-
A
PAGE 2| Introduction To The
Guidelines: Pediatric
Severe Sepsis And
Septic Shock
PAGE 2| Description Of The
Guideline Methodology
PAGE 3 | Recommendations And
Editorial Comments
PAGE 7 | References
PAGE 8 | CME Questions
Guidelines For The Management
Of Pediatric Severe Sepsis
And Septic Shock
A
lthough severe sepsis and septic shock is less common
in the pediatric population, it has been estimated that
approximately 100,000 infants and children present to
emergency departments (EDs) annually with severe sepsis. In
recent months, there has been increased focus on the manage-
ment of sepsis in the pediatric population. In 2012, an update
was published regarding the management of severe sepsis and
septic shock, which included specific guidelines for the pediatric
population. Although not intended specifically for emergency
physicians, these guidelines were provided for anyone caring for
term newborns or children with severe sepsis and septic shock.
Practice Guideline Impact
Parameters in defining severe sepsis in children are age
related.
Initial resuscitation includes administering oxygen, obtaining
intravenous and/or intraosseous access for fluid and medica-
tion administration.
Antibiotics should be administered within 1 hour of identifica-
tion of severe sepsis.
Fluid administration is critical in treating septic shock. Consid-
er inotropes if signs of volume overload develop and hypoten-
sion is still present.
September 2013
Volume 5, Number 9
Author
Karen Franco, MD
Clinical Assistant Professor of Emergency Medicine, Herbert Wertheim
College of Medicine, Florida International University, Miami Children's
Hospital, Miami, FL
Editor-In-Chief
Sigrid Hahn, MD
Associate Professor of Emergency Medicine, Department of Emergency
Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
Editorial Board
Luke K. Hermann, MD
Associate Professor of Emergency Medicine, Director of Quality and Finance,
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai,
New York, NY
Andy Jagoda, MD, FACEP
Professor and Chair, Department of Emergency Medicine, Icahn School of
Medicine at Mount Sinai, New York, NY
Eddy S. Lang, MDCM, CCFP (EM), CSPQ
Senior Researcher, Alberta Health Services; Associate Professor, University of
Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada
Gregory M. Press, MD, RDMS
Assistant Professor, Director of Emergency Ultrasound, Emergency Ultrasound
Fellowship Director, Department of Emergency Medicine, University of Texas at
Houston Medical School, Houston, TX
Christopher Tainter, MD, RDMS
Critical Care Fellow, Department of Anesthesia, Critical Care, and Pain
Medicine, Massachusetts General Hospital/Harvard Medical School, Boston,
MA
Scott M. Silvers, MD
Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
Scott D. Weingart, MD, FCCM
Associate Professor, Department of Emergency Medicine, Director, Division of
ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY
Editors Note: To read more about this publication
and the background and methodologies for practice
guideline development, go to:
http://www.ebmedicine.net/introduction
Prior to beginning this activity, see CME Information
on page 9
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Introduction To The Guideline: Pediatric Severe Sepsis And Septic Shock

T
his issue of EM Practice Guidelines Update reviews the pediatric Severe sepsis is sepsis plus 1 of the following3:
section of Surviving Sepsis Campaign: International Guidelines Cardiovascular dysfunction
for Management of Severe Sepsis and Septic Shock: 2012 pub- Acute respiratory distress syndrome
lished by the Surviving Sepsis Campaign.1 Two or more other organ dysfunction/failure

Available at: http://www.sccm.org/Documents/SSC-Guidelines.pdf Description Of The Guideline Methodology

For this current update of the previous 2008 Surviving Sepsis Guide-
lines, a consensus committee of 68 international experts represent-
ing 30 international organizations were appointed to different groups
according to their areas of expertise. Each group was responsible for
drafting the initial update for their assigned topic.
These recommendations are intended to provide the physician guidance
in treating a term newborn or child with severe sepsis in both an intensive
care unit (ICU) or non-ICU setting in an industrialized environment with
full access to mechanical ventilation. The recommendations are intended
to be best practice and are not meant to represent a standard of care.
In the United States, the hospital mortality rate for severe sepsis is 2%
in healthy children and 8% in children with chronic illnesses.2 The defi-
nition of sepsis in children is similar to the definition of sepsis in adults,
but it takes into account age-specific values.
Strength of evidence was determined using the Grading of Recom-
mendations Assessment, Development and Evaluation (GRADE) sys-
tem. Through this system, evidence is rated from high (A) to very low
(D). Level A studies are well-done randomized control trials (RCTs);
level B studies are downgraded RCTs (due to limitations, biases, in-
consistencies, etc) or upgraded observational studies; level C studies
are well-done observational studies with controlled RCTs; and a level
D study is a downgraded controlled study or expert opinion-based
evidence. Recommendations were also classified as strong (grade
1) or weak (grade 2). The higher the quality of evidence, the larger
the difference between desirable and undesirable consequences, the
more certainty or similarity in values, or the lower cost of an interven-
tion to the alternative, the more likely a strong recommendation was
given.

Sepsis in children is defined as the presence of at least 2 of the fol-

lowing criteria, 1 of which must be abnormal temperature or abnormal
leukocyte count3:
Rectal temperature of > 38.5C or < 36C
Tachycardia > 2 standard deviations above normal for age (in
absence of external stimuli: pain, crying, drugs) OR in those
aged < 1 year, bradycardia < 10th percentile (in the absence of
drugs, congenital heart disease)
Respiratory rate > 2 standard deviations above normal for age
High or low leukocyte count for age or 10% bands

EM Practice Guidelines Update 2013 2 www.ebmedicine.net September 2013

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Selected Guideline Recommendations, With Discussion
Recommendations For Initial Resuscitation
We suggest starting with oxygen administered by face mask or, if
needed and available, high-flow nasal cannula oxygen or nasopha-
ryngeal continuous positive airway pressure (CPAP) for respiratory
distress and hypoxemia. Peripheral intravenous access or intraos-
seous access can be used for fluid resuscitation and inotrope infu-
sion when a central line is not available. If mechanical ventilation is
required, then cardiovascular instability during intubation is less likely
after appropriate cardiovascular resuscitation. (Grade 2C)
We suggest that the initial therapeutic endpoints of resuscitation of
septic shock be capillary refill of 2 seconds, normal blood pressure
for age, normal pulses with no differential between peripheral and
central pulses, warm extremities, urine output > 1 mL/kg/h, and nor-
mal mental status. Thereafter, SCVO2 saturation 70% and cardiac
index between 3.3 and 6.0 L/min/m2 should be targeted. (Grade 2C)
We recommend following the American College of Critical Care
Medicine-Pediatric Advanced Life Support (ACCM-PALS) guide-
lines for the management of septic shock. (Grade 1C)
We recommend evaluating for and reversing pneumothorax,
pericardial tamponade, or endocrine emergencies in patients with
refractory shock. (Grade 1C)
Editorial Comment
Because lactate levels have not been shown to be correlated with sep-
tic shock in children (lactate levels can be normal in sepsis), the guide-
line recommends following cardiac index and SCVO2; however, the
specific modality used to do this is left to the practitioner. It is important
to remember that an abnormal lactate level would be concerning, but
a normal level does not rule out septic shock in children. Young infants
have low functional residual capacity and may require early intubation.
EM Practice Guidelines Update 2013 3
Recommendations On Antibiotic Administration
We recommend that empiric antimicrobials be administered within
1 hour of the identification of severe sepsis. Blood cultures should
be obtained before administering antibiotics when possible, but this
should not delay initiation of antibiotics. The empiric drug choice should
be changed as epidemic and endemic ecologies dictate (eg, H1N1,
methicillin-resistant Staphylococcus aureus, chloroquinolone-resistant
malaria, penicillin-resistant pneumococci, recent ICU stay, neutrope-
nia). (Grade 1D)
We suggest the use of clindamycin and antitoxin therapies for toxic
shock syndromes with refractory hypotension. (Grade 2D)
Clostridium difficile colitis should be treated with enteral antibiotics,
if tolerated. Oral vancomycin is preferred. (Grade 1A)
We recommend early and aggressive infection source control.
(Grade 1D)
Editorial Comment
Prompt administration of antibiotics reduces morbidity and mortality in
children. The referenced literature for this recommendation includes
2 quality control studies focusing on improving time to antibiotics, a
retrospective review examining daptomycin for MRSA infections and
a retrospective cohort study examining risk factors for acquiring Esch-
erichia coli and Klebsiella species infections while in the ICU. Although
the methodology is low, early antibiotics are strongly recommended,
and they should be administered within 1 hour.
Children are more prone to toxic shock syndrome due to the lack
of circulating antibodies to toxins. Therefore, clindamycin should be
administered in children with erythroderma and suspected toxic shock.
The use of antitoxin therapy (such as intravenous immunoglobulin
[IVIG]) in the treatment of toxic shock syndrome is unclear, but may be
considered in refractory cases. A multicenter retrospective cohort study
published in 2009 examining its use in children with streptococcal toxic
shock syndrome did not find improved outcome with its use, however.4
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Recommendations On Fluid Resuscitation
In the industrialized world, with access to inotropes and mechani-
cal ventilation, we suggest that initial resuscitation of hypovolemic
shock begin with infusion of isotonic crystalloids or albumin, with
boluses of up to 20 mL/kg for crystalloids (or albumin equivalent)
over 5 to 10 minutes. These should be titrated to reversing hypo-
tension, increasing urine output, and attaining normal capillary re-
fill, peripheral pulses, and level of consciousness without inducing
hepatomegaly or rales. If hepatomegaly or rales develop, inotropic
support should be implemented, not fluid resuscitation. In children
with severe hemolytic anemia (severe malaria or sickle cell crises)
who are not hypotensive, blood transfusion is considered superior
to crystalloid or albumin bolusing. (Grade 2C)
Editorial Comment
It is important to remember that children often compensate well for
early hemodynamic compromise, with increased heart rate and vaso-
constriction preventing the initial drop in blood pressure typically seen
in septic shock. Therefore, blood pressure alone should not be used to
assess either the need for fluid resuscitation or the adequacy of resus-
citation once started. Fluid resuscitation is recommended in children
who are both normotensive and hypotensive. For initial resuscitation,
40 to 60 mL/kg (or more) may be needed. Multiple randomized control
trials have demonstrated decreased mortality when adequate fluid
resuscitation is administered to children in septic shock. In cases of
purpuric or suspected meningococcal septic shock, aggressive hemo-
dynamic resuscitation and support with fluid boluses, inotropes and/
or mechanical ventilation are of particular importance as studies have
shown a nearly 10-fold reduction in mortality with appropriate interven-
tion in these children.
EM Practice Guidelines Update 2013 4
Recommendations For Inotropes/Vasopressors/Vasodilators
We suggest beginning peripheral inotropic support until central
venous access can be attained in children who are not responding
to fluid resuscitation. (Grade 2C)
We suggest that children with low cardiac output and elevated
systemic vascular resistance states with normal blood pressure be
given vasodilators in addition to inotropes. (Grade 2C)
Editorial Comment
Although the preferred method of delivery of an inotrope is through
a central venous line, it has been shown in the literature that a delay
in inotrope administration is associated with increased mortality risk.
Therefore, administration should not be delayed and can be admin-
istered via a peripheral IV line until central access can be obtained.
Available literature strongly supports the importance of early versus
late inotropic administration when clinically indicated in septic chil-
dren. These data underlie the recommendation for the use of inotropic
agents via peripheral access as the difficulty associated with obtain-
ing central access in children can lead to significant delays in care.
The addition of vasodilator therapy is recommended for children with
invasive monitoring in place and a persistent low cardiac output state
with high systemic vascular resistance and normal blood pressure de-
spite fluid resuscitation and inotropic support. Although the emergency
clinician is unlikely to encounter this particular scenario, it is important
to consider in cases where there is a delay in admission to the ICU or
with a transfer to a higher-level facility.
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Recommendation For Extracorporeal Membrane Oxygenation
We suggest extracorporeal membrane oxygenation (ECMO) in
refractory septic shock or with respiratory associated failure with
sepsis. (Grade 2C)
Editorial Comment
Reviews of the Extracorporeal Life Support Organization Registry have
shown survival rates of 73% for neonates and 39% for children after
the use of ECMO for the treatment of sepsis.5 The survival rate was
higher for those undergoing venovenous ECMO. A separate review
of the database reported a 41% survival rate to discharge for those
children undergoing ECMO for sepsis.6 A retrospective study, looking
at 1 institutions experience with venoarterial ECMO in refractory septic
shock reported a 74% (17 patients) survival rate to discharge.7 Be-
cause many centers are currently not capable of performing ECMO on
children, it is important to remember that early transfer to an appropri-
ate institution may be necessary for the survival of these patients.
Recommendations For Blood Products And Plasma Therapies
We suggest similar hemoglobin targets in children as in adults.
During resuscitation of low superior vena cava oxygen saturation
shock (< 70%), hemoglobin levels of 10 g/dL are targeted. After
stabilization and recovery from shock and hypoxemia, a lower tar-
get > 7.0 g/dL can be considered reasonable. (Grade 1B)
We suggest similar platelet transfusion targets in children as in adults.
(Grade 2C)
We suggest the use of plasma therapies in children to correct
sepsis-induced thrombotic purpura disorders, including progressive
disseminated intravascular coagulation, secondary thrombotic mi-
croangiopathy, and thrombotic thrombocytopenic purpura. (Grade
2C)
Editorial Comment
The evidence regarding the optimal hemoglobin level in children with
severe sepsis is limited. One trial compared hemoglobin levels of 7 g/dL
versus 9.5 g/dL without showing any difference in outcome. The current
recommendations suggest using the same target number as for adults.
EM Practice Guidelines Update 2013 5
Recommendation For Corticosteroids
We suggest timely hydrocortisone therapy in fluid-refractory,
catecholamine-resistant shock and suspected or proven absolute
(classical) adrenal insufficiency. (Grade 1A)
Editorial Comment
It has been shown in a prospective cohort study that absolute and rela-
tive adrenal insufficiency is common in children with fluid-refractory,
catecholamine-resistant shock.8 Another study investigating whether
serum cortisol and adrenocorticotropic hormone (ACTH) levels cor-
relate with severity of illness in severe meningococcal disease showed
that low cortisol and high ACTH concentrations were associated with
poor outcomes.9 Approximately 25% of children with septic shock have
adrenal insufficiency. Those at risk for adrenal insufficiency include pa-
tients with: severe septic shock, purpura, previous steroid use in chronic
illness, and pituitary or adrenal abnormalities. Treatment consists of IV
hydrocortisone infusion at stress dose levels (50 mg/m2/24 h). Death
from adrenal insufficiency and septic shock often occurs within 8 hours
of presentation; however, a multicenter retrospective cohort study
that included 477 children with severe sepsis did not find a definitive
improvement in outcomes for those receiving corticosteroid therapy
compared to those who did not.10
Recommendation For Mechanical Ventilation
We suggest providing lung-protective strategies during mechanical
ventilation. (Grade 2C)
Editorial Comment
The evidence cited in this recommendation includes a case series for
airway pressure release ventilation and a prospective clinical study for
the use of HFOV. A recent study from Brazil reported increased surviv-
al using high-frequency oscillatory ventilation in children with ARDS.11
Although it is unlikely that the emergency clinician will find themselves
using this type of ventilation in the ED setting, it is important to recog-
nize its potential utility in children with sepsis suffering from ARDS.
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Recommendations For Sedation/Analgesia/Drug Toxicities
We recommend use of sedation with a sedation goal in critically ill
mechanically ventilated patients with sepsis. (Grade 1D)
We recommend monitoring drug toxicity laboratory results because
drug metabolism is reduced during severe sepsis, putting children
at greater risk of adverse drug-related events. (Grade 1C)
Editorial Comment
Propofol should be avoided in children aged < 3 years due to associa-
tion with fatal metabolic acidosis. Etomidate use is discouraged as
well, as it can lead to hemodynamic instability from inhibition of the
adrenal axis and sympathetic nervous system.
Recommendation For Glycemic Control
We suggest controlling hyperglycemia using a similar target as in
adults ( 180 mg/dL). Glucose infusion should accompany insulin
therapy in newborns and children. (Grade 2C)
Editorial Comment
A prospective cohort study on children with septic shock showed that
serum glucose levels > 178 mg/dL are associated with increased mor-
tality risk.12 A prospective randomized controlled study was performed in
2009 investigating the effect of keeping serum glucose levels at age-
adjusted fasting levels in critically ill children.13 Short-term outcome was
found to be better in those receiving insulin therapy; however, long-term
survival and morbidity was not investigated. It is common for critically ill
children to develop hyperglycemia, and efforts should be made to keep
serum glucose levels < 180 mg/dL. Infants are at risk for developing
hypoglycemia when they depend on intravenous fluids. This means that
a glucose intake of 4 to 6 mg/kg/min or maintenance fluid intake with
dextrose 10% normal saline is advised (6-8 mg/kg/min in newborns).
EM Practice Guidelines Update 2013 6
Recommendation For Diuretics And Renal Replacement Therapy
We suggest use of diuretics to reverse fluid overload when shock
has resolved and, if unsuccessful, continued venous hemofiltra-
tion or intermittent dialysis > 10% total body weight fluid overload.
(Grade 2C)
Editorial Comments
When evaluating a child in severe sepsis/septic shock, it is important to
remember that there are differences in how they look or respond when
compared to their adult counterparts. These guidelines were written to
provide guidance to those caring for infants and children with severe
sepsis and septic shock. When reading through these guidelines, the
emergency clinician should remember that although many of the therapies
recommended will likely occur outside of the ED (ie, in the ICU setting), it
is important to be familiar with them in case the need to provide prolonged
care in the ED arises.
It should be noted that in a child with suspected severe sepsis/septic
shock, blood pressures can often be normal, as children can compensate
for hypotension with elevated heart rates and vasoconstriction more effec-
tively than adults. Low blood pressure is usually a late finding and cardio-
vascular collapse may be imminent in the hypotensive child. Therefore,
it is imperative to begin fluid resuscitation in normotensive children with
suspected sepsis. Delay in fluid administration may be quite harmful to the
patient and result in continued deterioration of the patient's clinical status.
Obtaining intravenous access may be extremely difficult in the child with
sepsis as they are often severely vasoconstricted from septic shock and/
or dehydrated as a result of fever or not tolerating fluids. Intraosseous
access is a perfectly acceptable method of giving antibiotics, medications,
and fluids until a more secure line can be established.
Once severe sepsis is identified, early administration of antibiotics is
essential. Although the preferred method is to collect cultures prior to
giving antibiotics, that is not the main priority in patients with sepsis.
Treating sepsis with antimicrobials as soon as possible is the goal. It
is important to remember that the choice of empiric antibiotics can and
should be altered based on endemic and epidemic ecologies.
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References
1. Dellinger RP, Levy MM, Rhodes A, Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup, et al. Surviving
sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.
(Practice guidelines)
2. Odetola FO, Gebremariam A, Freed GL. Patient and hospital correlates of clinical outcomes and resource utilization in severe pediatric
sepsis. Pediatrics. 2007;119:487-494. (Retrospective, 21,448 hospitalizations)
3. Goldstein B, Giroir B, Randolph A, et al. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction
in pediatrics. Pediat Crit Care Med. 2005;6(1):2-8. (Consensus guidelines; 20 experts)
4. Shah SS, Hall M, Srivastava R, et al. Intravenous immunoglobulin in children with streptococcal toxic shock syndrome. Clin Infect Dis.
2009;49(9):1369-1376. (Retrospective cohort study; 192 patients)
5. Skinner SC, Iocono JA, Ballard HO, et al. Improved survival in venovenous vs venoarterial extracorporeal membrane oxygenation for
pediatric noncardiac sepsis patients: a study of the Extracorporeal Life Support Organization registry. J Pediatr Surg. 2012;47(1):63-67.
(Registry review; 4332 subjects)
6. Domico MB, Ridout DA, Bronicki R, et al. The impact of mechanical ventilation time before initiation of extracorporeal life support on sur-
vival in pediatric respiratory failure: a review of the Extracorporeal Life Support Registry. Pediatr Crit Care Med. 2012;13(1):16-21. (Reg-
istry review; 1325 subjects)
7. MacLaren G, Butt W, Best D, et al. Central extracorporeal membrane oxygenation for refractory pediatric septic shock. Pediatr Crit Care
Med. 2011;12(2):133-136. (Retrospective case series; 23 patients)
8. Pizzaro CF, Troster EJ, Damiani D, et al. Absolute and relative adrenal insufficiency in children with septic shock. Crit Care Med.
2005;33(4): 855-859. (Prospective cohort study; 57 subjects)
9. De Kleijn ED, Joosten KF, Van Rijn B, et al. Low serum cortisol in combination with high adrenocorticotrophic hormone concentrations are
associated with poor outcome in children with severe meningococcal disease. Pediatr Infect Dis J. 2002;21(4):330-336.
10. Zimmerman JJ, Williams MD. Adjunctive corticosteroid therapy in pediatric severe sepsis: observations from the RESOLVE study. Pediatr
Crit Care Med. 2011;12(1):2-8. (Retrospective cohort study; 477 subjects)
11. Pinzon AD, Rocha TS, Ricachinevsky C, et al. High-frequency oscillatory ventilation in children with acute respiratory distress syndrome:
experience of a pediatric intensive care unit. Rev Assoc Med Bras. 2013;59(4):368-374.
12. Branco RG, Garcia PC, Piva JP, et al. Glucose level and risk of mortality in pediatric septic shock. Pediatr Crit Care Med. 2005;6(4):470-
472. (Prospective cohort study; 57 subjects)
13. Vlasselaers D, Milants I, Desmet L, et al. Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised con-
trolled study. Lancet. 2009;373(9663): 547-556. (Prospective randomized controlled study; 1083 subjects)

EM Practice Guidelines Update 2013 7 www.ebmedicine.net September 2013

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CME Questions
To take the CME test, visit: www.ebmedicine.net/CME or scan the QR code below with a smartphone:

1. Etomidate is the first-line sedative in meningococcal sepsis.

a. True
b. False

2. If hepatomegaly or rales develop during resuscitation in a child with septic shock, you should
a. Continue fluid resuscitation until blood pressure normalizes
b. Reverse volume overload with diuretics and continue fluid resuscitation
c. Begin inotropic support and continue fluid resuscitation
d. Stop fluid resuscitation, give diuretics, and begin inotropic support

3. Once severe sepsis is identified, antibiotics should be given:

a. Once all cultures have been obtained
b. Within 1 hour
c. Once the source is identified
d. Upon consultation with an infectious disease specialist

3. Which child is in severe sepsis?

a. A 4-year-old boy with temperature of 38C, normal white cell count, heart rate of 168 beats/min, and wheezing
b. A 4-year-old boy with temperature of 39C, normal white cell count, heart rate of 168 beats/min, and wheezing
c. A 4-year-old boy with temperature of 39C, normal white cell count, heart rate of 168 beats/min, and hypoxia despite being
on 100% nonrebreather mask
d. A 4-year-old boy with temperature of 37C, normal white cell count, heart rate of 168 beats/min, and no urine output in 18 hours

EM Practice Guidelines Update 2013 8 www.ebmedicine.net September 2013

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To contact the Editor-In-Chief, email Sigrid Hahn, MD at:
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Date of Original Release: September 1, 2013. Date of most recent review: August 1, 2013. Termination
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May 2012 Current Guidelines On Atrial Fibrillation In The Emergency Department www.ebmedicine.net/Afib 2
June 2012 Current Guidelines For The Management Of Hypertension In The Emergency Department www.ebmedicine.net/Hypertension 2
July 2012 Current Guidelines For The Management Of Pneumothorax In The Emergency Department www.ebmedicine.net/Pneumothorax 2
August 2012 Guidelines For The Management Of Cystitis And Pyelonephritis In The Emergency Depart- www.ebmedicine.net/Cystitis 2
ment
September 2012 Current Guidelines For Management of Acute Altitude Illness, Frostbite, And Snake Enven- www.ebmedicine.net/Envenomation 2
omation (Trauma CME)
October 2012 American Heart Association Guidelines For The Emergency Clinician: Cardiac Arrest In www.ebmedicine.net/CardiacArrest 2
Special Situations And First Aid (Trauma CME)
November 2012 Percutaneous Coronary Intervention: Current Guidelines For The Emergency Department www.ebmedicine.net/PCI 2
December 2012 Current Guidelines For Evaluating And Managing Symptomatic Early Pregnancy In The www.ebmedicine.net/EarlyPregnancy 2
Emergency Department
January 2013 Current Guideline For The Neurodiagnostic Evaluation Of The Child With A Simple Febrile www.ebmedicine.net/PedFebSeizure 2
Seizure
February 2013 Current Guidelines For The Evaluation And Management Of Community-Acquired Pneumo- www.ebmedicine.net/CAP 2
nia In The Emergency Department
March 2013 Current Guidelines For Management Of Bell Palsy And Herpes Zoster In The Emergency www.ebmedicine.net/BellPalsy 2
Department
April 2013 Current Guidelines For The Management Of Severe Sepsis And Septic Shock www.ebmedicine.net/Sepsis 2
May 2013 Current Guidelines For The Management Of Community-Acquired Pneumonia In Children www.ebmedicine.net/PedCAP 2
June 2013 Guidelines For The Evaluation And Management Of Upper Gastrointestinal Bleeding www.ebmedicine.net/UGIBleeding 2
July 2013 Guidelines For The Evaluation And Management Of Acute Cerebrovascular Syndrome Part www.ebmedicine.net/TIA 2
I: Diagnosis And Evaluation Of Transient Ischemic Attack (Stroke CME)
August 2013 Guidelines For The Evaluation And Management Of Acute Cerebrovascular Syndromes Part www.ebmedicine.net/Stroke 2
II: Evaluation And Management Of Acute Ischemic Stroke (Stroke CME)

EM Practice Guidelines Update 2013 10 www.ebmedicine.net September 2013

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based on strength of evidence.

of Medicine
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Diagnosis and treatment recommendations solidly based in the current literature.

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Diagnosis and treatment recommendations solidly based in the current literature.

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