Kocher criteria for pediatric septic hip

The Kocher criteria are useful for distinguishing between septic arthritis and transient synovitis in a child presenting with a painful hip.  The criteria are as follows:

1.  Non-weight-bearing on affected side
2.  ESR > 40 mm/hr
3.  Fever
4.  Serum WBC > 12,000

Criteria met and probability of septic arthritis:
0/4   0.3%
1/4   3%
2/4   40%
3/4   93%
4/4   99%


References:  
1.  Kocher MS, Zurakowski D, Kasser JR>  Differentiating between septic arthritis and transient synovitis of the hip in children:  An evidence-based clinical prediction algorithm.  J Bone Joint Surg Am.  1999;81:1662-70.

How to insert an LMA

How to put in an LMA:

A Laryngeal mask airway, or LMA, is a supraglottic airway device.  An LMA is a great rescue airway when you encounter difficulty in intubating a patient.  It can also be used to as an easy and more effective alternative to bag-valve mask ventilation.

To insert an LMA:
1.  Make sure the device is deflated.
2.  Apply lubricant to the anterior and posterior surfaces of the LMA.
3.  Standing at the head of the bed, hold the device in the dominant hand and open the airway (jaw-thrust is helpful to get tongue out of the way).  Tip of index finger should rest on cuff-tube junction.
4.  Point the tip of the LMA at the hard palate and advance along the hard and soft palates using a circular motion.

5.  Stop when resistance is met and only the tube is protruding from the mouth.
6.  Inflate the cuff.  Proper placement is confirmed by ability to ventilate the patient, end-tidal CO2 return, and seeing the tube elevate slightly when cuff is inflated.

Prevention of desaturation during intubations

A great article in this month's Annals of Emergency Medicine from Scott Weingart and Richard Levitan: "Preoxygenation and Prevention of Desaturation During Emergency Airway Management."

Recommendations for improving oxygenation and preventing desaturation during ED intubations:

1.  Preoxygenate patient using standard reservoir facemask with highest possible flow rate of O2, head-up position, when possible.

2.  If possible, preoxygenate for 3 minutes or have patient take 8 maximal inhalation/exhalation breaths.

3.  For patients who cannot achieve saturations > 93-95% with high FiO2, consider preoxygenation with PEEP, including CPAP masks, noninvasive positive-pressure ventilation, or PEEP valves on a bag-valve-mask device.  

4.  Provide passive oxygenation during RSI (using high-flow O2 via nasal cannula after sedatives and paralytics given) to increase duration of safe apnea in ED tracheal intubations.

6.  Ventilate hypoxemic patients during onset phase of muscle relaxants in RSI prior to tracheal intubation.  For fully oxygenated patients at low risk for desaturation, ventilation is not required during the onset phase of muscle relaxants.

7.  Position patients to maximize upper airway patency using ear to sternal notch positioning.


References:
1.  Weingart, S and Levitan, R.  Preoxygenation and Prevention of Desaturation During Emergency Airway Management.  Annals of Emergency Medicine 2012;59:165-75.

Normal ESR values by age

Rule for correcting erythrocyte sedimentation rate (ESR) by age:

Men:  Age in years  /  2
Women:  Age in years + 10  /  2


References:
1.  Miller A, Green M, Robinson D.  Simple rule for calculating normal erythrocyte sedimentation rate.  BMJ 1983; 286:266.  

What are the top causes of small bowel obstruction?

Upright abdominal film showing multiple air-fluid levels.

Most common causes of small bowel obstruction in adults:

#1.  Adhesions after abdominal surgery (60%)
#2.  Malignancy (20%)
#3.  Hernia (10%)
#4.  Inflammatory bowel disease (5%)

Intussusception is the most common cause of small bowel obstruction in children.

References:  
1.  Nobie, BA.  Small-Bowel Obstruction.  Emedicine.  Available at http://emedicine.medscape.com/article/774140-overview#aw2aab6b2b3.  Accessed March 3, 2012.

What are appropriate antibiotics for PID?

Pelvic inflammatory disease (PID), refers to infection and inflammation of the female genital tract, including endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.  PID is believed to be initiated by ascending infection from the vagina and cervix (often Chlamydia trachomatis), but is often polymicrobial.

The CDC recommends empiric treatment for PID in sexually active young women and other women at risk for STDs if no cause for symptoms can be found and the patient has at least one of the following:

1.  Cervical motion tenderness
OR
2.  Adnexal tenderness
OR
3.  Uterine tenderness

The following criteria enhance specificity and further support the diagnosis of PID:
1.  Temp > 101 F
2.  Abnormal mucopurulent cervical or vaginal discharge
3.  Presence of abundant leukocytes on wet prep
4.  Elevated ESR
5.  Elevated CRP
6.  Laboratory evidence of C. trachomatis or N. gonorrhea cervical infection

For patients with mild to moderate PID who can be managed as outpatients, the CDC recommends:

Patient who don't respond to oral therapy within 72 hours should be reevaluated both to confirm the diagnosis and to initiate parenteral therapy.

For patients with severe illness, tubo-ovarian abscess, pregnancy, or lack of response to oral agents, the CDC recommends inpatient therapy.  Recommended parenteral regimes include the following:

References:
1.  CDC Sexually Transmitted Disease Treatment Guidelines, 2010.  Available at http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.  Accessed Feb. 9, 2012.

Dog bites: When should you use prophylactic antibiotics?

Dog bites are the most common mammalian bite injury seen in the United States, followed by cat bites and human bites.  Management of minor dog bite wounds includes copious irrigation with normal saline (>150 mL through an 18 or 19 gauge plastic catheter), debridement of any devitalized or crushed tissue, assessment for underlying tendon or bone injury, updating tetanus status when indicated, and assessment of rabies risk.  Primary closure of bite wounds is controversial, but it is generally accepted that wounds can be sutured unless they are high risk or already infected.  High risk wounds should be closed with delayed primary closure 72 hours later.  Wounds to the face are usually sutured for optimal cosmetic results, and infection is rare due to copious irrigation, excellent blood supply, and use of antibiotic prophylaxis.

There is a lack of consensus about which type of wounds require antibiotic prophylaxis.  Risk factors for infection include location on hand, foot, or over a major joint, puncture wounds and crush injuries, treatment delay > 12 hours, and systemic factors such as advanced age, immunosuppression, asplenism, diabetes, and vascular disease.  Griego et al list the following indications for prophylactic antibiotics:

There is no clear consensus on the appropriate antibiotic choice for infection prophylaxis.  When infections do develop from dog bites, they are usually polymicrobial with both aerobic and anaerobic species.  Staphylococcus, Streptococcus, and Corynebacterium are the most common aerobic species isolated, with Bacteriodes fragilis, Prevotella, Peptostreptococcus, and Fusobacterium among common anaerobic isolates.  A rare, but potentially fatal infection associated with dog bites is Capnocytophaga canimorsus. Patients who develop this infection usually have a predisposing condition, such as splenectomy.

Amoxicillin/clavulanate is often prescribed due its dual aerobic and anaerobic coverage. Alternative regimens include clindamycin plus ciprofloxacin, TMP/SMX, and second- or third-generation cephalosporins such as cefuroxime.  Duration should be 5-7 days.  It is recommended that patients have an initial follow-up visit at 24-48 hours to assess wound healing and presence of infection.





References:
1.  Griego RD et al.  Dog, cat, and human bite wounds:  A review.  J Am Acad Dermatol 1995;33:1019-29.
2. Smith PF, Meadowcroft AM, May DB.  Treating mammalian bite wounds.  Journal of Clinical Pharmacy & Therapeutics.  2000;25:85-99