Factoid: All that wheezes…

In every emergency department there is an endless line up of wheezy children waiting to be seen, but all that wheezes is not asthma.

Common causes:

  • Reactive airways disease/asthma
  • Pneumonia
  • Bronchitis/Bronchiolitis
  • Foreign body aspiration
Uncommon Causes
  • Vascular abnormalities/Vascular ring
  • Mediastinal masses
  • Congestive heart failure
  • Tumor or malignancy
  • Vocal cord dysfunction
  • Cystic fibrosis

Otitis Media: How to treat your patients right and do the right thing

In a busy emergency department nothing is as wonderful as a simple and straight forward case. Otitis media used to be that case; a child is crying, the ear is sore and red, hand over a prescription for penicillin and the job was done. Happy parents, happy doctor, happy child….oh wait, the child was still unhappy but 2 out of 3 isn’t bad.

Mounting evidence and experience in European countries has shown us that immediate treatment of otitis media with antibiotics is probably not warranted. In a modern immunized society the majority of cases of OM are essentially benign self limited illnesses that don’t require treatment. In many North American emergency departments physicians have slowly been backing off of antibiotic treatment for OM. This past January 2 separate studies were published in the NEJM that have again shifted us back towards antibiotic prescribing for OM. Separate studies by Tahtinen and Hobermen┬áboth seemed to show a benefit in treating children less than 2 with a 10 day course of amoxicillin-clavulanate. There was much analysis of these studies, perhaps the best is by Dr. David Newman, and in the end it seems that perhaps there is a small reduction in symptoms when children are treated with antibiotics at a cost of significant antibiotic associated side effects, most commonly diarrhea.

Physicians are confused, we don’t know what to do, we try to read the parent and sense what they want and do what we think will make them happy. Parents are confused, sometimes doctors tell them their kids need antibiotics, sometimes they withhold antibiotics, it doesn’t make sense to them. What was once a lovely and brief encounter is turned into an emotionally turbulent episode of hand wringing, half explanations and crying children; a doctor who is unsure what to do, and a parent who is aggravated by the seeming randomness of the situation and a conflict around antibiotics.

The problem with ear infections is that they hurt, they hurt in the same way it hurts when a sadistic dentist blows compressed air onto a freshly drilled tooth (why do they do that!?). Adults with an ear infection want a shot of morphine, kids get a pat on the head and an ‘it’ll be okay buddy’. The only reason that anyone takes a marginal reduction of symptoms in an OM study seriously is because the symptoms are terrible and because we don’t treat the symptoms. It seems ridiculous that we are willing to accept a 15% risk of diarrhea with amoxicillin-clavulanate for 12 hours less of symptoms, particularly when the symptoms can be treated (if only we decide to treat them).

Here’s what I’ve found helpful in turning otitis media back into a great emergency department encounter:

  1. When I walk in the room and see a crying child with a bright red and bulging TM I say Wow! That looks really sore, we need to do something to get you feeling better right away!
  2. I always carry a couple of sterile ampules of 2% lidocaine in my breast pocket, and as long as there is no allergy I put 2-3 drops in the ear (there are commercial products designed for this, but they are expensive and single use lido works just fine). Then I tell the parents, just to keep him still for a minute while I go get a sticker to distract the child.
  3. When I get back into the room no one wants to talk about antibiotics because the child is now happy and smiling. What they want to talk about is the magic pocket drops and where they can get some of their own.
  4. I then give the child 15mg/kg of po acetaminophen.
  5. Then I say to the parents; Now that he’s feeling better we can talk about what to do. These days in children who are immunized ear infections are not dangerous and get better with time, people sometimes worry that they might turn into meningitis but I can reassure you that that is not going to happen. The biggest problem is that ear infections are painful so the first thing we need to talk about is how to control the pain…I give them a talk on using proper weight based doses of acetaminophen or ibuprofen and a topical agent like the lidocaine drops or a commercial alternative and that typically symptoms last 5 to 7 days…When it comes to antibiotics the studies that are out there don’t show a lot of benefit and they do show a lot of children getting side effects like diarrhea, so I like to start with getting the child feeling better with pain control. I’m not dogmatic about antibiotics though, if you are worried he is not getting better we are always happy to see him again and reassess the situation or if you would like I will even write you a prescription for antibiotics you can fill in a couple of days if things are not getting better.
Almost no one takes the delayed antibiotics script, and often when they bring in another child for an ear infection the parents decline antibiotics and ask for pain control options instead. The whole encounter takes about 5 minutes. It is much faster and easier to control the pain and explain the options than to have a tense antibiotic associated stand-off to the tune of a screaming child.
And ahhhhhhhhh, that’s the sound I remember from the old otitis media visits, happy parents, happy doctor and happy child, oh wait this time we are 3 out of 3….