Stroke is one of the leading causes of death in the United States. Approximately 87% of all strokes are ischemic. Available therapies are limited and include thrombolysis and thrombectomy. There is a known risk of hemorrhagic conversion of acute ischemic strokes with the use of thrombolytics. Of the 12 clinical trials comparing thrombolysis vs. either placebo or no treatment for acute ischemic stroke,
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Oxygenation is particularly important in children undergoing endotracheal intubation. They have higher oxygen consumption than adults and become hypoxemic more quickly with rapid sequence intubation. Apneic oxygenation (AO) is the process of providing a high flow rate of oxygen through a standard nasal cannula prior to endotracheal intubation (ETI) without bag-valve mask ventilation. It is thought that the high flow rate results in nitrogen washout (replacing nitrogen with oxygen) which provides an oxygen reservoir as well as provides some degree of positive end expiratory pressure keeping airways open.
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Status epilepticus is associated with significant morbidity and mortality. Benzodiazepines are recommended as first line agents but their efficacy is approximately 50%. The most commonly recommended 2nd line agents are Phenytoin and Fosphenytoin. Their use is associated with an efficacy of approximately 50%. In addition, their use is associated with significant adverse events. Levetiracetam (Keppra) had been proven efficacious in small case series,
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Pain is typically under-treated in children. Intranasal administration of analgesics has the benefits of rapid, needleless administration and a more rapid onset compared to oral administration. Ketamine is used frequently by the intravenous or intramuscular route for procedural sedation due to its efficacy and safety.
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The evaluation and management of febrile neonates remains controversial. Approximately, 10% of these patients will have a serious bacterial infection (SBI). Identification of the febrile neonate at low risk for serious bacterial infection could allow for a reduction in the rates of lumbar puncture, unnecessary antibiotics and hospital admission. The approach to these patients should evolve as the epidemiology changes and new diagnostic tests become available.
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Imaging is one of the most important diagnostic modalities that physicians utilize. In 2013 alone, over 70 million CT scans were performed. Contrast-enhanced imaging can aid in diagnosing certain pathology and improve image quality. There has historically been a concern for post-contrast acute kidney injury (AKI), which is generally considered an increase in creatinine or a decrease in glomerular filtration rate hours to days after contrast administration.
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The sepsis 3 guidelines recommended the use of the Sepsis Related Organ Failure Assessment (SOFA) score for early identification of sepsis in adults (Singer 2016, PMID: 26903338). An abbreviated version of SOFA (Quick SOFA or qSOFA) includes variables available at the bedside in the ED (systolic BP, respiratory rate and mental status). The 2017 pediatric surviving sepsis guidelines acknowledge that there is insufficient evidence to endorse a specific sepsis trigger tool and recommend that each institution develop their own recognition bundle (Amer College Critical Care 2017,
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