Contributor: Meghan Hurley, MD

Educational Pearls:

• Gastroenteritis clinical diagnoses:

• • Diarrhea with or without vomiting and fever

• Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis

• Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest

• Treatment for mild to moderate dehydration: oral or IV rehydration

• • Begin orally to avoid unnecessary IV in a pediatric patient

1. Administer ODT Ondansetron (Zofran) to prevent vomiting

   1. Meta-analysis showed that 2-8 mg orally, based on body weight, decreased vomiting quickly

2. Wait 15-20 minutes for the medication to take effect

3. Use streamlined method for oral rehydration: Fluids such as over-the-counter Pedialyte, Infalyte, Rehydrate, Resol, and Naturalyte may be used

   1. If patient weighs less than 10kg: administer 5mL of fluid per minute for 20 minutes

   2. If patient weighs 10kg or more: administer 10mL of fluid for 20 minutes

4. If the patient can keep the fluid down, double the fluid volume and repeat

5. If the patient once again keeps the fluid down, double the fluid volume and repeat

• If successful with each attempt, the patient may be discharged home

• • Can prescribe ODT Zofran for 1-2 days at home

• If the patient vomits more than once during this oral rehydration process, intravenous rehydration must be initiated

References

1. Churgay CA, Aftab Z. Gastroenteritis in children: Part II. Prevention and management. Am Fam Physician. 2012 Jun 1;85(11):1066-70. PMID: 22962878.

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best?

• A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and Steri-Strips. It also assessed pain and satisfaction with the procedure from both guardian and provider perspectives.

• Participants: 55 patients were enrolled; 30 completed the 3-month follow-up.

• • Cosmetic Ratings (Median and IQR):

  • • Sutures: 70.5 (59.8–76.8)

    • Dermabond: 85 (73–90)

    • Steri-Strips: 67 (55–78)

    • (P = 0.254, no statistically significant difference)

  • Satisfaction and Pain:

  • • No significant differences in guardian or provider satisfaction

    • Pain levels were comparable across all methods

• Even though there was no statistically significant difference in guardian-perceived cosmetic outcomes, the Dermabond did have the highest ratings at the end of the study.

References

• Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024). A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatric emergency care, 40(10), 700–704. https://doi.org/10.1097/PEC.0000000000003244

Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

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Contributor: Jorge Chalit-Hernandez, OMS3

Educational Pearls:

• Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs

• Examples of unexpected monoamine oxidase inhibitors

  • Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins

  • Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia

• Other medications that can interact with SSRIs to cause serotonin syndrome

  • Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin reuptake inhibition

• Clinical presentation of serotonin syndrome

  • Altered mental status

  • Autonomic dysregulation leading to hypertension (most common), hypotension, and tachycardia

  • Hyperthermia

  • Neuromuscular hyperactivity - tremors, myoclonus, and hyperreflexia

• Hunter Criteria (high sensitivity and specificity for serotonin syndrome):

  • Spontaneous clonus

  • Inducible clonus + agitation or diaphoresis

  • Ocular clonus + agitation or diaphoresis

  • Tremor + hyperreflexia

  • Hypertonia, temperature > 38º C, and ocular or inducible clonus

• Management of serotonin syndrome

  • Primarily supportive - benzodiazepines can help treat hypertension, agitation, and hyperthermia. Patients often require repeated and higher dosing of benzodiazepines

  • Avoid antipyretics to treat hyperthermia since the elevated temperature is due to sustained muscle contraction and not central temperature dysregulation

  • In refractory patients, cyproheptadine (a 5HT2 antagonist) may be used as a second-line treatment

  • Patients with temperatures > 41.1º C or 106º F require medically induced paralysis and intubation to control their temperature

References

1. Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007 Jun 7;356(23):2437] [published correction appears in N Engl J Med. 2009 Oct 22;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867

2. Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109

3. Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007;152(6):946-951. doi:10.1038/sj.bjp.0707430

4. Schwartz AR, Pizon AF, Brooks DE. Dextromethorphan-induced serotonin syndrome. Clin Toxicol (Phila). 2008;46(8):771-773. doi:10.1080/15563650701668625

5. Thomas CR, Rosenberg M, Blythe V, Meyer WJ 3rd. Serotonin syndrome and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;43(7):790. doi:10.1097/01.chi.0000128830.13997.aa

Summarized & Edited by Jorge Chalit, OMS3

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