Episode 141Full episode audio for MD edition238:49 min - 100 MB - M4AEM:RAP junio 2013 en españolEspañol74:06 min - 25 MB - MP3EM:RAP 2013 June Mp3190 MB - ZIPEM:RAP June 2013 Written Summary915 KB - PDFEM:RAP June 2013 Board Review Questions644 KB - PDFEM:RAP June 2013 Board Review Questions: Answer Sheet636 KB - PDF
Greg S. - June 13, 2013 10:47 AM
This is the same overly nuanced thing we've heard before - for the last ten years. If I have to hear about Rochester, Boston and Philadelphia in the same lecture again going to shit bricks. Under two months, drain all bodily fluids and replace with antibitics. Over 2 months, a la carte. Is it really that complex that we have to keep invoking these old studies? Don't pediatric emergency people have anything better to talk about yet? Give us something meatier.
Andrew E. - July 2, 2013 1:13 PM
This didn't address changes in rates of SBI since Boston and Philadelphia. With current immunization scheduled these are out of date. I agree with Greg S, the paradigm based on old criteria is too invasive, and will lead to a high rate of false positives given lower rates of SBI.
ilene c. - July 5, 2013 2:43 PM
Andrew: I apologize if there was any confusion about age groups, criteria, and vaccinations. For older children, Prevnar has made a big impact regarding rates of invasive pneumococcal disease, and thus invasive bacterial disease overall, and with PCV-13, the hope and expectation is that IPD will decrease to about 9 cases per 100,000 per year over the next decade. For these kids, less overall testing is reasonable. But the criteria you mention typically refer to kids <2 months of age (in all fairness, Boston does go to 90d). Other than Hep B, most kids under 2 months have not been vaccinated yet and, even though there is something to be said for herd immunity, very little invasive disease in this age group is vaccine-preventable. For kids under 2 months, 39% of meningitis is GBS and 32% is gram negative. Even with the maternal screening for GBS, meningitis rates have not really changed under 2 months of age (73/100,000 in 1998 and 83/100,000 in 2007). So, if we gave the impression that some degree of caution should still be exercised in this age group, it may not be what people want to hear, but it is something we need to recognize.
Edward D., M.D. - July 19, 2013 1:54 PM
On a more basic level, our nursing is pushing for use of Temporal Artery Thermometry to measure temperature. They are trying to get away from rectal temps for any nimber of reasons. What do you think of this modality and the process of temperature measurement in general?
ilene c. - July 19, 2013 6:29 PM
It seems like the more recent studies show pretty good correlation with rectal temps, although these were small and some of the older studies are less compelling. It certainly is better than axillary, and probably should replace that in the older kids. I can understand wanting to move away from rectal temp- I feel uncomfortable when I see an almost 2 year old getting a rectal temp in triage! My take is this: it's pretty good with some potential misses. In kids where we don't care that much (for the most part over 2 months), might as well use it. In the neonates, I think I'd feel more comfortable with a rectal temp pending more definitive data.
Susannah G. - August 1, 2013 4:09 PM
Can you comment on the utility of cxr in the <2m old for septic work up? (For example in the board questions it suggests you should despite no cough or respiratory symptoms in the stem). What would be your practice in reality?
ilene c. - August 14, 2013 10:20 AM
As far as I know, most of the studies on this exact question are old, and predated the pneumococcal vaccinations. That said, pneumococcus accounts for a small percentage of SBI in kids <2 months, so my suspicion is that the numbers would change little if re-done today. In the febrile infant <60 days without respiratory symptoms, the risk of a pneumonia identified on radiograph is about 1% (vs up to 30% in the infant with symptoms of pneumonia and a fever). Most people I know don't check, and I was taught it wasn't mandatory. That said, I suppose if you are doing a lumbar puncture for a risk of meningitis in the <1% range, it seems odd not to do a simple radiograph for a similar risk.
ryan l. - September 26, 2013 10:09 PM
Sorry reviewing this again - What about 1-2 months with a positive RSV or Influenza test? Thanks
ilene c. - October 1, 2013 8:12 AM
Ryan- That is a great question and I'm not sure it has a definitive answer. I usually get a urine and blood culture and next day follow-up in these kids (and skip the LP) if they look great and have a good clinical picture for RSV or influenza (as opposed to the kid whose symptoms peaked 10 days ago but is still positive on testing). There are a few studies that I know of on the topic, each with about 100-200 patients. The best known are from the PECARN network and include kids <60 days. Of these, the 123 influenza + kids had a 2.5% serious bacterial infection rate (2.4% UTIs) with no bacteremia or meningitis. The 269 RSV+ kids had a 7% SBI rate (5.4% UTIs and 1 case of bacteremia- no meningitis). I don't think we have enough patients to guarantee that there is no risk of bacteremia or meningitis, but it is unlikely enough that it is not unreasonable to consider a good discussion with the family and careful follow-up in lieu of LP/ceftriaxone in most cases. Still have to do the urine.