Zika virus: Overview and Testing

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By Jacob Beniflah

jacob.beniflah@emory.edu

By now you have undoubtedly heard from both patients and the media about Zika virus. The information out there can be confusing and contradictory. With the help of the CDC, we will give a general overview.

Zika virus is spread primarily by the Aedes species mosquito which is mostly a daytime biter but also bites at night. Active Zika virus transmission has been confirmed in all of North America (except Canada), Central America, South America and the Caribbean. The US has, as of 8/31, reported 35 locally spread cases (all in 2 areas of Miami-Dade country) and 2686 travel-associated cases.

Infection with Zika virus can be completely asymptomatic. If a patient shows symptoms they are usually mild and include fever, rash, joint pain, conjunctivitis, muscle pain, and headaches. Most people will only have symptoms for a few days to a week. Long term effects include a known risk of birth defects. Currently, a strong association between Guillain-Barre and Zika virus is being researched but nothing is conclusive yet.

Zika virus should be suspected in an infant or child who has traveled or lived in an affected area within the past 2 weeks and have 2 or more of the following: fever, rash, conjunctivitis, or arthralgia.

Testing at this time is only done thru the Georgia Department of Health (GDH). CHOA does not do in-house testing and will send samples to the GDH. A provider wishing to send testing must first call the GDH’s Epidemiology section for an approval code. During the day call 404-657-2588 or after-hours at 770-578-4104.

There is no current treatment for Zika. Treatment is with standard supportive care but the CDC recommends avoiding NSAIDs such as aspirin or ibuprofen until Dengue has been ruled out.

 

 

 

 

 

 

Kids shooting kids: Today’s reality and empowering parents with the ASK campaign

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by Sofia Chaudhary

schaud3@emory.edu

A 2-year old child has wandered into his parent’s bedroom and found an unlocked, loaded gun hidden in the top nightstand drawer.  Seconds later a shot is fired and the parent runs into the room to find their child lifeless.  As pediatricians we have all heard or encountered a similar story- all involving a child having access to an unlocked, loaded firearm.  According to the American Academy of Pediatrics, around 40% of homes with children in the US have a gun with an average of one child under age 10 being killed or disabled by a gun every other day (Pediatrics 2016-1).  In 2014 firearm injury was the 2nd leading cause of injury death in ages 15-19, 4th leading cause for ages 5-9 and 10-14, and 8th leading cause for ages 1-4 (CDC-2016-2).  Although mortality rates are high there is a larger rapid rise of unintentional pediatric injuries from firearms.  In a study reviewing an 8-month period of US pediatric firearm related injuries in 2014: two thirds were non-fatal, 50% of the victims were younger than 13 years of age, 25.3% younger than age 7, 84.3% were the child victims themselves or a family member/friend.  Of note 77% of events took place at the residence and 68% of the families  were the gun owners (J. Trauma Acute Care Surg. 2015-3).

Perhaps the most chilling recent headline from the Washington Post stated “Toddlers have shot at least 23 people this year.” Georgia was the top state with 8 listed self-inflicted shooting, with children ages 2 to 3 with hand guns all found within the home, parental purse, or vehicle (Washington Post-2016-4).  Many non-gun owner caregivers are not aware that there is indeed an accessible and loaded firearm in their home. In 2000, a study in Pediatrics found that in gun-owning homes with children, non-gun owners (87% women) reported significantly lower rates of a gun being stored loaded (7%) and unlocked (2%) in comparison to gun owners (21% loaded, 9% unlocked).  Those with a handgun were more likely to store it loaded and unlocked (Pediatrics-1999-5).  Parental perception of their child’s potential behavior around a firearm is also misleading.  In a survey published in Pediatrics 52% of the parent gun owners stored their firearms loaded or unlocked of which 75% believed that their 4 to 12-year-old child would be able to tell the difference between a toy gun and a real gun, and 23% thought that their child could be trusted with a loaded gun (Brady Center 2016-6)

In the US today 1.7 million children and teens live in a home with a loaded and unlocked gun (AAP-2016-7). One in every 25 admissions to pediatric trauma centers is due to a gunshot wound with major urban trauma centers reporting an increase of 300 percent in the number of pediatric gunshot wounds treated (AAP-2016-8).  Despite this national public health crises, in 2004 Congress banned the CDC from continuing gun violence related research and in 2011 the state of Florida passed a Privacy of Firearm Owners Act prohibiting pediatricians from asking patients and families about firearms in the home-this is currently under review and being appealed later this month.  As pediatricians our first priority is in providing developmentally appropriate advice on how parents can keep their child healthy and safe.  These safety measures include keeping medications out of reach, using appropriate car passenger seats according to age, vaccinating their children, wearing protective helmets when riding wheeled objects, and keeping guns locked and out of reach with the ammunition stored separately.   An AAP policy statement from 2012 reiterates the safest measure to prevent firearm related injuries being the absence of guns from homes and that pediatrician counseling on safe gun storage practices has shown significant reduction in injury. On June 21st the AAP is joining the Brady Campaign and asking parents to ASK (Asking Saves Kids) to save lives.  This campaign is asking parents to ask if there is an unlocked gun where their child plays.  It is encouraging parents to ask these questions as they would discuss other topics for a playdate such as supervision, TV/internet access, or food allergies.  I encourage each and every one of you to not only continue to ASK your patient’s families about firearm storage practices in their homes but also that they in turn ASK their kid’s playmates.

For more information for parents on firearm safety please visit: healthychildren.org

 

References:

  1. American Academy of Pediatrics. Reduce the Risk of Gun Injury. Available at: https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Reduce-the-Risk-of-Gun-Injury.aspx Accessed: April 27, 2016.
  2. WISQARS. Center for Disease Control. Injury Prevention and Control: National Center for Health Statistics (NCHS), National Vital Statistics System. 10 Leading Causes of Injury Deaths by Age Group Highlighting Violence- Related Injury Deaths, United States- 2014. Available at: http://www.cdc.gov/injury/images/lc-charts/leading_causes_of_injury_deaths_violence_2014_1040w760h.gif Accessed: June 1, 2016.
  3.  Faulkenberry J, Schaechter J. Reporting on pediatric unintentional firearm injury-Who’s responsible.  J. Trauma Acute Care Surg. 2015 79 (3): S2-S8.
  4. The Washington Post. Toddlers have shot at least 23 people this year. Posted May 1, 2016. Available at: https://www.washingtonpost.com/news/wonk/wp/2016/05/01/toddlers-have-shot-at-least-23-people-this-year/  Accessed: May 27, 2016.Azrael D, Miller M, Hemenway D.  Are Household Firearms Stored Safely? It Depends on Whom You Ask. Pediatrics. 2000; 106 (3).
  5. Farah M, Simon H, Kellerman A. Firearm in the Home: Parental Perceptions. Pediatrics. 1999; 104 (5): 1059-1063.
  6. Brady Center to Prevent Gun Violence. Keeping Kids and Families Safe. Available at: http://www.bradycampaign.org/our-impact/campaigns/keep-kids-and-families-safe Accessed: March 27, 2016. 
  7. American Academy of Pediatrics. Handguns in the Home. Available at https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Handguns-in-the-Home.aspx. Accessed: May 27, 2016.
  8. American Academy of Pediatrics. Council on Injury, Violence, and Poison Prevention Executive Committee. AAP policy statement.  Firearm-related injuries affecting the pediatric population. November 2012; 130 (5)

 

 

 

ED Guidelines on Child Sex Trafficking and Exploitation

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by Jordan Greenbaum, MD

Virginia.Greenbaum@choa.org

The number of cases of suspected sex trafficking seen in Children’s emergency departments (ED) is steadily rising.  This is largely due to improved recognition by law enforcement and the implementation of a community protocol that directs authorities to bring newly identified victims to a Children’s emergency department for immediate medical evaluation.  Between 2014 and 2015, 92 medical exams were completed in the 3 EDs.  In response to the increased awareness of this vulnerable group of youth, Children’s has implemented guidelines for recognizing and responding to suspected cases of child sex trafficking and exploitation.  The guidelines are the product of a multidisciplinary collaboration between providers at the Stephanie Blank Center for Safe and Healthy Children (SVB), and staff from a variety of Children’s departments, including the multiple EDs. Along with a comprehensive overview of sex trafficking, including definitions, potential indicators and detailed instructions on making reports to authorities, the guidelines provide flow diagrams for recognizing and responding to suspected cases.

In the Emergency Departments, providers are asked to consider the possibility of sex trafficking if a child > 11 years old presents with chief complaints of:

  • Vaginal or penile discharge
  • Requests for STI or pregnancy testing
  • Intoxication or ingestion
  • Suicide attempt
  • Clearance exam for the Division of Family and Children’s Services (DFCS)
  • Acute sexual assault

OR, child has

  • History of running away from home
  • An injury that is suspicious for being inflicted

If these or other concerns are noted, staff should request a social work consult.  The social worker will use the Short Screen for Child Sex Trafficking (also included in guidelines) to further assess for possible victimization.  If staff continues to have concerns, they should contact the Child Protection team by calling the Transfer Center.  A trained nurse practitioner from the SVB Center is available anytime of day to come to the ED to conduct a medical evaluation.  Social work will contact law enforcement, DFCS and Georgia Cares.  The latter is an organization that serves as the entry point for services for child trafficking victims.  Upon notification, staff from Georgia Cares will begin an evaluation and work with authorities to determine post-discharge housing, and further referrals.

Should a child protection on-call nurse practitioner not be available, the guidelines include detailed discussions related to issues of confidentiality and assent, obtaining a medical history and prepping interpreters.  The medical exam protocol is also included, as are STI prophylaxis and HIV PEP guidelines. In addition, the on-call child protection team physician is available for phone consultation at anytime at 404-785-DOCS.

 

 

A review of a few good applications (apps)

 

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By Connie Gong (constance.gong@emory.edu)

Over the years, doctors have gone from carrying fat medical books to PDAs to mobile devices to house the rapidly growing medical information that we are responsible for knowing. As a pediatric emergency medicine

(PEM) physicians at Emory, we carry our own personal “medical consultants” on my phone. In this 3-part series, we will be covering the many apps, websites, and blogs that area available to the general public and provides the latest evidence based medicine (EBM) in PEM.

Today, we’ll be discussing applications or “apps.” There are so many available, many covering similar topics. Ultimately you need to pick your favorites. All applications can be found on iphone or android platforms. Continue reading

The story of Pediatric Emergency Medicine at Emory University and Children’s Healthcare of Atlanta at Egleston and Hughes Spalding

 

by Wendy Little (wendalyn.little@emory.edu)

Children’s Healthcare of Atlanta is one of the largest and busiest pediatric healthcare systems in the United States. The three CHOA emergency departments collectively encounter over 200,000 visits per year and the hospitals, with their full complement of pediatric subspecialty providers, care for some of the sickest and most medically complex patients in the state and the region. While specialized pediatric healthcare in Atlanta dates back to the early 1900s, there were no pediatric emergency departments and no pediatric emergency specialists in Atlanta until the mid 1980’s The growth of emergency medical care for children in Atlanta over the past 30 years has been phenomenal! Continue reading

Simple Abscess Clinical Practice Guideline

 

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By Rebecca Burger (beckyburger@emory.edu)

In the emergency department we implemented a simple abscess Clinical Practice Guideline (CPG) almost one year ago. Here is some key information about the CPG and about loops.

Which patients require I&D in the ED?

Abscess ≥ 1cm in diameter. Smaller abscesses may be lanced with a scapel after LMX is applied.

Continue reading

CHOA Diversion Policy-Reminder and Updates

I hope that the winter season is going well for you.  We all know this is our busiest season of the year.  I just wanted to update you all about winter related changes.

Due to the high volume of patients we are currently seeing in our Children’s Healthcare of Atlanta Hospitals we are currently on a diversion for patients aged 15 and older who have not previously established care with one of our clinics. If your patient presents to the ED without a referral and they are over 15 they will be evaluated.  We have an agreement with Dekalb Medical Center who has agreed to accept patients of this age for admission.

As always if you have a patient who is under the age of 15 and you would like to send them to CHOA to be seen please call the transfer center at 404-785-7778 and update them on your concerns and evaluation recommendations. Please always take the time to call the transfer center if you are referring a patient this helps us to identify your concerns and alleviates the confusion when families say my pediatrician sent me but are unclear of the reason why. If you are a pediatrician and would like to speak with an pediatric emergency medicine physician you can also upon request be transferred to one of us. If you would like a call back please specifically indicate that to the transfer center and give a number that is reliably answered such as a cell phone number or backline number.

Updates:

  • Our PEMCONNECT newsletter will be published quarterly from this point on.
  • We will send email updates via our ED outreach listserve
  • In an effort to obtain important information about community pediatric practices please look out for an email survey via the listserve in the new year-2016!

Have a blessed holiday season and Happy New Year.  We hope to visit more of your practices and Emergency Departments next year.