Influenza Vaccination
BY  SEAN M. FOX · PUBLISHED OCTOBER 23, 2015 · UPDATED OCTOBER 22, 2015
Obviously, the audience (you all) who read these Morsels love critical care topics (Post-Tonsillectomy Hemorrhage has been the most viewed Morsel since it was written in 2012), but excellent care in the Peds ED often requires some considerations that emergency providers don’t often list in their skill set.  Issues that we might assume are in the realm of the Primary Care provider (ex, Asthma Control, Developmental Milestones, Firearm Safety, Submersion Prevention, and Injury Prevention) actually can play critically important roles in the management of our patients in the ED.  One such topic is Vaccinations.  We need to help children stay healthy by giving at risk patients the Influenza Vaccination.

Vaccination in the ED is NOT Unusual

• The ED is a critical frontier for public health.
  • This is certainly true for critical injuries and illnesses.
  • It is also true for sub-acute and chronic disorders.
  • It has an equally important role in injury and illness prevention.
    • ACEP Policy Statement

• The ED has already been administering vaccinations as part of appropriate care.
  • Tetanus
    • Every time someone scratches their skin, we “update the tetanus.”
    • Now, this actually should include “update the diphtheria.” [CDC Tdap Recommendations]
  • Rabies
    • Certainly animal bites can cause more than just flesh wounds.
    • In 2010, the Rabies Vaccination regimen changed from 5 doses to 4 doses (one days 0, 3, 7, and 14). [CDC Rabies Vaccine Recommendations]

Influenza

• Influenza is highly contagious.
• Influenza can may cause mild disease, but can also lead to severe illness and complications. [CDC, Disease Burden]
• Anyone can contract the illness, but there are special populationswho are at greater risk from the disease:
  • >65 years of age
  • Pregnant (and up to 2 weeks post partum)
  • Residents of long-term care facilities
  • Children <5 years of age (particularly <2 years of age)
  • Patient with chronic medical problems (abridged):
    • Asthma
    • Cystic Fibrosis
    • Neuromuscular disorders
    • Seizure disorders
    • Congenital heart disease
    • Sickle Cell Disease and other blood disorders
    • Diabetes mellitus
    • Chronic renal disease
    • Chronic liver disease
    • Inborn Errors of Metabolism
    • Immunocompromised states
    • Children on long-term aspirin therapy
    • Morbidly obese 

• Influenza Vaccination has proven to be an effective means to reduce influenza-related morbidity.
• Vaccination of one group of at risk patients can also reduce influenza-related morbidity morbidity in other groups. [Gatewood, 2011]
• Unfortunately, influenza vaccination is still underused among at risk patients. [CDC, Flu Vaccination Rates]

Vaccination for Influenza in the ED

• The vast majority of the vaccination should occur in the outpatient environment, but there are potential barriers to achieving this:
  • Lack of access to primary care office visit during the vaccination period
  • Lack of education about specific risk
  • Lack of education about recommendations
  • Parental preference / concern for vaccine safety [Strelitz, 2015]
  • Provider discomfort (hopefully, you are less uncomfortable now)

• An ED visit offers an opportunity to influence many of these barriers.
  • Certainly discussing influenza, at risk populations, and the recommendations can improve awareness and influence subsequent vaccinations.  [Dappano, 2004]
  • Offering the influenza vaccination in the ED has also proven to be helpful. [Dappano, 2004]

• Having a concurrent illness should not prevent vaccination.
  • The largest group of at risk patients we encounter in the ED are patients with asthma.
  • Does being on steroids interfere with the vaccination? NO.
  • Influenza vaccination can be given safely and effectively to kids with an asthma exacerbation even if they are on steroid therapy. [Park, 1996]

Moral of the Morsel

• Providers in the ED encounter patients when they are most receptive to education about their illness.
• Patients with asthma are often cared for in the ED and are one of the at risk populations.
• Help prevent that patient from returning to the ED or causing someone else from becoming ill by expanding the exposure to influenza vaccination.

Oseltamivir (Tamiflu) for Children, Maybe Not a Magic Pill
BY  SEAN M. FOX · PUBLISHED MARCH 2, 2018 · UPDATED FEBRUARY 28, 2018
Making a patient feel better is empowering and rejuvenates our professional spirits. This is why we all love taking care of the patient with a Patellar Dislocation, Shoulder Dislocation, or a Nursemaid’s elbow. Obviously, administering Adenosine for SVT can make you feel like a magician also! Unfortunately, the availability of Magic Medicine is limited. Even more unfortunate, our patients are often preconditioned to look for a magic pill. This flu season has been challenging, on multiple fronts, because patients have been told of the importance of Oseltamivir (Tamiflu). I, personally, however, have not seen a magic pill in our clinical environments. When something seems to be incongruent, I look to see what the Cochrane Library has to say. Let us review what is known about oseltamivir today (and actually since 2014):

Influenza

• Influenza is highly contagious.
• Influenza can may cause mild disease, but can also lead to severe illness and complications. [CDC, Disease Burden]
  • Remember — never say “It’s just a virus” as a means to convey reassurance…
  • Numerous viral infections can lead to horrific outcomes.

• There are special populations who are at greater risk from the disease:
  • >65 years of age
  • Pregnant (and up to 2 weeks post partum)
  • Residents of long-term care facilities
  • Children <5 years of age (particularly <2 years of age)
  • Patient with chronic medical problems, like asthma (see CDC list)

• Influenza Vaccination has proven to be an effective means to reduce influenza-related morbidity.
• Unfortunately, influenza vaccination is still underused among at risk patients. [CDC, Flu Vaccination Rates]

Influenza: Therapies(?)

• The Center for Disease Control (CDC) currently states:
  • “Prescription medications called ‘antiviral drugs’ … can be used to treat flu illness.” (CDC.gov)
  • “It’s very important that flu antiviral drugs are started as soon as possible to treat: (CDC.gov)
    • hospitalized flu patients, 
    • people who are very sick with the flu but who do not need to be hospitalized, 
    • and people who are at high risk of serious flu complications.” 
  • “…most people who are otherwise healthy and get the flu do not need to be treated with antiviral drugs.” (CDC.gov)

• The available “therapies” for children:
  • Peramivir – for patients 2 years and older (only in IV form)
  • Zanamivir – for patients 7 years and older (not for pts with asthma)
  • Oseltamivir – for patients 14 days and older
    • Oseltamivir is on the World Health Organizations List of Essential Medicines
    • Governments now stockpile Oseltamivir to be prepared for pandemics.

Oseltamivir and Neuraminidase Inhibitors: The Problem

• Much of the the justification for recommendations and stockpiling are based on pharmaceutical company-based research. [Gupta, 2015]
  • Not that industry-sponsored research is unable to generate important information and be valuable… but…
  • These particular studies, when re-reviewed, had issues: [Jefferson, 2014]
    • The original detailed data was not made easily available.
    • Definitions of disease and complications were vague.
    • Placebo interventions (when used) may have had active substances.

• In order to address developing concerns about zanamivir and oseltamivir, Jefferson et al.: [Jefferson, 2014]
  • Did not use the journal publications (as there was publication bias and discrepancies).
  • Instead, obtained the manufacturers’ reports to regulators and the regulators’ comments.
    • These are unpublished, extensive documents with great detail on the trials that formed the basis for market approval.
    • They include the protocols, methods and results.
    • They are typically confidential – seen only by the manufacturers and regulators.
  • After review of this information, found “substantial problems with the design, conduct, reporting, and availability of information from many trials.”

• Based on this re-review, several areas of potential bias were found:
  • Performance Bias – from differences in care provided to participants.
  • Selection Bias – there was inadequate reporting to understand how groups were assigned to therapies
  • Attrition Bias – participants who drop out (possible due to side-effects) not being included in the results.

Oseltamivir: What is Concluded

• For adults, Oseltamivir (Tamiflu): [Jefferson, 2014]
  • Reduced time to alleviation of symptoms by 16.8 HOURS.
  • Prophylactic use can reduce the risk of developing symptomatic influenza.
  • Had no significant effect on hospitalizations.
  • Did not reduce complications classified as serious.
  • Did not reduce the otitis media or sinusitis.
  • May have reduced self-reported, unverified pneumonia (lack of definition)
  • Side-effects seen:
    • Nausea with Number Needed to Harm (NNTH) = 28
    • Vomiting with NNTH = 22
    • Dose-response effect on psychiatric events.
    • Headache, renal and psychiatric events seen during prophylaxis therapy.

• In children, Oseltamivir (Tamiflu): [Jefferson, 2014]
  • Reduced time to alleviation of symptoms by 29 HOURS in healthy children.
  • Had NO SIGNIFICANT effect in children with asthma (one of the high risk groups).
  • Had NO SIGNIFICANT effect in hospitalizations.
  • Had NO SIGNIFICANT effect in prophylaxis.
  • Did not reduce complications classified as serious.
  • Did not reduce the otitis media or sinusitis.
  • Did not have an effect on unverified pneumonia.
  • Nausea is seen frequently as side-effect with NNTH = 19

Moral of the Morsel

• Don’t be Biased! Regardless of where research originates from, its conclusions may be substantially influenced by numerous biases… good study design aims to help reduce this risk.
• Don’t be Bullied! Understand the recommendations… but also their limitations. Asthma may place a patient in the high risk category, but there is no evidence that a child with asthma benefits from oseltamivir.
• Weigh Risk and Benefit! We do this with all conditions, evaluations, and therapies… hopefully this Morsel will help you with the true weight of the items in this specific equation.
• Educate Your Patients and Their Families! This goes without saying… but is the most important.

Pleural Effusions
BY  SEAN M. FOX · PUBLISHED AUGUST 31, 2018 · UPDATED AUGUST 29, 2018
Respiratory Distress is a common emergent complaint encountered when caring for children. Whether it is Out of Control Asthma or Pneumonia, or Severe Croup or Aspirated Foreign Bodies, or Bronchiolitis or Heart Failure, or Spontaneous Pneumothorax or Traumatic Pneumothorax … (goodness, that is a lot of stuff!) we have to be prepared to evaluate and manage a wide variety of conditions that may initially look very similar to one another. Of course, sometimes even when we make the correct diagnosis and management plan, things can become even more complicated (ex, Negative Pressure Pulmonary Edema, Mechanical Ventilation for Status Asthmaticus). Let’s take a look at a condition that may catch you by surprise and, even once managed appropriately, deserves specific vigilance- Pediatric Pleural Effusion and Reexpansion Pulmonary Edema: (it’s like 2 Morsels for the price of one!)


Pleural Effusion: Basics

• Pleural effusion = fluid accumulation in pleural space.
• Occur at ANY AGE … even neonates! [Lee, 2018]
• Occur when rate of absorption < rate of accumulation
• Factors that influence development of pleural effusion: [Lee, 2018]
  • Hydrostatic Pressure
  • Oncotic Pressure
  • Lymphatic Pressure
  • Regional Inflammation

• Clinical presentation of pleural effusions depends on size of effusion and any associated medical conditions/causes.

Pleural Effusion: Causes

• There are numerous causes!
  • Anything that affects the factors noted above can lead to pleural effusion.
  • Often individual causes influence development via multiple factors.
  • Infection is the leading identified cause of pleural effusions. [Utine, 2009]
    • Parapneumonic Effusion accounted for ~78% of cases in one study. [Utine, 2009]
    • Tuberculous is a notable cause as well. [Utine, 2009]
  • Malignant Effusions accounted for ~4% of cases. [Baniak, 2017; Utine, 2009]
  • Congenital Heart Diseases accounted for ~1% [Utine, 2009]
  • Chylothorax accounted for <1% of cases. [Utine, 2009]
  • Many causes go Unidentified. [Utine, 2009]

• Acquired or Iatrogenic pleural effusions occur TWICE as often as congenital effusions. [Lee, 2018]

Pleural Effusion: Management

• Imaging:
  • CXR is often first image obtained and may show:
    • Fluid in fissures
    • Blunting of costophrenic angle
    • Mass effect
    • Meniscus formation
  • Ultrasound should be considered early!
    • It is timely and “easy” to do at the bedside …
      • So sick child doesn’t have to leave your department
      • Check out video at bottom of this page (and on mededmasters.com)
    • Can detect smaller volumes of effusion than CXR.
  • CT may be useful in evaluation, but not until patient is clinically stable.
    • May help show associated anatomic abnormality or cause (ex, migrated VP shunt tip). [Porcaro, 2018]
    • May show associated traumatic injuries (if effusion related to trauma). [Kulaylat, 2014]

• Drainage / Thoracentesis:
  • Small bore catheters are generally favored over large calibre tubes.
    • Better tolerated.
    • Less complication risk.
    • Do the job!
    • See Morsel on Pigtails Catheters.
  • SMALL Asymptomatic pleural effusions may resolve with treatment aimed at underlying condition.
    • Medical Management may include:
      • Specialty nutrition with high medium-chain triglyceride content (decreases intestinal lymph production and decreases flow through thoracic duct).
      • Octreotide may reduce need for surgical intervention.
    • Treat underlying issue:
      • If related to uremia – initiation of hemodialysis. [McGraw, 2017]
      • If central line in place, remove as it may be causing obstruction. [Lee, 2018; Siddiqui, 2015]

• Characterize Pleural Fluid:
  • Samples of pleural fluid should be sent for: [Lee, 2018]
    • pH
    • Cell Count
    • Gram Stain and Culture
    • Protein
    • Glucose
    • Lactate Dehydrogenase
    • Triglycerides
  • Transudative vs. Exudative Process [Lee, 2018]
    • Exudative effusion tend to have:
      • Cloudy appearance
      • Specific gravity > 1.020
      • Elevated protein
      • Lactate dehydrogenase levels > 2/3rds the serum level
    • Transudative effusion tend to have:
      • Clear appearance
      • Specific gravity < 1.012
      • Protein level < 2.5 g/dL
      • Fluid Protein: Serum Protein < 0.5
      • Lactate dehydrogenase level < 2/3rds the serum level
    • Light’s Criteria is often used to help classify pleural fluid, although it hasn’t been validated in children. [McGraw, 2018; Less, 2018]

ReExpansion Pulmonary Edema

• Reexpansion Pulmonary Edema is uncommon, but can occur AFTER expansion of a collapsed lung.
• Most commonly described in the setting of treatment of Pneumothorax or Pleural Effusion. [Hirsch, 2018]
• Risk Factors: [Hirsch, 2018]
  • There is no clear evidence to attribute any specific risk factor for development of Reexpansion Pulmonary Edema in children.
  • Some considerations though are:
    • Younger age
    • Use of high suction pressure (recommended to use between -10 to -20 cmH2O, or even just water seal at first).
    • Chronically collapsed lung
    • Larger size of Pneumothorax or Pleural Effusion
  • In the end, Reexpansion Pulmonary Edema can occur in a variety of situations and requires vigilance.
• Presentation: [Hirsch, 2018]
  • May be asymptomatic (only seen on repeat imaging)
  • Tachypnea, worsening dyspnea
  • Cough, sometimes productive with pink frothy sputum

Moral of the Morsel

• Be Kind! Use a pigtail catheter to drain effusion.
• Characterize the Fluid! Light’s Criteria may help distinguish exudative from transudative, but nothing is perfect.
• Don’t ignore that cough! After placement of the pigtail catheter, don’t just assume all will be fine. Monitor for Reexpansion Pulmonary Edema.

Pulmonary Embolism
BY  SEAN M. FOX · PUBLISHED MAY 22, 2015 · UPDATED MAY 21, 2015
Last week we discussed a basic look at Chest Pain in children presenting to the ED. This sparked several questions about Pulmonary Embolism in children. Let us take a little more specific look at PE in kids.
​
Pulmonary Embolism: Rare but Real

• National Hospital Discharge Survey – 0.9 / 100,000 children per year
• Venous thromboembolism rates have increased over the past 2 decades. [Boulet, 2012; Raffini, 2009]
  • Consideration and detection of the condition has increased.
  • Increase use of intravascular devices (ex, central lines, PICC lines).
• Typically found to have a bimodal distribution with highest rates found in: [Stein, 2004]
  • Kids 0-1 year of age
  • Kids 15-17 years of age
• Mortality rate – Up to 20% with 1st diagnosis, up to 30% with recurrence

 
Pulmonary Embolism: Red Flags

• Risk stratification tools:
  • PERC – not validated in children
    • When PERC was applied RETORSPECTIVELY, 84% would have been missed. [Agha, 2013]
  • Wells Criteria – not validated in children
    • Even when Wells Criteria has heart rate adjustments for age, there is still not a statistical difference between PE (+) and PE (-) children. [Biss, 2009]
  • D-Dimer
    • Not validated as a diagnostic tool in children [Biss, 2009]
    • Can be used in adolescents
    • D-Dimer may vary with age and, hence, test threshold levels are not yet known.

 

• Diagnosis of Pulmonary embolism is challenging in adults, it is even more so in children… so remain vigilant (while being reasonable).
• Risk factors for thromboembolic disease in children:
  • Obesity (50% in Agha, 2013 study]
  • Oral Contraceptive Use [38% in Agha, 2013 study]
  • Central Venous Catheter
  • Cancer
  • Congenital Heart Disease
  • Prothombotic States
    • Protein C and S Deficiency
    • Antiphospholipid Antibiodies
    • Nephrotic Syndrome
    • Systemic Lupus

 
Moral of the Morsel

• The rarity of the condition can lead to complacency; remain vigilant.
• The lack of validated decision rules may lead to over-testing; be reasonable.
• Always actively look for Red Flags!
• Always reconsider the Differential Diagnosis for the patient that returns for similar complaints… does the child really have a repeat “atypical pneumonia” or is it a pulmonary embolism?