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Pediatric Emergency Medicine Practice Clinical Pathways:

Evidence To Improve Patient CareIn Emergency Medicine

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Table Of ContentsAllergy/Endocrine EmergenciesClinical Pathway For Initial Evaluation Of Diabetic Ketoacidosis ............................................................................1Clinical Pathway For Treatment Of Diabetic Ketoacidosis .........................................................................................2Clinical Pathway For Emergency Care Of Patients With A Metabolic Disorder.................................................3Clinical Pathway For The Diagnosis Of Anaphylaxis ....................................................................................................4Clinical Pathway For The Treatment Of Anaphylaxis ...................................................................................................5

General Emergency MedicineClinical Pathway: The Evaluation Of The Lower Extremity .........................................................................................6Clinical Pathway: Noninvasive Ventilation In Children ................................................................................................7Clinical Pathway: Management Of Dehydration In Pediatric Gastroenteritis ....................................................8Clinical Pathway: Management Of The Critically Ill Neonate ...................................................................................9Clinical Pathway: Pediatric Pain And Anxiety In The ED ..........................................................................................10Clinical Pathway For The treatment Of Jaundice In 2- To 8-Week Old Infants ..............................................11

Infectious DiseaseClinical Pathway For The Treatment Of Enterovirus In The Neonate .................................................................122009-2010 Influenza Season Triage Algorithm For Children (≤ 18 years) With Influenza-Like Illness ....................................................................................................................................... 13-14

Neurologic EmergenciesClinical Pathway For The Management Of Pediatric Seizures ..............................................................................15Clinical Pathway: Patient With ANC < 500 Or Chemotherapy-Induced Neutropenia ................................16Clinical Pathway: Patient With Mild To Moderate Neutropenia ...........................................................................17Clinical Pathway For Evaluation And Treatment Of Cerebral Edema .................................................................18Clinical Pathway: Migraine Headache Neuroimaging ..............................................................................................19Clinical Pathway: Pediatric Migraine Clinical Treatment Pathway .......................................................................20

Toxicology And Environmental EmergenciesClinical Pathway: Oil Of Wintergreen, Pennyroyal Oil, Camphor, Eucalyptus, Imidazoline Decongestant ..............................................................................................................................................21Clinical Pathway: Diphenoxylate-Atropine ...................................................................................................................21Clinical Pathway: Organophosphates .............................................................................................................................22Clinical Pathway: Sulfonylureas .........................................................................................................................................22

TraumaClinical Pathway For The Treatment Of Pediatric Burns ..........................................................................................23Clinical Pathway For The Treatment Of Mammalian Bites .....................................................................................24Clinical Pathway For Treatment Of Traumatic Dental Injuries ...............................................................................25Clinical Pathway For Treating Pediatric Wounds ........................................................................................................26

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Clinical Pathway For Initial Evaluation Of Diabetic Ketoacidosis

• InitiatePediatricAdvancedLifeSupport

• Administer0.9%normalsalineorlactatedringers10mL/kgbolusover1-2hours.(Class II)

• Followinitialmanagementalgorithm(see Clinical Pathway For Treatment of Diabetic Ketoacidosis Pathway)

• Areresultsofhistoryandphysicalexaminationconsistentwithdiabeticketoacidosis(ie,polyuria,polydipsia,weightloss,fatigue,nausea/vomiting)?

• Doesrapidglucosetestingshowelevatedbloodglucoselevel?

• Areketonespresentinurineorblood?

Initiate evaluation for diabetic ketoacidosis.• Establishaflowsheet.(Class III)• Orderthefollowinglaboratorytests(Class III):

• Serumglucose• Arterialbloodgas• Electrolyteswithaniongapcalculation• Calcium,magnesium,phosphorus• Serumureanitrogen/Creatinine• Serumketones• Serumosmolality• Completebloodcellcountwithdifferentialcellcount• Urinalysis

Arethereanyairway,breathing,orcirculation

concerns?

Classify diabetic ketoacidosis severity (Class II).• Severe:pH<7.1orbicarbonate<5mmol/L• Moderate:pH7.1-7.2orbicarbonate5-10mmol/L• Mild:pH7.2-7.3andbicarbonate10-15>15mmol/L

Doesthepatientshowsignsof

shock?

YES NO

YES NO

Thisclinicalpathwayisintendedtosupplement,ratherthansubstitutefor,professionaljudgmentandmaybechangeddependinguponapatient’sindividualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardofcare.

Copyright©2009EBPractice,LLC.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLC.

Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandeffectiveness

LevelofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)

•High-qualitymeta-analyses•Studyresultsconsistentlyposi-tiveandcompelling

Class II•Safe,acceptable•Probablyuseful

LevelofEvidence:•Generallyhigherlevelsofevidence

•Non-randomizedorretrospec-tivestudies:historic,cohort,orcasecontrolstudies

•LessrobustRCTs•Resultsconsistentlypositive

Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralterna-tivetreatments

LevelofEvidence:•Generallylowerorintermediatelevelsofevidence

•Caseseries,animalstudies,consensuspanels

•Occasionallypositiveresults

Indeterminate•Continuingareaofresearch•Norecommendationsuntilfurtherresearch

LevelofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory

•Resultsnotcompelling

Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-

tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcar-diopulmonaryresuscitationandemergencycardiaccare.Emer-gencyCardiacCareCommitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensur-ingeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.

Class Of Evidence DefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.

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Clinical Pathway For Treatment Of Diabetic Ketoacidosis

• Determine the extent of dehydration.lConsideranestimateof5%-7%

dehydrationasmoderateand7%-10%dehydrationassevere.(Class III)

• Calculate fluid requirement.lConsider1.5-2.0timesmainte-

nanceplusdeficit.(Class III)lConsidersubtractingbolus(es)

previouslygivenforresuscitation.(Class III)

lCalculatetherateoffluidreplace-mentwithagoalofreplacinglossesover36-48hours.(Class II)

Isthepatient’sserumpotassiumlevel>5.5mmol/L?

• Placepatientonelectrocardiogrammonitor.(Class II)

• Initiate0.9%normalsalineorLRatcalculatedrequirements.(Class II)

• Considerevaluationforvoiding.(Class III)

• Recheckserumpotassiumlevel.(Class III)

• Beginfluidreplacementwith0.9%normalsa-lineorLRplus40mEq/Lofpotassiumchloride.(Class II)

• Consideralternativelystartingwith0.9%nor-malsalineorLRplus20mEq/Lofpotassiumchlorideand20mEq/Lofpotassiumphospho-rusifphosphoruslevelis<1mg/dL.

•Initiateinsulintherapy.lDonotusebolusinsulin.(Class II)lUseIVformofinsulin.(Class I)lStartat0.1U/kg/h.(Class I)

• Regularlyreassessthepatient’sneurologicstatus.(Class II)

• Monitorlaboratoryvaluesevery2-4hours.(Class III)

• Adddextrosetofluidifbloodglucoselevelhasdecreasedto<250mg/dL.(Class III)

• Considercerebraledemaevaluationandtreat-mentifneurologicexaminationresultschange(see Clinical Pathway For Evaluation And Treatment Of Cerebral Edema).(Class III)

• Considerdecreasingtherateofinsulininfusionifthepatient’sbloodglucoseleveldecreasesbymorethan50-75mg/dLperhour.(Indeter-minate)

• Considerdecreasingtherateofinsulininfusionifthepatient’sserumosmolalitydecreasesbymorethan3mmolperhour.(Indeterminate)

YES NO



Class I•Alwaysacceptable,safe•Definitelyuseful•Proveninbothefficacyandef-fectiveness


•High-qualitymeta-analyses•Studyresultsconsistentlypositiveandcompelling


LevelofEvidence:•Generallyhigherlevelsofevidence•Non-randomizedorretrospectivestudies:historic,cohort,orcase

controlstudies•LessrobustRCTs•Resultsconsistentlypositive

Class III•Maybeacceptable•Possiblyuseful•Consideredoptionaloralternativetreatments





LevelofEvidence:

•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradictory•Resultsnotcompelling

Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresentativesfromtheresuscitationcouncilsofILCOR:HowtoDevelopEvidence-BasedGuidelinesforEmergencyCardiacCare:QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcardiopulmonaryresuscitationandemergencycardiaccare.EmergencyCardiacCareCommit-teeandSubcommittees,AmericanHeartAssociation.PartIX.Ensuringeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.






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Clinical Pathway For Emergency Care Of Patients With A Metabolic Disorder

Perform ABCDEsA–Airway-Evaluateandprotectairwayasneeded.B–Breathing-Ensureadequateventilation

• Non-invasiveventilatorysupportmaybeconsideredwhereappropriate.• Aggressivehyperventilationforcerebraledemashouldbeavoided.

C–Circulation-Volumeexpansionshouldbeprovidedwhenthereisevidenceofdehydrationorvolumedepletion.D–Disability-Bedsidebloodglucosetesting:

• Ifbelow60mg/dL,obtaincriticalsample,IVaccessandprovideglucoseorallyorviaIV• Lowosmolarityglucosesolutions(D5W,D10W)arepreferredwhereavailable• Criticalsample:serumglucose,insulin,cortisol,andgrowthhormone

E–Exposure-Evaluateforexposuretoinfectiousorganisms,drugs,toxicsubstances,ornewfoods

Consider Additional Laboratory TestingPrimary:(mostcanbeobtainedwithpointofcaretestingdevices)

• Arterialorvenousbloodgas• Electrolytes• Serumureanitrogenandcreatinine• Urinedipstick

Secondary:• General–completebloodcellcountwithdifferentialcount• Hypoglycemia–insulin,cortisol,corticotropin,b-hydroxybutryate• Encephalopathy–ammonia,aspartateaminotransferase,alanineaminotransferase,bilirubin• Suspectedgalactosemia–urine-reducingsubstances

Tertiary:• Quantitativeplasmaorganicacids• Quantitativeurineorganicacids• Plasmaacylcarnitine• Tandemmassspectroscopyfordisordersoffattyacidoxidation• Aminoacidsintheblood,urine,andcerebrospinalfluid• Oroticacidintheurine• Comprehensivenewbornscreenwithtandemmassspectroscopy

TreatmentIfthechildhasadiagnosedmetabolicdisorder,followinstructionsprovidedbytheirMetabolicspecialist.Hydration–D101/2NSat1.5timesmaintenanceuntilneedsforfluid,glucose,andelectrolytereplacementhavebeendetermined.

GlucoseMedications(asdirectedbyMetabolicspecialist,exceptasnoted)

• Fattyacidoxidationdisorders–L-carnitine• Hyperammonenia–sodiumphenylacetate,sodiumbenzoate,arginine• Neonatalseizures–pyridoxine(maybegivenempiricallywithconcurrentEEGmonitoringasavailable)• Organicaciddefects–biotin

Consider Consultations Or Referrals To:• CriticalCare• Genetics/Metabolism• Nephrology–asindicatedforrenalreplacementtherapyforhyperammonemia





4


Clinical Pathway For The Diagnosis Of Anaphylaxis

YES

YES

YES

NO

NO

NO

Doespatienthaveacuteonsetofthefollowingwithoutamoreplausibleexplanation?• Mucocutaneoussigns(urticaria,generalizedflushing,

pruritis,angioedema)AND• Oneofthefollowing:Respiratorycompromise(wheeze,

stridor,hypoxemia,dyspnea)ORhypotension,collapse,syncope,incontinence

Initiatetreatmentforanaphylaxis.

Doesthepatienthaveatleast2ofthefollowingAFTERrecentexposuretoalikelyallergen?• Mucocutaneoussigns(urticaria,generalizedflushing,

pruritis,angioedema)• Respiratorycompromise(wheeze,stridor,hypoxemia,

dyspnea)• Hypotension,collapse,syncope,incontinence• Persistentgastrointestinalsymptoms(vomiting,crampy

abdominalpain)

Initiatetreatmentforanaphylaxis.

DoesthepatienthaveaknownallergenANDhypotension*withinhoursofexposuretothatallergen? Initiatetreatmentforanaphylaxis.

Consideralternatediagnoses

AdaptedfromSampsonHA,Munoz-FurlongA,CampbellRL,etal.Secondsymposiumofthedefinitionandmanagementofanaphylaxis:Summaryreport—SecondNationalInstituteofAllergyandInfectiousDisease/FoodAllergyandAnaphylaxisNetworksymposium.JAllergyClinImmunol.2006;117:391-397.

*ordropofatleast30%frombaselinebloodpressure





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Clinical Pathway For The Treatment Of Anaphylaxis

YES

NO

NO

NO

Ispatientincardiopulmonaryarrest? InitiatePediatricAdvancedLifeSupportorAdvancedCar-diacLifeSupport

Administerepinephrine1:1000(1mg/mL)0.01mg/kgtoamaximumof0.3-0.5mgintramuscu-

larly(Class II)PLUS

Oxygenandairwaymanagementasneeded

Arelife-threateningsymptomsofhypotension,respira-torydistress,orstridorresolved?

Repeatepinephrineevery3-5minutesasnecessary.Givefluidbolusasnecessary.

ConsiderinhaledB-agonistsforpersistentwheezing.

Aresymptomsresolved?

Considerintravenousepinephrinebolusesoranepi-nephrinedripforpersistenthypotension.


Copyright©2010EBPractice,LLCd.b.a.EBMedicine.1-800-249-5770.NopartofthispublicationmaybereproducedinanyformatwithoutwrittenconsentofEBPractice,LLCd.b.a.EBMedicine.


















• ConsideranH1blockerforcutaneoussymptoms(Class III)

• ConsideranH2blockerforcutaneoussymptoms(Class III)

• Consideracorticosteroidtopreventbiphasicreac-tions(Class Indeterminate)

YES

Ifpatientdoesnothaveriskfactorsforfatalorbiphasicanaphylaxis,observefor6hoursanddischargewithan

epinephrineauto-injector.

YES Consideradmissiontoamonitoredbed.

Admittopediatricintensivecareunit(PICU).





6


PerformPALS/ATLSand/orABCs.Havethepatientevaluatedbyatrauma

surgeon.Transferpatientifneeded.(Class I)

Clinical Pathway: The Evaluation Of The Lower Extremity

Performacompletehistoryandphysical.Doespatientshowsignsoftraumaor

significantmechanismofinjury?

Orderappropriateimagingstudies.

(Class I)

Orderanemergentorthope-dicconsult.(Class I)

Ifsignsandpredictorsarenotapparent,dischargepatientwithfollowup

in24hours.(Class III)

Ifsignsandpredic-torsareapparent,admitpatientforobservationandserialexams.

(Class III)

NO

YES

Admitforobservation.Considerpediatricandrheumatologyconsults.

(Class II)

Doserialexaminationsshowworseningsymptoms? YES

YES

Doesthepatienthaveafunctional

deficit? Istheinjurynon-weightbearing?

(Class II)

Orderanorthopedicconsultandfollowup.(Class I)

YES

YES

NO

YES

NO

YES

NO

Clearpatientforactivityastoler-ated.FollowupwithPRN.

(Class III)

NO

NO

YES

NO



YES

Isafracturepresent?

Orderlaboratorystudies:CBC,ESR,CRP,and

films.(Class II)

ExamineforKocherpredictorsandLuhmansigns.Makeaclini-

caljudgment.(Class III)

Issepticarthritislikely?

NO


ClassofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)



ClassofEvidence:•Generallyhigherlevelsofevidence



Class III•Maybeacceptable

•Possiblyuseful•Consideredoptionaloralterna-tivetreatments

ClassofEvidence:•Generallylowerorintermediatelevelsofevidence




ClassofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory


Significantlymodifiedfrom:TheEmergencyCardiovascularCareCommitteesoftheAmericanHeartAssociationandrepresen-tativesfromtheresuscitationcouncilsofILCOR:HowtoDe-velopEvidence-BasedGuidelinesforEmergencyCardiacCare:

QualityofEvidenceandClassesofRecommendations;also:Anonymous.Guidelinesforcardiopulmonaryresuscitationandemergencycardiaccare.EmergencyCardiacCareCom-mitteeandSubcommittees,AmericanHeartAssociation.PartIX.Ensuringeffectivenessofcommunity-wideemergencycardiaccare.JAMA.1992;268(16):2289-2295.

ClassOfEvidenceDefinitionsEachactionintheclinicalpathwayssectionofPediatricEmergencyMedicinePracticereceivesascorebasedonthefollowingdefinitions.

ArefilmsabnormalorisSCFEorLCP

present?

Isthepatienttoxicappearingand/or

limping?

Isthepatientstable?





7


Clinical Pathway: Noninvasive Ventilation In Children

YES

NO




ClassofEvidence:•Oneormorelargeprospectivestudiesarepresent(withrareexceptions)



ClassofEvidence:•Generallyhigherlevelsofevidence




ClassofEvidence:•Generallylowerorintermediatelevelsofevidence




ClassofEvidence:•Evidencenotavailable•Higherstudiesinprogress•Resultsinconsistent,contradic-tory





Explainproceduretopatient.Showpatienttheequipmentandmask.Ensurepatientisonmonitorandpulseoximeter.Ensureadequatepersonneltomonitorpatient.

Applymasktopatient.CPAP: Startwithlowpressures(5cmH20).Increasein

incrementsof1cmH2O.BiPAP:Startwithlowsettings.IPAPof8-10cmH2O

andEPAPof2-4cmH2O.Titratetoeffect.TypicalIPAPlevelsinchildrenare8-16cmH2O,andtypicalEPAPlevelsare4-8cmH20.

(Class Indeterminate)

Hemodynamicinstability?Alteredmentalstatus?Excessivesecretionsorvomiting?UpperGIbleeding?Recentfacial,upperairway,orupperGIsurgery?

Intubate.(Class I-II)

Positiveresponsetotherapy?• Decreasedrespiratoryrate?• Decreasedworkofbreathing?• Improvedoxygenation?

Worseningagitation?Poormaskfit?Worseninghypoxia?Worseningrespiratorydistress?

Continuenoninvasiveventilation.(Class III)

Intubate.(Class II)

NO

YES





8


Clinical Pathway: Management Of Dehydration In Pediatric Gastroenteritis

YES

Whatclinicalsignsofdehydrationarepresent?

Isdehydrationresolved? Isdehydrationresolved?

StartORTat50-100mL/kg,plusre-placeongoinglosses.(Class II)

UseanoralantiemeticifvomitingispresentandlikelytoimpedeORT.

(Class II)

Admitpatient.

Givea20mL/kgbolusofnormalsaline;repeatuntilstable.(Class II)

Admittowardorobservationunit. AdmittoPICU.Ifpreviousdehydrationwasnoted,ob-serveforaperiodoftimeintheED.

Continuepatient’sregulardiet.

Dischargehomewithhydrationinstructionsandsignsofdehydration

tolookfor.

NONO YES

NONE MILD/MODERATE SEVERE




















ORT,oralrehydrationtherapy;ED,emergencydepartment;PICU,pediatricintensivecareunit

Abbreviations:





9


Clinical Pathway: Management Of The Critically Ill Neonate

Doestheneonaterequireemergentresuscitation?

Whatisthesuspecteddiagnosis?Performhis-toryandphysicalexamination;checklaboratorytestandradiographresults;

conductfurthertestingas

needed.

StartPGE1at0.05µg/kg/min(Class 2);correctacidosis(Class 3);ifindi-cated,consider:furosemide1mg/kg,

dobutamine2to20µg/kg/min;packedredbloodcells10mL/kg.

Startampicillin/gentamicin(Class

1);startIVacyclovirifWBCsinCSF(Class 2).For

sepsis,startnormalsalinewith10-to20-mL/kgbolusesuntilpatientisstableor60mL/kgisreached

(Class 1).

Considersurgeryforperforation(Class 2);adminis-terantibiotics(Class 2);obtainradiograph

every6-8hours(Class 3).

InsertNGTorOGT;arrangeforsurgical

consult;IVF.

Correctcoagu-lopathy;consultneurosurgery;

contactDepartmentofChildandFamily

Services.

StartD10¼normalsalineat1.5timesmaintenance(Class

1);initiatesodiumbenzoateandso-diumphenylacetate

at0.25g/kg(Class 1);consider

L-carnitine(Class 3);correcthypoglycemia.

Securetheairway;performchestcom-pressionsifheartrate<60bpm;

checkglucoselevel(Class 1);initiateappropriatePALS

algorithm.

Cardiacdisease

GIdiseaseMetabolicdiseaseSBI

NEC Malrotation

Schedulesurgery.

NAT

NO




















Abbreviations:BPM,beatsperminute;CSF,cerebrospinalfluid;D10,dextrose10%;GI,gastrointestinal;IV,intravenous;IVF,intravascularfluids;NAT,nonaccidentaltrauma;NEC,necrotizingenterocolitis;NGT,nasogastrictube;OGT,orogastrictube;PALS,pediatricadvancedlifesupport;PGE1,pros-taglandinE1;WBC,whitebloodcells;SBI,seriousbacterialinfection.

YES





10


Clinical Pathway: Pediatric Pain And Anxiety In The ED

InvasiveEDprocedurethatproducespain,anxiety,orboth

Thisclinicalpathwayisintendedtosupplement,ratherthensubstitutefor,professionaljudgementandmaybechangeddependinguponpatient’sindi-vidualneeds.Failuretocomplywiththispathwaydoesnotrepresentabreachofthestandardcare.

Reprintedfrom:MatsunoWE,OtaFS.ManagingPediatricProceduralPainAndAnxietyInTheEmergencyDepartment.PediatricEmergencyMedicinePractice2006;3(5):1-28.(Review, Evidence-based)

Cantheprocedurebecompletedwithlocalanesthesiaalone?

Willtheadditionofchildlifeorotherbehavioraltechniquebeenoughtocompletetheprocedure?

Willinhalednitrousoxidebeahelpfuladjunct,andisthischildcooperative?

WillPOmidazolambeahelpfuladjunct?

IsthereanyreasonthatthepatientisnotanappropriatecandidatetobesedatedintheEDtocompletetheprocedure?

Topicalanesthesia,localanesthesia,orboth(Class II)

Localanesthesiaalongwithchildlifeorotherbehavioraltechnique(Class II)

Inhalednitrousoxidebydemandmask(Class II)

Oralorintranasalmidazolam(Class II)

Consultationortransfertoafacilitywithpediatricanesthesiaandsurgicalservices(Class II)

Chooseappropriatedrugregimen(Class II)AdministersedationintheEDunderappropriate,closemonitoring(Class II)Dispositionwhenappropriatelybacktobaselinementalstatus(Class III)

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO





11


Jaundicedinfant2to8weeksold

Isthepatientacutelyill?Requireurgentcare?

• Managetheacuteillness• Considerurinarytractorotherin-

fection,glactosemia,tyosinemia,hypopituitarism,fructosemia,ironstoragedisease,metabolicdisorders,acutecommonductonstruction,hemolysis.

Istheredirecthyperbilirubinemia?

Measureserumdirectbilirubin

CholestaticJaundice

Isthereevidenceofbiliaryobstruction?

Medicalevaluation:• Infection• Metaboolicdisorders• Geneticdisorders• Other

History,physicalexam,Urinalysis,urineculture

Findingsofspecificdisease?

Isthenewbornscreenpositiveforgalactosemiaorhypothyroidism?

Lowa-1antitypsin?

Consider:• Percutaneousliverbiopsy• Scintiscan• Duodenalaspirate• ERCP

• Consultpediatricsurgeon.

• Operativechol-angiogram

Choledochalcyst?

• ConsultPediatricGI• CBC,plateletcount• Totalanddirectbilirubin,ALT,AST,alkalinephosphate,glucose• Prothrombintime,albumin• a-1antitypsin• Urinereducingsubstances• Abdominalultrasound

Evaluatefurther

Referforfurthermanagement

• Pityping• Furthermanagement

Doesbilirubinnormalizeby6weeksofage?

Nohyperbilirubinemia

Indirecthyperbilirubinemia

Evaluatefurther(SeeAAPguideline)

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NONO

NORMAL

ABNORMAL

Clinical Pathway For The Treatment Of Jaundice In 2- To 8-Week Old Infants

FromMoyerV,FreeseDK,WhitingtonPF,etal.Guidelinefortheevaluationofcholestaticjaun-diceininfants:recommendationsoftheNorthAmericanSocietyforPediatricGastroenterology,HepatologyandNutrition.JPediatrGastro-enterolNutr.2004;39(2):115-128.UsedwithPermissionofWoltersKluwer.www.lww.com





12


Clinical Pathway For Treatment Of Enterovirus In The Neonate

StronglyconsiderCSFPCR.Considerviralcultureforserotype.

ConsiderCSFPCRorviralcultureforserotype.

Signsofheartfailure?(cardiomegaly,prolongedfeeding,shock,cold/mottledskin,gallop)

Signsofliverfailure?(hepatomegaly,splenomegaly,bleeding/bruising)

ConsiderorderingECG,ECHO,andCXR.Consultwithcardiology

andtreatformyo-carditis.

Orderliverfunctiontests,

coagulation,andbilirubin.

Consultwithgas-troenterology.

Isthepatientfebrile?

Considerthefollowingteststoruleoutsepsis:CBCwithdiff,BCx,UCx,CSFCx,CSFprotein,

glucose,andcellcount.Startantibiotics.

Isthepatientexperiencingmild

congestion?

Considerviralculture.OrdernasalPCRif

possible.

Noworkupisneeded.Providesupportivecareandclosefollowupwith

PMD.

Considerthefollowingteststoruleoutsepsis:CBCwithdiff,BCx,UCx,CSFCx,BCx,UCx,

CSFCxCSFprotein,glucose,andcellcount.

Startantibiotics.

Istheweathertemperatewhereyouare?

NOYES

YES NO

NO NOYES

Doespatientdemonstrate:

Providesup-portivecareandclose

followupwithPMD.

Providesup-portivecareandclose

followupwithPMD.

YES

NOYES

CBC:completebloodcount;BCx:bloodculture;UCx:urineculture;CSF:cerebralspinalfluid;CSFCx:cerebralspinalfluidculture;EV:En-terovius;PCR:polymerasechainreaction;ECG;electrocardiogram,ECHO:echocardiogram;CXR:chestx-ray;PMD:primarymedicaldoctor

YES

Doestheneonateappeartoxic?

NO





13


Ifchild<2yearsold,areallofthefollowingpresent?1. Feverorfeelsfeverish(ifnothermometeravailable)*2. Irritabilityorcoughorvomiting/unabletokeepfluidsdown

Ifchild≥2yearsold,areallofthefollowingpresent?1. Feverorfeverishness*2. Coughorsorethroat*Ifantipyreticsaretaken,thismayinhibitapatient’sabilitytomountafever.Ifantipyreticshavebeentaken,thepatientcanbereassessed4to6hoursafteracetaminophenor6to8hoursafteribuprofen.

Isthechildyoungerthan12weeksold?

Areanyofthefollowingsignsorsymptomspresent?†Age 12 weeks to < 5 years• Fastbreathing‡ordifficultybreathingorretractionspresent• Dehydration(nourineoutputin8hours,decreasedtearsornotearswhenchildiscrying,

ornotdrinkingenoughfluids)• Severeorpersistentvomiting/unabletokeepfluidsdown• Lethargy(excessivesleepiness,significantdecreaseinactivitylevel,and/ordiminished

mentalstatus)• Irritability(cranky,restless,doesnotwanttobeheldorwantstobeheldallthetime)• Flu-likesymptomsimprovedbutthenreturnedorworsenedwithinonetoafewdays• Paininchestorabdomen(forchildrenwhocanreliablyreport)Age ≥ 5 years• Fastbreathing‡ordifficultybreathing• Dizzinessorlightheadedness• Severeorpersistentvomiting/unabletokeepfluidsdown• Flu-likesymptomsimprovedbutthenreturnedorworsenedwithinonetoafewdays• Paininthechestorabdomen

Isthechildatleast12weeksoldbutlessthan2yearsold?

seenextpage

Althoughsomechildrenwithinfluenzamaynotexhibittheusualinfluenzasymptomsincludingfever,thischild’ssymptomssuggestthatinfluenzaislesslikely.Theydonotmeetcriteriaforthisalgorithm.Thechildshouldbeassessedforalternativediagnoses.

Recommendimmediatemedicalevalu-ationforchild,preferablywithchild’smedicalhome/primarycareprovider,orreferforemergencymedicalcareor911ifanysignsorsymptomsoflifethreateningillness.

Recommendimmediatemedicalevalu-ationforchild,preferablywithchild’smedicalhome/primarycareprovider.

Thischildfallsintoagroupthatmaybeatelevatedriskforcomplicationsfrominfluenza.Recommendthattheybeevaluatedforpossibletreatment.Recommendthatthechild’scaregivercontactthechild’smedicalhome/pri-marycareproviderthatday.

YES

YES

YES

YES

NO

NO

NO

NO

2009-2010 Influenza Season Triage Algorithm for Children (≤ 18 years) With Influenza-Like Illness

†Thesesymptomsarepurposelybroadtominimizethepossibilityofmisclassifyingpeoplewhotrulyhaveseveresymptoms.Thepersonattemptingtotriagethepatientshouldtakeintoaccounttheseverityanddurationofthesymptomswhendecidingwhetherornotpatientsshouldbeadvisedtoseekevaluationimmediately‡Suggestedrespiratoryratesindicativeof“fastbreathing”includedinBox

Box 1: Definition of “Fast Breathing”Age Respiratoryrate

Birthupto3months >60/min3monthsupto1year >50/min1to<3years >40/min3to<6years >35/min6to<12years >30/min12to18years >20/min

Adaptedfromhttp://www.cdc.gov/h1n1flu/clinicians/pdf/childalgorithm.pdf





14


For all patients triaged using this algorithm, the following should also be assessed:

Doestheillchildhaveanyofthefollowingconditions?Neurologicaldisorderssuchas:1. Epilepsy,cerebralpalsy,brainorspinalcordinjuries,andneuromusculardisorders(eg,

musculardystrophy)2. Chronicrespiratorydiseasessuchasthoseassociatedwithimpairedpulmonaryfunction

and/ordifficultyhandlingsecretions;thoserequiringoxygen,tracheostomy,oraventila-tor;andthosewithasthma.

3. Moderatetoprofoundintellectualdisability(mentalretardation)ordevelopmentaldelay4. Deficienciesinimmunefunctionorconditionsthatrequiremedicationsortreatments(eg,

certaincancertreatments,HIVinfection)thatresultinsignificantimmunedeficiencies5. Cardiovasculardiseaseincludingcongenitalheartdisease6. Significantmetabolic(eg,mitochondrial)orendocrinedisorders7. Renal,hepatic,hematological(includingsicklecelldisease)disorders8. Receivingchronicaspirintherapy9. Pregnancy

Isthechildatleast2yearsoldbutlessthan5yearsold?

Thischildappearstobeatlowerriskforcomplicationsfrominfluenzaandmaynotrequiretestingortreatmentiftheirsymptomsaremild.Inordertohelppreventspreadofinfluenzatoothers,thesepatientsshouldbeadvisedto:• Keepawayfromotherstotheextentpossible,particularlythoseathigherriskforcompli-

cationsfrominfluenza(seeboxbelow).Thismayincludestayinginaseparateroomwiththedoorclosed.

• Covertheircoughsandsneezes• Avoidsharingutensils• Washtheirhandsfrequentlywithsoapandwateroralcohol-basedhandrubs• Stayhome(eg,noschool,childcare,groupactivities)until24hoursaftertheirfever

resolveswithouttheuseofantipyretics(ie,acetaminophen,ibuprofen)

Moreinformationisavailableat:http://www.cdc.gov/flu/homecare/index.htm.Inaddition,rememberthatvaccinationforseasonalinfluenzaandpandemic(H1N1)influenzaisrecom-mendedforallchildren6monthsthrough18yearsoldandhouseholdcontactsandout-of-homecaregiversofchildrenlessthan6monthsold.

Doespatientlivewithapersonathigherriskforcomplicationsofinfluenzaincludingsomeonewhois:• Age<2orage≥65,or• PregnantOrsomeonewithanyofthefollowingcomorbidconditions:• Chronicpulmonarydisease(includingasthma),cardiovasculardisease(exceptisolated

hypertension),renaldisease,hepaticdisease,hematologicaldisorders(includingsicklecelldisease),ormetabolicdisorders(includingdiabetesmellitus)

• Disordersthatthatcancompromiserespiratoryfunctionorthehandlingofrespiratorysecretionsorthatcanincreasetheriskforaspiration(eg,cognitivedysfunction,spinalcordinjuries,seizuredisorders,orotherneuromusculardisorders)

• Immunosuppression,includingthatcausedbymedicationsorbyHIV• Child(<18)onchronicaspirintherapy

Inaddition,vaccinationforseasonalinfluenzaandpandemic(H1N1)influenzashouldberecommendedforallchildren6monthsthrough18yearsoldandhouseholdcontactsandout-of-homecaregiversofchildrenlessthan6monthsold.

Thischildfallsintoagroupthatmaybeatelevatedriskforcomplicationsfrominfluenza.Recommendthattheybeevaluatedforpossibletreatment.Recommendthatthechild’scaregivercontactthechild’smedicalhome/pri-marycareproviderthatday.

Thischildfallsintoagroupthatmaybeatelevatedriskforcomplicationsfrominfluenza.Recommendthatthechild’scaregivercontactthechild’smedicalhome/primarycareproviderthatdaytodiscusstheneedforfurtherevaluationandtreatment.

Shouldsymptomsworsen(eg,short-nessofbreath,unresolvingfever)orshouldthechild’scaregiverhavefurtherquestionsorconcernsaboutthechild’shealth,recommendthecaregivercon-tactthechild’shealthcareprovider.

Thehigherriskcontactsofthesepa-tientsshouldbeadvisedtocontacttheirmedicalhome/primarycareproviderthatdayforadviceonstepstheymightneedtotaketopreventinfection.

YES

YES

YES

NO

NO

2009-2010 Influenza Season Triage Algorithm for Children (≤ 18 years) With Influenza-Like Illness (continued)





15


Clinical Pathway For The Management Of Pediatric Seizures

*Highriskcondition(indicatesCTbrainrecommended):Recenttraveltoendemiccystercercosisregion,headinjury,VPshunt,focalseizurelessthan33monthsofage,malig-nancy,HIV,suspicionforincreasedICpressure,neurocutaneousdisorder,persistentseizure,sicklecelldiagnosis,malignancy1

Neuro-surgeryconsult,admittoPICU

Admittoappropriateunitwithpediatricneurology47

Dischargehomewithappropriatefollowupandseizureprecuations3,47

YES

AEDs3,8,13

1.phenobarbital2.phenytoin3.benzodiazepineConsiderpyridoxineandotherAEDsuntilseizureiscontrolled;maintainairway

NO

Isneonatestillseizing?

CBC,bloodcultures,AEDmedicationlevelifappropriate,calcium,magnesiumlevel,BMP3

Ifmeningitisissuspected,giveIVantibiotics;ifherpesissuspected,giveantivirals.Per-formLPifnotcontraindicated.

Neonatalneuroimaging3

1.BrainCT2.Possiblecranialultrasound3.ConsiderinpatientMRI

Admitortransfertoappropri-atelevelofcare(ie,NICU),orderpediatricneurologyconsult,andcontinueairwayandseizuremanagement

PediatricseizurepatientpresentstotheED

ABC’s,IV,monitor,pulseoximetry,bedsideglucose,stabilizecervi-calspineiftrauma

Determinetypeofseizurefromdirectobservationorhistory

Ispatientaneonate?

Giveanti-pyretic

Ifthepatientisstillseizing,giveAEDsasappropriateuntilseizurestops;maintainairway

ConsiderbrainCTifhighriskcriteriaofrecenttraveltoendemicareaforcystercercosis,suspectedincreasedintracranialpressure,etc1,3

Simplefebrileseizure

Workupforfeverwithorwithoutsource:CBC,bloodculture,cathUA,viralswabs,stoolcultures,treatinfectionasappropriate.

**Meningitishigh-riskcriteria1.RecentMDvisit/antibiotics2.Focalseizure3.Lessthan12monthsofage4.12to18monthsofagewithsymptomssuggestiveofmeningi-tis(ie,increasedICP,petechiae,Kernig’s,Brudzinski’s)

Ifthepatientisstillseiz-ing,giveAEDs1.phenobarbital2.phenytoin3.benzodiazepineConsiderpyridoxineandotherAEDsuntilseizureiscontrolled;maintainairway3,8,13

Laboratorytests:testelectrolytesifpatientisaninfant,hasatemperaturelessthan36.5°C,orisactivelyseizingintheED36

BrainCTifhigh-riskorpredisposingcondition*

AbnormalCT?

NO

YES

PerformLP

IVantibioticsifmeningitisissuspectedYES

YES

NO

NO

YES

Anymeningitishighriskcriteria**?13,16,17,19

NO

Doeschildlooksick?(Abnormallabsoranysignsofmeningitis)

Wasseizurecomplex?

Istherefever>100.4°Frectalplusaseizure?

NO

LPcontraindicated?

NegativeLP?

Doesthechildappearwellandhavefollow-uparranged?

YES

NO

YES

NO

NO

NO

YES

YES

YES





16


Clinical Pathway: Patient With ANC < 500 Or Chemotherapy-Induced Neutropenia




















Evaluateairway,breathing,andcirculation.

Obtainbloodculture.(Class I)

PerformurinalysisandCXRifclinicallyindicatedaswellasfurtherculturesbasedonhistoryandphysicalexamination.(Class II)

Startcefepime50mg/kg/doseormeropenem20mg/kg/dosewithorwithoutvancomycin15mg/kg/dose.*¥(Class I)

Admittohospital.

*Thepractitionershouldchooseantibioticsbasedonhospitalpolicyandlocalbacterialresistancepatterns.¥Maximumdosesofmedicationsarenotlistedhere.Pleaserefertoadatabaseforcompletedosingrecommendations.

YESNO

Doesthepatienthavehypotensionorsignsofshock?

Obtainbloodcultureandinitiatebroadspectrumantibioticswithmeropenem20mg/kg/doseandvancomycin15mg/kg/dose.*(Class I)

PerformurinalysisandCXRaswellasfurtherculturesbasedonhistoryandphysicalexamination.(Class II)

TreathypotensionwithisotonicIVFboluses.Reassessaftereach20mL/kgbolus.(Class I)

Hashypotensionresolvedwithisotonicboluses?

YESNO

Initiateinotropes.(Class I)AdmittoPICU.

Admittohospital.





17


Evaluateairway,breathing,andcirculation.

NO YES

Clinical Pathway: Patient With Mild To Moderate Neutropenia*

Isthepatientunstable?

IstheWBCtheonlycelllinethatisabnormal? ProceedtoPathway1.

Doesthepatienthavesignsofsystemicbacterialinfection?

Consultahematologisttoruleoutotheretiologiessuchasaleukemicprocessor

aplasticanemia.

Sendbloodculture.(Class I)

PerformurinalysisandCXRaswellasfur-therculturesbasedonhistoryandphysicalexamination.(Class II)

Startcefepime50mg/kg/doseormeropenem20mg/kg/dose.(Class I)

Admittohospital.

Doespatienthavesignsoflocalizedinfection?

Doespatienthavesignsofviralinfection?

Ifthepatientiswellappearingwithmildtomoderateneutropeniaunrelatedtocancerorprimaryimmunodeficiency,considerdischargetohomewithappropriateoralantibioticcoverage.Closefollow-upmustbeensured.Admissiontothehospitalwillberequiredifinfectiondoesnotimprovewithoralantibiotics.

Ifthepatientiswellappearing,withoutsourceofinfection,consider

bloodcultureandceftriaxone50mg/kgwithfollow-upthenextday.

Providesupportiveoutpatientcarewithclosefollow-up.

*Anypatientwhoisill-appearingshouldhavebroad-spectrumantibioticsinitiatedandshouldbeadmittedtothehospitalregardlessoftheANCvalue.Thepractitionershouldalsoriskstratifybasedonsuspectedunderlyingcauseandexpecteddurationofneutropenia.

NO YES

NO YES

NO YES

NO YES





18


Clinical Pathway For Evaluation And Treatment Of Cerebral Edema

• Astaffmemberisconcernedaboutanacuteneurologicchangeinthepatient.

• Considermannitol0.25-1.0g/kgIVover20minutes.Repeatforcon-tinuingsymptoms.(Class II)OR

• Consider3%normalsaline5-10mL/kgIVover30minutes.Repeatforcontinuingsymptoms.(Class III)

• Continuecurrentmanagement.

• Consider criteria-based assessment for cerebral edema. (Indeterminate)

lDoesthepatienthaveatleast1ofthefollowing:abnor-malmotororverbalresponsetopain,posturing,cranialnervepalsy,orneurologicrespiratorypattern?OR

lDoesthepatienthaveany2ofthefollowing:alteredorfluctuatingconsciousness,sustainedheartratedecel-erations,orage-inappropriateincontinence?OR

lDoesthepatienthave1criteriafromthesecondgroupplusatleast2ofthefollowing:emesis,headache,leth-argyordecreasedarousability,diastolicbloodpressure>90mmHg,orage<5years?

YES NO





19


Clinical Pathway: Migraine Headache Neuroimaging

YES




















Doesthepatienthaveamigraineheadache?

Isthepatient’sneurologicalexamnormal?

NO

NO

NO

YES

YES

Isthereseizureassociatedwiththehead-ache?

Obtainneuroimaging(Class II)


Noneuroimagingrequired(Class II)

NO

Evaluateothercausesofheadache


Isthisheadachesimilartopatient’spriorheadaches?

YES





20


Clinical Pathway: Pediatric Migraine Clinical Treatment Pathway




















Utilizeoutpatient/oralmedications(Class I)

Intravenousfluids(Class II)Decreaseenvironmentalstimuli(Class II)

Istheheadacheduration<4hours?

Prochlorperazine(Class II)

“Triptans”SumatriptanSQ/PO/INZolmatritanPO/INRizatriptanPOAlmotriptanPO

(Class II)

Istheheadacheimprovedafter1to2hours?

Consider2ndmedication:ValproicAcid(Class III)

Dihydroergotamine(Class III)

Dischargepatient

Istheheadacheimprovedafter1to2hours? Dischargepatient

Inpatientadmission(Class I)

NO

NO

NO

YES

YES

YES

YES

FPS-Rpainscale>3?

NO





21


Monitorfordevelopmentofcentralnervoussystemdepressionandseizures.Ifchildremainsasymptomaticfor4hourspostingestion,thendischargetohome.

Ingestionofcamphor,eucalyptusoil,oranimidazoline

Clinical Pathway: Oil Of Wintergreen, Pennyroyal Oil, Camphor, Eucalyptus, Imidazoline Decongestant

NO

NO

YES

Shortstayadmission;consideradministrationofactivatedcharcoal;administerN-acetylcysteine;monitorforhypoglycemiaand

liverdysfunction.

Obtainsalicylatelevel.Ifchilddevelopsalteredmentalstatusorhasasalicylatelevelgreaterthan100mg/dL,thenconsiderdialysis.Ifchild

remainsasymptomaticfor4hoursandsalicylatelevelsarenottoxicandaredeclining,thenthechildmaybedischargedtohome.

Anysymptomaticchildshouldbeadmittedtoamonitoredsetting.

NO

NO

YESChildasymptomatic

Consideradministrationofactivatedcharcoal.Monitorthechildforatleast12hourspostingestionfordevelopmentofananticholinergicsyn-dromeduetoatropineand/orforopioidsyndromeduetothediphenoxyl-

ate.

YESCentralnervoussystemand/orrespiratorydepression

Administernaloxoneuntilopioideffectsarereversed.Admittoamoni-toredsetting.

YES

YES

Ingestionofpennyroyaloil

Ingestionofoilofwintergreen

Clinical Pathway: Diphenoxylate–Atropine

YES

Ingestionofoilofwintergreen,pennyroyaloil,eucalyptusoil,camphor,oranimidazoline

YES

Ingestionofdiphenoxylate–atropine





22


Consideroctreotide;admittomonitoredsetting.

NO

NO

YES

HypoglycemiaIfthechilddevelopsnohypoglycemiaforatleast8hours

followingtheingestion,thenthechildmaybedischargedbacktounmonitoredsetting.

YESHypoglycemiaresolvesfollowingoralorparenteralglucose

Admitandmonitorforreoccurrenceofhypoglycemia.

Anysymptomaticchildexposedtoanorgano-phosphateshouldbemonitoreduntilcomplete

resolutionofsymptoms.

Seizure

Ingestionofanorganophosphate-containingproduct

NO

NO

YES

YESChildasymptomatic

YES

Monitorforatleast4hours.Ifthechilddemonstratesnosignsorsymptoms,thechildmaybedischargedtohome

YESWheezingorairwaysecretions

Administeratropinebytheintravenous,intramuscular,orendotra-chealrouteatadoseof0.02mg/kg(minimumof0.1mg)every5minutesuntilresolution.Considerpralidoximeadministration.

Administerbenzodiazepinesuntilresolutionofseizureactivity.Inaddition,consideradministrationofatropine.Contactneurology

andconsiderelectroencephalogrammonitoring.Considerpralidoximeadministration.

NO

Clinical Pathway: Organophosphates

Clinical Pathway: Sulfonylureas

YES

Ingestionofsulfonylureabyachild





23


Clinical Pathway For The Treatment Of Pediatric Burns

1.Earlyintubation(Class II)2.Oxygensupplementation3.ChestX-ray(Class III)4.EvaluateforCOpoisoning

1.20to40mL/kgbolusnormalsalineorlactatedRinger’s(Class II)2.Cardiacpressuresifneeded3.Evaluateforactivebleeding

1.Cervicalspineprecautions(Class II)2.HeadCT(Class II)3.Radiographstolookforfractures(Class II)4.Bloodfortypeandcrossmatch

1.Identify%TBSAburned(LundandBrowder,ruleofninesorpalmrule(Class II)

2.UsetheParklandformula:4mL/kg/%TBSA(Class II)3.PlaceaFoleytomonitorurineoutput(Class II)

1.Considertransfertoaburncenterspecializinginpediat-rics(Class II)

1.Washburnwithmildsoapandwater2.Debridetheburn.(Class II)3.Applyantimicrobialointmentorcream(ClassII)4.Applyasyntheticskinsubstituteorocclusivedressing.

(optional)(Class II)5.Providetetanustoxoidinjection+/-tetanusimmune

globulin(TIG)

1.Notifytheappropriateauthoritiestoensurethechild’ssafety

Theevidence for recommendationsisgradedusingthefollowingscale.Class I:Definitelyrecommended.Definitive,excellentevidenceprovidessupport.Class II:Acceptableanduseful.Goodevidenceprovidessupport.Class III:Maybeacceptable,possiblyuseful.Fair-to-goodevidenceprovidessupport.Inde-terminate: Continuingareaofresearch.



YES

YES

YES

YES

YES

YES

YES

PrimarySurvey:AirwayandBreathingl Aretheresignsofairwaycompromise,stridor,significant

facialinjury,orinhalationinjury?

PrimarySurvey:Circulationl Aretheresignsofhypotensionorshock?

PrimarySurvey:Disabilityl Removeclothing,jewelry,andharmfulforeignbodies.

SecondarySurvey:l Multisystemtrauma?

SecondarySurvey:BurnEvaluationl Largeburn(>20%TBSA)

BurnEvaluation:l Istheburninaconcerninglocation(hand,feet,face

genitalia,overajoint)l Doestheburnrequireadmission?

Istheburnpartialorfull-thickness?

Isthereconcernthisinjurywasinflicted?

NO

NO

NO

NO

NO

NO





24


Clinical Pathway For The Treatment Of Mammalian Bites

YES NO

High risk injury?(includingthosewithdelayedpresenta-tion,bitestothehand,andimmuno-compromisedpatients)

Lower risk injury?(includingthosetoyoung,otherwisehealthypatientswhowerenotbittenontheirhand)

Perform physical examination.• Notethelocationofwound.• Notethedepthandtypeofwound(eg,avulsion,puncture,crush).• Assessfunctionifanextremityisinvolved.• Performaneurovascularexamination.• Assesspatientforsignsofinfectionifdelayedpresentation.

Consideraconsultationandprescribingantibiotics.

Order diagnostic studies.• Orderradiographsifbonyinjury,violationofjoint,orforeignbodyissuspected.• OrderawoundcultureandGramstainforinfectedwounds.• Orderadditionalstudiesifbacteremia/sepsisispresentincludingacompletebloodcell

count,bloodculture,coagulationstudies,andliverpanel.

Isitalaceration?

Iftheinjuryisuncomplicated,ask:If the injury is complicated:(involvestendons,joints,bones,and/ornerves,orsepsisisevident)

Isitapuncturewound?

Cleanseanddressthewound.Considerantibiotics.

Consideraconsultandpossibleadmission.

Considersuturingthewoundifneeded.Suturethelaceration.

Perform wound care.• Irrigate.• Debrideifindicated.• Performincisionanddrainageifanabscessispresent.• Considerwoundclosureincosmeticallyimportantareas.• Elevateandimmobilizeifwoundisonextremity.

Isthelacerationofcosmeticconcern?

NO

YES YES

Gather the history of the injury.• Obtainpatientinformationincludingpastmedicalhistory,medica-

tions,drugallergies,tetanusimmunizationstatus,andsocialfactors.

• Obtainanimalinformationincludingrabiesimmunizationstatus,animal’shealth,andlocationofanimal.

• Obtaininformationregardingtheinjuryincludingprovokedvsun-provokedinjuries,timing,anddelayinseekingmedicaltreatment.





25


Clinical Pathway For Treatment Of Traumatic Dental Injuries

Typeofinjury

AnalgesicsSoftdiet

AnalgesicsSoftdiet

NOYES

AnalgesicsSoftdiet

Splint,ifsevereAnalgesicsSoftdiet

NOYES

Allowtore-eruptIfnore-eruptionafter2

months:extract

Allowtore-eruptIfnore-eruptionafter3to6weeks:extract,splint,rootcanal

NOYES

RepositionSplint

RepositionSplint

NOYES

Donotre-implant Re-implantimmediatelyNOYES

Pulpectomyorpulpotomy

Enamelonly:analgesics

Enamelanddentin:cap,restoration

NOYES

Ifapical:restorationIfcoronalormiddle:

extract

Concussion—istoothprimary?

Subluxation—istoothprimary?

Intrusion—istoothprimary?

Extrusion,lateralluxation—istoothprimary?

Avulsion—istoothprimary?

Fractureofthecrown(primaryandperma-nent)--Isthefracturecomplicated(ie,in-

volvesenamel,dentin,andpulp)?

Fractureoftheroot,primaryandpermanent







26


Clinical Pathway For Treating Pediatric Wounds




















YES

YES

NO

NO

NO

Woundriskfactors:• Infected?(Class I)• Obviouscontamination?(Class I)• Sustained>18hrago?(Class II)

Closurebysecondaryintentionor

Delayedprimaryclosure

Wound<6hrold?(Class I)

Closurebysecondaryintentionor

Delayedprimaryclosure

• Anesthesia—topicalorinjectable(Class I)• Cleanse:chlorhexidine–alcoholpreparation(Class II)• Irrigation:tapwaterorsaline(Class II)• Chooseclosuremethod:suture,cyanoacrylate,staples

Referto“ClinicalPathway:PediatricPainAndAnxietyInTheED”

• Imaging,ifindicated,forforeignbodies• Consultspecialist,ifindicated

Primaryclosurepreparation

Sedationneeded?

• Clean,viabletissue?• Well-vascularizedarea?• Nocomorbiditiesthatmightleadtopoorwoundhealing?(Class II)

NO

YES

YES





27

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