Method of Participation: To earn AMA PRA Category 1 Credit™
- Complete the post-test and evaluation (Note: A score of at least 80% must be achieved to earn CME credit)
- Participate in the discussion/debate thread about specific articles
- Process your online payment of $10 (fees are non-refundable).
- A certificate of attendance will be forwarded within 4 to 6 weeks of participation
Release Date: March 12, 2013
Expiration Date: March 12, 2014Estimated Time of Completion: 1 hour
Fee: This CME activity costs $10, payable by credit card at the completion of the activity. Fees are non-refundable.
The Center for Emergency Medical Education (CEME) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The Center for Emergency Medical Education (CEME) designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
This activity is designed for emergency medicine physicians and other health care providers interested in the treatment of patients with cardiopulmonary arrest.
The Center for Emergency Medical Education (CEME) offers a one-credit content-specific posttest and evaluation based on an article in the Emergency Physicians Monthly magazine as each issue is published.
Disclosure of Faculty Financial Interests or Relationships:
It is the policy of Center for Emergency Medical Education (CEME) to insure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities, and that all contributors present information in an objective, unbiased manner without endorsement or criticism of specific products or services and that the relationships that contributors disclose will not influence their contributions. In accordance with the Standards for Commercial Support issued by the Accreditation Council for Continuing Medical Education (ACCME), the Center for Emergency Medical Education (CEME) requires resolution of all faculty conflicts of interest to ensure CME activities are free of commercial bias. Those involved in the planning and teaching of this activity are required to disclose to the audience any relevant financial interest or other relationship.
All faculty, planners, and staff in a position to control the content of this CME activity have indicated that he/she has no relationship, which, in the context of the article, could be perceived as a potential conflict of interest:
Kevin M. Klauer, DO, FACEP, Director, CEME
Logan Plaster, Editor/Creative Director, Emergency Physicians Monthly
Ginger Brake, CEME Program Coordinator
Participants must have access to the Internet:
CEME Program Coordinator
Emergency Medicine Physicians
4535 Dressler Road NW
Canton, Ohio 44718
(330) 493-4443 Ext: 1445
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When you submit online registration, the information you provide is confidential. At no point do we now, or will we ever sell, rent or lease information we collect to any outside individual or organization.
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The materials on this site are protected by copyright laws and may not be reproduced, modified, displayed, transmitted, or otherwise published without the prior written consent of The Center for Emergency Medical Education (CEME). You may access the materials on this website only for your personal, noncommercial use.
The materials on this site are provided for general medical education purposes only and are not meant to be applied rigidly and followed in all cases. Use of this information in a particular situation remains the professional responsibility of the practitioner. In no event will CEME be liable for any decision made or action taken in reliance upon the information provided.
Copyright © 2010 Center for Emergency Medical Education. All Rights Reserved
STEP 2: READ THE ARTICLE
STEP 3: TAKE THE QUIZ
STEP 4: PROCESS PAYMENT
After evaluating this article, participants will be able to:
1. Incorporate into practice strategies to reduce the need for intravenous fluid administration in dehydrated children
2. Develop strategies to reduce the need for admission in dehydrated children
Q. Can ondansetron decrease the need for intravenous fluids in children with acute gastroenteritis?
A. This study found similar results to the 2002 trial by Ramsook etal who found that ondansetron was effective in reducing the emesis from gastroenteritis during the ED phase of oral rehydration and in lowering the rates of intravenous fluid administration and hospital admission (Ann Emerg Med. 2002 Apr;39(4):397-403).
Citation: Roslund G, Hepps TS, McQuillen KK. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med. 2008 Jul;52(1):22-29.e6. Epub 2007 Nov 19.
OBJECTIVE: The hypotheses were: 1) that ondansetron would facilitate oral rehydration therapy in children with acute gastritis or acute gastroenteritis and mild to moderate dehydration who failed initial oral rehydration therapy; 2) that subjects receiving ondansetron would tolerate oral rehydration and that a lower proportion of patients would require intravenous hydration than subjects receiving placebo, with a clinically important difference of at least 30% when comparing 2 groups of patients presenting to the ED with acute gastritis/acute gastroenteritis; and 3) subjects receiving ondansetron will have a lower proportion requiring admission, fewer episodes of vomiting and diarrhea, and fewer revisits.
METHODS: This double-blind, placebo-controlled, prospective, randomized trial enrolled a convenience sample of subjects 1 to 10 years old, with acute gastritis or acute gastroenteritis, who failed oral rehydration therapy in the emergency department (ED). Subjects received a weight-based dose of ondansetron (0.15 mg/kg of the orally dissolving tablet) or placebo, and oral rehydration therapy was reattempted 30 minutes later. If a subject vomited or refused to drink, he or she was considered a failed oral rehydration therapy and received IV hydration [corrected] If a subject tolerated adequate oral rehydration therapy, he or she was discharged. Parents completed symptom diaries and were contacted by telephone for follow-up. The chi squared test was used to compare the proportions of subjects requiring IV hydration [corrected] in each group.
RESULTS: 106 subjects were enrolled: 51 received ondansetron and 55 received placebo. Eleven of 51 (21.6%; 95% confidence interval [CI] 11.3% to 35.3%) of subjects who received ondansetron required intravenous hydration and 30 of 55 (54.5%; 95% CI 40.6% to 68%) of placebo subjects required intravenous hydration (p <0.001) for a difference of 32.9% (95% CI 14.54% to 48.37%). Admission rates were 5.9% (3/51) with ondansetron and 12.7% (7/55) with placebo.
CONCLUSION: In subjects with acute gastritis/acute gastroenteritis and mild to moderate dehydration who failed initial oral rehydration therapy, the proportion of children who received intravenous hydration was smaller in the ondansetron group than in the placebo group
Q. Does the use of ondansetron have an effect on hospitalization and return rates and does its use mask underlying serious illness?
A. In this study, the use of ondansetron reduced hospital admissions for suspected gastroenteritis and vomiting. However, children who received ondansetron appeared more likely to return to the pediatric ED and be admitted on this return visit than their counterparts. However, the use of ondansetron does not appear to be associated with increased risks of masking serious diagnoses in children. I believe that the return rate is higher only due to patients who receive ondansetron feeling better in the ED and then having recurrent symptoms at home while those who do not receive medication and continue to vomit in the ED are more likely to be admitted on the first visit.
Citation: Sturm JJ, Hirsh DA, Schweickert A, Massey R, Simon HK. Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses? Ann Emerg Med. 2010 May; 55(5):415-22. doi: 10.1016/j.annemergmed.2009.11.011. Epub 2010 Jan 19.
OBJECTIVE: The effect of ondansetron use in cases of suspected gastroenteritis on the proportion of hospital admissions and return visits was evaluated and an assessment was made of whether children who receive ondansetron on their initial visit to the pediatric emergency department (ED) for suspected gastroenteritis return with an alternative diagnosis more frequently than those who did not receive ondansetron.
METHODS: This is a retrospective review of visits to 2 tertiary care pediatric EDs with an International Classification of Diseases, Ninth Revision diagnosis of vomiting or gastroenteritis. A logistic regression model was developed to determine the effect of ondansetron use during the initial pediatric ED visit on hospital admission, return to the pediatric ED within 72 hours, and admission on this return visit. For patients who returned within 72 hours and were admitted, hospital discharge records were reviewed. The proportions of alternative diagnoses, defined as a hospital discharge diagnosis that was not a continuation of gastroenteritis or vomiting, were compared between the groups.
RESULTS: During the 3-year study period (2005 to 2007), 34,117 patients met study criteria. Ondansetron was used for 19,857 (58.2%) of these patients on their initial pediatric ED visit. After controlling for differences between the groups, patients who received ondansetron were admitted on their initial visit less often: odds ratio (OR) 0.47 (95% confidence interval [CI] 0.42 to 0.53). However, those who received ondansetron were more likely to return to the pediatric ED within 72 hours (OR 1.45; 95% CI 1.27 to 1.65) and be admitted on the return visit (OR 1.74; 95% CI 1.39 to 2.19). The proportions of alternative diagnoses at hospital discharge were not significantly different in the group that received ondansetron on the initial pediatric ED visit (14.9%) compared with the group that did not (22.4%) (absolute difference 7.5% [95% CI -0.5% to 16.4%).
CONCLUSION: Ondansetron use in the pediatric ED reduces hospital admissions for suspected gastroenteritis and vomiting. However, children who receive ondansetron in the pediatric ED appear more likely to return to the pediatric ED and be admitted on this return visit than their counterparts. Furthermore, the use of ondansetron does not appear to be associated with increased risks of masking serious diagnoses in children
Q. Does the use of ondansetron in children with vomiting after a head injury mask serious illness?
A. Similar to the results seen in the previous study, ondansetron use does not appear to be associated with an increased risk of masking serious illnesses. This study was not able to determine whether or not the caregivers filled the prescription for outpatient ondansetron.
Citation: Sturm JJ, Simon HK, Khan NS, Hirsh DA. The use of ondansetron for nausea and vomiting after head injury and its effect on return rates from the pediatric ED. Am J Emerg Med. 2013 Jan;31(1):166-72. doi: 10.1016/j.ajem.2012.07.002. Epub 2012 Sep 20.
OBJECTIVE: The aim of this study was to evaluate the use of ondansetron in children with head injury and symptoms of vomiting in the pediatric emergency department (PED) and its effect on return rates and masking of more serious injuries.
METHODS: Visits to 2 PEDs from 2003 to 2010 with a diagnosis of head injury were evaluated retrospectively. Patients discharged home after a head computed tomography (CT) are the primary cohort for the study. A logistic regression model was used to analyze ondansetron’s effects on the likelihood of return to the PED within 72 hours for persistent symptoms. A secondary analysis was performed on patients with a diagnosis of head injury who did not receive a head CT and were discharged.
RESULTS: A total of 6311 patients had a diagnosis of head injury, had a head CT performed, and were discharged from the PED. The use of ondansetron increased significantly from 3.7% in 2003 to 22% in 2010 (P < .001). After controlling for demographic/acuity differences, receiving ondansetron in the PED was associated with a lower likelihood of returning within 72 hours (0.49, 95% confidence interval [0.26-0.92]). In patients with head injury who did not have a head CT performed and were sent home, the use of ondansetron in the PED was not associated with an increased risk of missed diagnoses.
CONCLUSION: Ondansetron use in children with a CT scan who are dispositioned home is relatively safe, does not appear to mask any significant conditions, and significantly reduces return visits to the pediatric emergency department.
SummaryOndansetron use is increasing in the management of children with vomiting due to various causes. The recommended dose of ondansetron is 0.15mg/kg, for the oral dissolving tablets, it is easier to calculate the dose based on weight keeping in mind that the typical age for ODT use is 6 months of age and up. For children 8-15 kg: 2mg; 15-30kg: 4mg; >30kg: 8mg. If a head CT is not performed, then the better part of valor until further studies are conducted is to not prescribe ondansetron. The Strum study revealed a slightly higher unadjusted return rate to the ED in patients who received ondansetron in the ED and did not have a head CT performed. This was likely due to parental and provider concern of masking a more serious diagnosis versus the comfort of knowing that the head CT was negative prior to discharge. It is always wise to only give a few doses of outpatient ondansetron so that patients with persistent symptoms will follow up more closely.
Dr. Ghazala Sharieff is the Director of Pediatric Emergency Medicine. Palomar Health, San Diego, CA, and a Clinical Professor, University of California, San Diego
STEP 3: TAKE THE QUIZ
STEP 4: PROCESS PAYMENT