assitant Professor Department of Pediatrics University of Toronto, Staff Physician Hospital for Sick Children, Adjunct Scientist Institute for Clinical Evaluative Sciences

Resources

National Network of Hospital-based Violence Intervention Programs – http://nnhvip.org/

Saunders NR, Lee H, Macpherson A, Guan J, Guttmann A. Risk of firearm injuries among children and youth of immigrant families. CMAJ. 2017;189(12):E452-E458.
Snider CE, Ovens H, Drummond A, Kapur AK. CAEP Position Statement on Gun Control. Canadian Journal of Emergency Medicine. 2009;11(1):64-72
Snider CE, Brownell M, Dufault B, Barrett N, Prior H, Cochrane C. A multilevel analysis of risk and protective factors for Canadian youth injured or killed by interpersonal violence. Inj Prev. July 2017:injuryprev–2016–042235–7
Snider C, Woodward H, Mordoch E, et al. Development of an Emergency Department Violence Intervention Program for Youth: An Integrated Knowledge Translation Approach. Progress in Community Health Partnerships. 2016;10(2):285-291

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Episode 7: Reframing how we think about firearm violence Mar 01, 2018

Violent injury, particularly related to firearms, has been at the forefront of national discussion recently. Pediatric victims and survivors have begun to enter into the public discussion via a strong social media presence, and as clinicians who treat these patients’ injuries, we are also obligated to participate in prevention. This is the first in a series of episodes to address what we know about firearm violence, what interventions have been tried, and how we can reframe the discussion to focus less on political beliefs and more on harm reduction.

Host Jason Woods MD gathered national firearm violence experts Megan Ranney MD MPH, Patrick Carter MD, and Stephen Hargarten MD MPH to introduce where the research, policy, and political climate sits currently and to give some ideas on how to think and speak about this issue with patients and families.

Guests

Megan Ranney MD MPH- Associate Professor of Emergency Medicine at Brown University, violence prevention researcher, past chair of ACEP Trauma and Injury Prevention Section
Stephen Hargarten MD MPH – Professor and chair of Emergency Medicine of Medical College of Wiscone, Director of MCW Comprehensive Injury Center
Patrick Carter MD – Assistant Professor of Emergency medicine, and Assistant Director of the Injury Prevention Center at the University of Michigan

Resources

Videos from University of Michigan “Open Michigan” site on how to talk to patients and families about firearms

Articles

McCourt AD, Vernick JS, Betz ME, Brandspigel S, Runyan CW. Temporary Transfer of Firearms From the Home to Prevent Suicide. JAMA Intern Med 2017;177(1):96–6.
Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med 2016;165(3):205–10.
MPH MLRM, MD JF, MPH HAM, et al. A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research. YMEM 2017;69(2):227–40.
Parikh K, Silver A, Patel SJ, Iqbal SF, Goyal M. Pediatric Firearm-Related Injuries in the United States. Hospital Pediatrics 2017;:hpeds.2016–0146–12.
Hargarten S. Firearm Injury in the United States: Effective Management Must Address Biophysical and Biopsychosocial Factors. Ann Intern Med 2016;165(12):882–2.
Carter PM, Cook LJ, Macy ML, et al. Individual and Neighborhood Characteristics of Children Seeking Emergency Department Care for Firearm Injuries Within the PECARN Network. Acad Emerg Med 2017;24(7):803–13.
Goldstick JE, Carter PM, Walton MA, et al. Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk. Ann Intern Med 2017;166(10):707–15.
Carter PM, Walton MA, Goldstick J, et al. Violent firearm-related conflicts among high-risk youth: An event-level and daily calendar analysis. Preventive Medicine 2017;102(C):112–9.

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Episode 6: What is the ED role in Child Abuse Evaluation and Documentation? Jan 31, 2018

Host Jason Woods MD chats with Dan Lindberg MD, national expert in Child Abuse evaluation, on what role the ED plays in the evaluation of child abuse, and addresses the things that scare the ED doc the most. How do I avoid going to court? What and how should I document? What can I do so that I don’t screw up the case for the lawyers?

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Episode 5: Establishing an Education Brand with Brad Sobolewski Jan 11, 2018

Host Jason Woods MD chats with Brad Sobolewski MD, on how he established his own brand as a medical educator, with advice for new medical educators just starting on this path.

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Episode 4: Youth Concussions with Joe Grubenhoff Nov 21, 2017

Host Jason Woods MD chats with Joe Grubenhoff MD, on what role the ED plays in concussion evaluation, the updated concussion guidelines, and where the pendulum will come to rest on rest versus activity in the post-concussion time period.

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Episode 3: Leaving the ED with an Oxygen Tank – Bronchiolitis with Lalit Bajaj Oct 25, 2017

Host Jason Woods MD talks with Lalit Bajaj MD on the use of home oxygen dispensed from the emergency room in the treatment of bronchiolitis. Dr. Bajaj is an emergency medicine physician at the University of Colorado and Children’s Hospital Colorado and was one of the early participants in their home oxygen protocol initiation and evaluation.

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Episode 2b: Guidelines Update for Pediatric Sepsis Oct 09, 2017

Hot on the heels of our previous recording, new guidelines were published on the care of pediatric sepsis by the American College of Critical Care Medicine/Society of Critical Care Medicine. Host Jason Woods MD and Halden Scott MD evaluate how these new guidelines change our previous discussion on the use of lactate measurement in the treatment of pediatric sepsis in the emergency department.

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Episode 2a: Lactate in Pediatric Sepsis with Halden Scott Oct 06, 2017

Host Jason Woods MD sits down with Halden Scott MD to discuss the state of pediatric sepsis, and specifically the use of lactate measurements in the Emergency Department. Dr. Scott is a leading expert in pediatric sepsis in the Emergency Department, with multiple articles published on the topic of the use of lactate measurement in the treatment of pediatric sepsis.

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Episode 1: Pediatric Impact of Marijuana Legalization Sep 15, 2017

The inaugural episode of Little Big Med: Little Patients, Big Medicine! Host Jason Woods MD sits down with Sam Wang MD (pediatric emergency medicine physician and toxicologist) and Matt Zuckerman MD (emergency medicine physician, toxicologist, and host of the ToxNow podcast) to discuss the pediatric medical issues surrounding marijuana legalization.

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