Treating the wrong children with fluids will cause harm... as a recent NEJM paper about fluid boluses in very sick African children showed.   We thought we'd get in on the discussion, before everyone goes throwing the baby out with the bathwater.  In this PEMcast we try to appraise the Maitland paper in a rational, unemotional way... and almost manage!

Fluid Controversies

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We are honoured to be joined by an expert in the field of ethical decision making in CPR, Dr Barbara Hayes.  Join us for a lively discussion as we navigate the perils of talking about death and dying, and the role of CPR.

Ethical CPR Decisions

ACEM 2013 Winter Symposium in Broome was amazing.  Here is Colin Parker's talk about Holmesian Diagnostics for a Nautical Model.  A bit left-field, but we think you'll pick up a few handy hints... Scroll through the slides as you listen - on empem.org.

Holmesian Diagnostics

This debate is going to be HUGE… Does paracetamol (acetaminophen) cause asthma?
A series of large international studies and reviews dedicated to the question raise some interesting questions.  There appears to be an epidemiological association – not the same as a causal association – but something’s going on…

For those of us who have been using APAP (=acetaminophen, =paracetamol) liberally throughout our paediatric careers, this new evidence comes as bit of a shock.  You can hear it in the way we talk about these studies – trying not to let evidence get in the way of our own prejudices!


Outline: ISAAC vs APAP
[cp] Welcome, introduction, disclaimer
[cp] Background
Previous PEMcasts on fever and antipyretics
Advantages of antipyretics:

relieve pain
improve comfort
can facilitate clinical assessment

[sf] Disadvantages of antipyretics:

Do not prevent febrile convulsions
May increase fever phobia
Unhelpful in risk stratifying Fever Without Source
May prolong infective illness
Impair immune response to vaccination

[RR] APAP = N-Acetyl Para-Amino-Phenol
= acetaminophen = paracetamol
Most widely used drug in pediatrics, increasing use in last 30 years.
Recent market favour towards ibuprofen despite concerns of gastric inflammation, renal damage, wheezing.
[cp] Several papers now added to initial ISAAC 2008 publication; lessons from history include aspirin, phenacetin, thalidomide.
[cp] Beasley 2008 & accompanying editorial (Barr 2008)
[sf] Etminan 2009
[cp] Beasley 2011
[RR] McBride 2011
Often referenced: Lesko 2002
[all] Conclusions, goodbye

References
Beasley R, Clayton T, Crane J, von Mutius E, Lai CK, Montefort S, Stewart A;
ISAAC Phase Three Study Group.
Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years: analysis from Phase Three of the ISAAC programme.
Lancet. 2008 Sep 20;372(9643):1039-48. PubMed PMID: 18805332.
Barr RG.
Does paracetamol cause asthma in children? Time to remove the guesswork.
Lancet. 2008 Sep 20;372(9643):1011-2. PubMed PMID: 18805311.
Etminan M, Sadatsafavi M, Jafari S, Doyle-Waters M, Aminzadeh K, Fitzgerald JM.
Acetaminophen use and the risk of asthma in children and adults: a systematic
review and metaanalysis.
Chest. 2009 Nov;136(5):1316-23. Epub 2009 Aug 20. Review. PubMed PMID: 19696122.
Beasley RW, Clayton TO, Crane J, Lai CK, Montefort SR, Mutius E, Stewart AW;
ISAAC Phase Three Study Group.
Acetaminophen use and risk of asthma, rhinoconjunctivitis, and eczema in adolescents: International Study of Asthma and Allergies in Childhood Phase Three.
Am J Respir Crit Care Med. 2011 Jan 15;183(2):171-8. Epub 2010 Aug 13. PubMed PMID: 20709817.
McBride JT.
The association of acetaminophen and asthma prevalence and severity.
Pediatrics. 2011 Dec;128(6):1181-5. Epub 2011 Nov 7. PubMed PMID: 22065272.
Lesko SM, Louik C, Vezina RM, Mitchell AA.
Asthma morbidity after the short-term use of ibuprofen in children.
Pediatrics. 2002 Feb;109(2):E20. PubMed PMID: 11826230.
ISAAC Website: http://isaac.auckland.ac.nz/

ISAAC blows wheezy whistle on APAP

Some lessons for Pediatric Emergency Medicine, from 1971 - a children's book, about a boy who hurts his finger at school, and has to see the school nurse.  James feels Just Awful - until after the 3-part treatment...

Fluid Controversies

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