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Fleisher & Ludwig’s
5-Minute
Pediatric
Emergency
Medicine
Consult
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EDITORS ASSOCIATE EDITORS
Robert J. Hoffman, MD, MS Sandip A. Godambe, MD, PhD, MBA
AssociateProfessorofEmergencyMedicine AssociateProfessorofPediatrics
AlbertEinsteinCollegeofMedicine UniversityofTennesseeHealthScienceCenter
Bronx,NewYork MedicalDirector,MedicalStaffQualityand
ResearchDirector QualityEducation
DepartmentofEmergencyMedicine AssociateMedicalDirector-EDT,EmergencyServices
BethIsraelMedicalCenter LeBonheurChildren’s Hospital
NewYork,NewYork Memphis,Tennessee
Director,MedicalToxicology
EmergencyServicesInstitute Raymond Pitetti, MD, MPH
SheikhKhalifaMedicalCity AssociateProfessorofPediatrics
AbuDhabi,UnitedArabEmirates UniversityofPittsburghSchoolofMedicine
MedicalDirector,SedationServices
Vincent J. Wang, MD, MHA AssociateMedicalDirector,EmergencyDepartment
AssociateProfessorofPediatrics Children’s HospitalofPittsburghofUPMC
KeckSchoolofMedicineoftheUniversityof Pittsburgh,Pennsylvania
SouthernCalifornia
AssociateDivisionHead
DivisionofEmergencyMedicine
Children’s HospitalLosAngeles
LosAngeles,California
Richard J. Scarfone, MD
AssociateProfessorofPediatrics
UniversityofPennsylvaniaSchoolofMedicine
MedicalDirector,EmergencyPreparedness
TheChildren’s HospitalofPhiladelphia
Philadelphia,Pennsylvania
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Fleisher & Ludwig’s
5-Minute
Pediatric
Emergency
Medicine
Consult
Editors
RobertJ.Hoffman,MD,MS
VincentJ.Wang,MD,MHA
RichardJ.Scarfone,MD
Associate Editors
SandipA.Godambe,MD,PhD,MBA
RaymondPitetti,MD,MPH
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PREFACE
We have produced this first edition of The 5-Minute Pedi- oughbutveryconcise,succinctmannersothatallkeypointsabout
atricEmergencyMedicineConsult with the specific goal clinical presentations, differential diagnoses, diagnostic investiga-
ofprovidingaconcise,formattedresourcefortheclinical tions, therapeutic interventions including medications and doses,
managementofpediatricemergenciesandcommonpediatriccom- and admission or discharge criteria are presented. This text has
plaintsencounteredinemergencydepartmentsandothersettings. been authored by selected pediatric emergency physicians from
Asacademicpediatricemergencyphysicians,ourgoalistoapply both emergency and pediatric medicine backgrounds to provide
thebestevidence,publishedclinicalpracticeguidelines,andother truesubspecialtyexpertise.
informationtooptimizepatientcare.Numerousconstraintsmayin- The5-MinutePediatricEmergencyMedicineConsultwillbeuse-
terferewithone’sabilitytostayappraisedofthemostcurrentevi- fultotraineesaswellastocliniciansfarbeyondtraining.Thoughthe
denceandguidelinesapplicabletopediatricemergencymedicine. editorsandauthorspracticepediatricemergencymedicinewithin
We recognize this and present this book as a resource for those theconfinesofemergencydepartmentsinacademicmedicalcen-
whoalsowishtopracticeevidence-basedmedicinebutrequirethe ters,werecognizethatmostpediatricemergenciesarenottreated
information distilled in a single, easily accessible reference. This insuchsettings,andmanypediatricemergenciesaretreatedout-
5-MinutePediatricEmergencyMedicineConsult is exactly such a sideofanemergencydepartmentaltogether.Thus,wehavetaken
reference book. Honorifically named for the Fleisher and Ludwig greatstridestoproduceareferencethatrepresentsoptimalman-
Textbook of Pediatric Emergency Medicine, which is the seminal agement of emergent and urgent pediatric conditions as well as
comprehensivetextbookofpediatricemergencymedicine,ourtext commonpediatriccomplaintsinallsuchlocations.Cliniciansprac-
seekstoprovidearapidreferenceforuseintheclinicalworkplace ticing in a tertiary care academic medical center with extensive
ratherthanthorough,extensivecoverageofthesubjectmatter.The subspecialty support or those in the community setting in which
5-MinutePediatricEmergencyMedicineConsult isintendedtobe littleornosubspecialtysupportwillfindthistexttobeaninvaluable
accurate, pointed, and readily integrated into practice rather than resource.
definitive. We hope this book will serve as a useful and frequently used
Clinicians at all levels of training and all stages of career de- resourcetoassistinourcommongoalofprovidingthebestpossible
velopment need references to facilitate the provision of optimal pediatricemergencycaretoourpatients.
patientmanagement.Eachchapterpresentsinformationinathor-
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FOREWORD
FiveMinutes–Whatcanyoudoin5minutes?Workinginthe portant overview. At other points, it will be used for a familiar or
pediatricemergencydepartmentformorethan35yearshas commonclinicalsituationbuta5-minuterefresherwillprovideare-
often been a humbling experience. Along the way, we have assuringdoublechecktomakesurenothinghasbeenoverlooked
learned many lessons. One of the most important has been the orforgotten.Ineithercase,thatinitialorientationandpreparation
valueoforientationandpreparation.Wehaveallprovidedcarefor willprovemostvaluable.
children when they suddenly burst through the doors in the arms We are honored to have our names as part of the title of this
ofapoliceofficerorparamedicwithmajormultisystemtraumaor book.WeviewitasaperfectcompaniontotheTextbookofPediatric
cardiacarrest.Wehavebeeninthesamecriticalsituationwhenwe EmergencyMedicine,6thEditionwheremorein-depthinformation
hadjust5minutestopreparefortheevent.Asmanyofthereaders canbelearned.Wethanktheeditorsandauthorsforallowingus
ofthisbookknow,thatextra5minutesmakesaworldofdifference to share in this work. We see it as yet another important step in
totheoutcomeandperceivedqualityofcareprovided.Evenwhen improvingtheemergencycaretoillandinjuredchildren,whichhas
residentsareassignedtotheemergencydepartmentforarotation beenthefoundationofourlife’swork.
itisourperceptionthatthosewhogetabrieforientationtothesite Fiveminutescanmeanalot,and5minutesofreadingoneof
performmuchbetterthanthosewhodonot.Andthosewhotakea thetopicsthatfollowwillsetyouonapathwaytowardrewarding
minutetopreparebeforegoingintoatreatmentroomalsoevolve clinicalcare.
tobebetterphysicians.
Thatbringsustothisbook,The5-MinutePediatricEmergency STEPHENLUDWIG,MD
Philadelphia,Pennsylvania
MedicineConsult.Weknowthatusingthisbookwillprovidephysi-
cianswiththeorientationandpreparationneededtoaddressawide GARYR.FLEISHER,MD
rangeofclinicalproblems.Sometimesitwillbeanewconditionthat Boston,Massachusetts
the physician has not faced before, and the topic will give an im- February2011
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ACKNOWLEDGMENTS
IthankmywifeMiyaforherunderstanding,support,andsacrifice Iwouldliketothankmypatients,colleagues,andmentorswhohave
duringtheproductionofthistext. taught me so much in my career. Your collective inquisitiveness,
IsincerelythankLewisGoldfrankandSteveDavidsonforgiving selflessness, and support have inspired me to become a clinician
me the most formative academic opportunities of my career, and worthyofyourtrust.Iamgratefultothemanyauthorsofthisbook
LewisNelsonandBobHoffmanforservingasidealmodelsofaca- who have worked so hard to create an outstanding resource for
demicemergencyphysiciansandclinicianeducators.Tothemany patientcare.Thankyoutomywife,Karen,foryourloveandsupport,
emergencymedicineresidencyclassesandnotablythechiefres- andthankyoutomywonderfulchildrenStevenandJulia—Iloveyou
identsofBethIsraelMedicalCenter,Iextendthanksforyearsof andI’mproudoftheyoungpeoplethatyouhavebecome.
rewardinginteractionandinspirationtoremaininacademics. R.J.S.
Iacknowledgefriendsacrosstheglobepastandpresentwho
haveassistedmyendeavorsbyhelpingmebalanceproductivework This book is the result of the hard work of countless dedicated
withenjoyablerecreation.Lastly,Ithankthefamiliesandpatients authors.Ithasbeenapleasuretoworkwiththemandtheeditorial
towhomI’veprovidedemergencycarefortheprivilegeoftreating andpublishingteamofthisbook.Iwanttoextendaspecialthanksto
them. themanyresidentsandfellowspastandpresentwhosequestions
R.J.H. andpursuitofknowledgehavemademeabetterclinician–educator.
Iwouldalsoliketothankmymanymentorsthroughoutmytraining.
Withanysignificantwork,thereareinevitablynumerousindividuals Finally,manythankstomylovingfamily,especiallymywife,Libby,
whohavecontributedtobringthisprojecttofruition.Iwouldliketo andthreechildren,Maya,Samir,andRiya,whohavemadesacrifices,
thanktheauthorsandeditors,whohavespentenormousamounts yethavebeentheretosupport,entertain,andinspireme.
of their own personal time to produce this book. Thanks to the
patients and my colleagues: my co-attendings, the residents and S.A.G.
fellows,andthenurses,whohaveinspiredmetobeabetterclinician
andteacher.IalsowanttoacknowledgeGaryFleisherandthelate Iwouldfirstliketothankmywife,Leslie,mysonsNoah,Benand
MichaelShannonfortheirmentorshipandguidance.Finally,Ideeply Logan, and my daughter Lia, for all of their support and love. Ev-
appreciatemywifeEsther,andmyparentsJawandJean,fortheir erything I am, I owe to them. I would also like to thank the au-
continualsupport,patience,andsacrifice. thors that I have worked with, the editorial staff for their support,
V.J.W. andmyco-editorswhohadtoputupwithme.Ithastrulybeena
pleasure to work on this project, and I have learned a great deal
fromall.
R.P.
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CONTRIBUTORS
TzviAaron,MD CarlaMariaP.Alcid,MD BhawanaArora,MD
Fellow AssistantProfessor PediatricEmergencyMedicineFellow
DepartmentofPediatricEmergency DepartmentofPediatrics DepartmentofEmergencyMedicine
Medicine TulaneUniversitySchoolofMedicine Children’sHospitalofMichigan
NewYork-PresbyterianHospital MedicalDirector Detroit,Michigan
WeillCornellMedicalCenter DepartmentofPediatricEmergency
DanaAronsonSchinasi,MD
NewYork,NewYork TulaneUniversityHospitalandClinics
Fellow
JacoboAbadi,MD NewOrleans,Louisiana
DepartmentofEmergencyMedicine
AssociateProfessor MichelleJ.Alletag,MD TheChildren’sHospitalofPhiladelphia
DepartmentofPediatrics Fellow Philadelphia,Pennsylvania
AlbertEinsteinCollegeofMedicine PediatricEmergencyMedicine
MagdyW.Attia,MD
JacobiMedicalCenter YaleUniversity
Bronx,NewYork NewHaven,Connecticut Professor
DepartmentofPediatrics
AlyssaAbo,MD
NaharD.Alruwaili,MD JeffersonMedicalCollege
AssistantClinicalProfessor,Pediatrics
Toronto,Ontario,Canada Philadelphia,Pennsylvania
UCDavisSchoolofMedicine
FellowshipDirector
Sacramento,California CarolineAltergott,MD
AssociateDirector
JenniferAdu-Frimpong,MD AttendingPhysician
DivisionofEmergencyMedicine
CooperUniversityHospital DivisionofEmergencyMedicine
AlfredI.duPontHospitalforChildren
Camden,NewJersey Children’sHospitalLosAngeles
Wilmington,Delaware
LosAngeles,California
DeweshAgrawal,MD
MarkA.Auerbach,MD
AssociateProfessor RobinL.Altman,MD
AssistantProfessorofPediatrics
DepartmentofPediatricsandEmergency AssociateProfessor
YaleUniversitySchoolofMedicine
Medicine DepartmentofPediatrics
AttendingPhysician
GeorgeWashingtonUniversitySchool NewYorkMedicalCollege
SectionofPediatricEmergencyMedicine
ofMedicine Chief
YaleNewHavenChildren’sHospital
Director SectionofGeneralPediatrics
NewHaven,Connecticut
PediatricResidencyProgram MariaFareriChildren’sHospitalat
Children’sNationalMedicalCenter Westchester JeffreyR.Avner,MD
Washington,DC Valhalla,NewYork Professor
FaizAhmad,MD DepartmentofPediatrics
ChristopherS.Amato,MD
AssistantClinicalProfessor AlbertEinsteinCollegeofMedicine
DepartmentofEmergencyMedicine
DepartmentofPediatrics Chief,Children’sEmergencyService
MorristownHospital
ColumbiaUniversityCollegeofPhysicians DepartmentofPediatrics
Morristown,NewJersey
andSurgeons Bronx,NewYork
AttendingPhysician YasmeenAnsari,MD
MichaelR.Baker,MBBS
DivisionofPediatricEmergencyMedicine DepartmentofEmergencyMedicine
MorganStanleyChildrenHospitalof NorthShoreUniversityHospital
NewYorkPresbyterian Manhasset,NewYork
NewYork,NewYork
AlexandreArkader,MD
SaraAhmed,MD AssistantProfessor
AssistantProfessor DepartmentofOrthopaedicSurgery
DepartmentofPediatricEmergency KeckSchoolofMedicineoftheUniversity
Medicine ofSouthernCalifornia
TheChildren’sHospitalofMichigan Director,BoneandSoftTissueTumor
Detroit,Michigan Program
KhalidAlansari,MD Children’sOrthopaedicCenter
DepartmentofPediatrics Children’sHospitalLosAngeles
PediatricEmergencyCenterAl-Sadd LosAngeles,California
HamadMedicalCorporation
Doha,Qatar
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x (cid:2) (cid:2) (cid:2) Contributors
MichaelD.Baldovsky,DO,MBA RobertA.Belfer,MD StuartA.Bradin,DO
Fellow AttendingPhysician AssistantProfessorofPediatricsand
DivisionofEmergencyServices DepartmentofPediatrics EmergencyMedicine
LeBonheurChildren’sMedicalCenter Children’sHospitalofPhiladelphia TheUniversityofMichigan
Memphis,Tennessee Philadelphia,Pennsylvania AttendingPhysician
Director,PediatricEmergencyMedicine Children’sEmergencyServices
NelsonH.Bansil,DO
DepartmentofPediatrics DepartmentofEmergencyMedicine,
Fellow
VirtuaHospital DivisionofPediatricEMergency
DepartmentofPediatricEmergency
Voorhees,NewJersey Medicine
Medicine
TheUniversityofMichiganHelathSystem
LomaLindaUniversityMedicalCenter
BrendaJ.Bender,MD AnnArbor,Michigan
LomaLinda,California
AttendingPhysician
KristenBreslin,MD
BeshBarcega,MD DepartmentofEmergencyMedicine
Fellow
AssistantProfessor AlfredI.duPontHospitalforChildren
DivisionofEmergencyMedicine
DepartmentofEmergencyMedicineand Wilmington,Delaware
Children’sNationalMedicalCenter
Pediatrics
EyalBen-Isaac,MD Washington,DC
LomaLindaUniversitySchoolofMedicine
andChildren’sHospital AssistantProfessor SethL.Brindis,MD
MedicalDirector,Pediatric KeckSchoolofMedicineoftheUniversity ClinicalInstructor
DepartmentofEmergencyMedicine ofSouthernCalifornia DepartmentofPediatrics
LomaLindaUniversityMedicalCenter Director,PediatricResidencyProgram DavidGeffenSchoolofMedicineat
LomaLinda,California DepartmentofPediatrics UniversityofCalifornia,LosAngeles
Children’sHospitalLosAngeles AttendingPhysician
PeterL.J.BarnettMBBS,MSc,MSpMed
LosAngeles,California DepartmentofEmergencyMedicine
AssociateClinicalProfessor
Children’sHospitalofOrangeCounty
DepartmentofPaediatrics SeemaBhatt,MD
Orange,California
UniversityofMelbourne AttendingPhysician,EmergencyMedicine
DeputyDirector CincinnatiChildren’sHospitalMedical KevinD.Buckley,MD
DepartmentofEmergencyMedicine Center Director,MedicalServices
RoyalChildren’sHospital Cincinnati,Ohio EmergencyDepartment
Parkville,Victoria,Australia NavalHospitalSigonella
MercedesM.Blackstone,MD Sicily,Italy
SylviaBaszak,MD
AssistantProfessorofClinicalPediatrics
AssistantProfessor CaseyW.Buitenhuys,MD
UniversityofPennsylvaniaSchoolof
DepartmentofPediatrics,Divisionof ClinicalInstructor
Medicine
EmergencyMedicine DepartmentofEmergencyMedicine
AttendingPhysician
RobertWoodJohnsonMedicalSchool, HarborUniversityofCaliforniaMedical
DepartmentofEmergencyMedicine
UniversityofMedicineandDentistryof Center
TheChildren’sHospitalofPhiladelphia
NewJersey Torrance,California
Philadelphia,Pennsylvania
MedicalStaff
KristyBunagan,MD
DepartmentofPediatrics,Divisionof KeithBlum,MD
EmergencyCare
UniversityofNevada,LasVegas
RobertWoodJohnsonUniversityHospital
SunriseHospitalMedicalCenter SeanE.Button,MD
NewBrunswick,NewJersey
LasVegas,Nevada Fellow
JeffBeecher,DO DepartmentofPediatricEmergency
DivisionofNeurosurgery RichardG.Boles,MD Medicine
StateUniversityofNewYork,StonyBrook AssociateProfessorofPediatrics Children’sHospitalofPittsburghofUPMC
StonyBrook,NewYork KeckSchoolofMedicineoftheUniversity Pittsburgh,Pennsylvania
ofSouthernCalifornia
SolomonBehar,MD DivisionofMedicalGenetics JamesM.Callahan,MD
AssistantProfessor Children’sHospitalLosAngeles AssociateProfessorofClinicalPediatrics
KeckSchoolofMedicineoftheUniversity LosAngeles,California DivisionofEmergencyMedicine,
ofSouthernCalifornia DepartmentofPediatrics
AttendingPhysician CaraBornstein,DO UniversityofPennsylvaniaSchoolof
DepartmentofEmergencyMedicine AttendingPhysician Medicine
LosAngelesCountyMedicalCenter DepartmentofPediatricEmergency AttendingPhysician
DivisionofEmergencyMedicine Medicine EmergencyDepartment
Children’sHospitalLosAngeles LongIslandJewishMedicalCenter TheChildren’sHospitalofPhiladelphia
LosAngeles,California NewHydePark,NewYork Philadelphia,Pennsylvania
