Aadil Vora, OMS-IV

The Pediatric Sedation State Scale to assess pediatric procedural sedation (July 2017)

Scales that seek to describe the level of sedation achieved during procedural sedation focus largely on physiologic depth, primarily airway and cardiovascular impairment. But a new tool called the Pediatric Sedation State Scale (PSSS) seeks to incorporate patient behavior along with physiologic parameters. The PSSS is a simple scale that monitors pain, anxiety, movement, and adverse side effects of sedation on a scale from zero to five where zero is over-sedation requiring an acute intervention (ie. BVM ventilations) and five is under-sedation with movement impeding the procedure (ie. requires forceful immobilization). Researchers at Boston Children’s Hospital created videos of children undergoing a laceration repair with sedation, and had 20 providers from various specialties grade the stages of sedation they saw using the PSSS. The tool has demonstrated a 96% correlation to the Observational Scale of Behavioral Distress–revised scale, which was an arduous tool that was difficult to use in the clinical setting. Moreover, it is the first objective tool with strong inter and intra-observer reliability, healthcare providers such as Anesthesiologists and Emergency Medicine Physicians used the scale to grade videos of children undergoing various invasive procedures, and demonstrated a 99.4% consensus. Providers used the scale again six months later to asses more videos and the interrater reliability was 98.6%. Since the PSSS includes the full extent of pediatric patient presentations from over to under-sedation, the scale can be used to evaluate various types of procedural sedation, including the non-pharmacologic such as distraction and verbal persuasion. The authors further suggest that this tool should be used in the pediatric EM community to develop new methods of pediatric procedural sedation that can be described by the objectivity of the PSSS.

Cravero JP, Askins N, Sriswasdi P, et al. Validation of the Pediatric Sedation State Scale. Pediatrics. 2017 May;139(5). pii: e20162897.

Antibiotic therapy for skin abscess (July 2017)

An antibiotic course in conjunction with incision and drainage is recommended for treating an abscess with surrounding cellulitis, systemic signs of toxicity, risk factors for MRSA, or size over 2cm. The perception that cure rates of skin abscesses requiring incision and drainage do not improve with antibiotics was propagated by smaller trials and expert opinion, but has been challenged by larger trials such as Talan et al and a new large multicenter trial investigating the 7-10 day clinical outcome of an abscesses less than 5cm in size treated with incision and drainage and either Clindamycin, TMP-SMX, or placebo. Cure rates were 82% and 83% respectively for clindamycin and TMP-SMX as compared to 69% for placebo. Secondary analysis showed that Clindamycin was particularly more effective in treating abscesses among children. Clindamycin had a lower abscess recurrence rate at the 1 month visit than TMP-SMX, 6.8% vs 13.5% respectively. However, Clindamycin had a higher rate of side effects, with diarrhea being the most common complaint. Interestingly, none of the cases were associated with C. difficile.

Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med. 2017;376(26):2545

Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim–sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J Med 2016;374:823-832

ACC/AHA/HRS guideline for the evaluation and management of syncope (July 2017)

The American College of Cardiology, American Heart Association, and the Heart Rhythm Association have published new syncope guidelines. Major points from the new guidelines include an emphasis on the initial evaluation, which includes a detailed history and physical examination along with an ECG. The history should focus on the frequency and duration of episodes, onset, position of the patient, provocative factors, associated symptoms preceding and following the syncopal event, witnessed signs, preexisting medical conditions, and family history of early cardiac death and disease or seizure disorders. The physical exam should focus on vital signs, cardiovascular, and neurologic systems. Routine and comprehensive laboratory evaluation is not useful in the evaluation of syncope, as well as neurologic imaging, and electroencephalography in routine evaluation of the syncopal patient without focal neurologic deficits. Prevalence of syncope is reported to be as high as 41%, with vasovagal syncope as the most common type. Reasonable treatment includes beta blockers and ICDs for adult patients with long QT syndrome and suspected arrhythmic syncope. In patients with moderate or severe atherosclerotic coronary heart disease and unexplained syncope, it is reasonable to conduct electrophysiological studies. Additionally, syncopal patients with neurodegenerative disease may benefit from autonomic evaluation.

Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2017 Aug 1;70(5):e39-e110.