Epileptic seizures in paediatric patients: many rescuers will have had to manage this type of emergency and deal with the concern of the child and family members

We propose an interesting evidence-based guideline for the management of paediatric pre-hospital seizures using the GRADE methodology

The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence.

A multidisciplinary panel was chosen based on expertise in pediatric emergency medicine, prehospital medicine, and/or evidence-based guideline development.

The panel followed the National Prehospital EBG Model using the GRADE methodology to formulate questions, retrieve evidence, appraise the evidence, and formulate recommendations.

The panel members initially searched the literature in 2009 and updated their searches in 2012.

The panel finalized a draft of a patient care algorithm in 2012 that was presented to stakeholder organizations to gather feedback for necessary revisions.

Pediatric seizures are a high-incidence condition in the prehospital setting, and the potential morbidity and mortality of poorly managed seizures and their sequelae can be substantial if not rapidly treated.1

Pediatric prehospital seizure management is characterized by variability in care related to providers’ infrequent exposure to children, difficulty maintaining skills, and limited knowledge of pediatrics.2–8

Prehospital providers may have more difficulty in rapidly obtaining intravenous (IV) access in children relative to adults,9,10 and the stress of managing critically ill children poses an added challenge.11,12

While high quality studies are available to guide the management of adult patients with seizures in the prehospital setting,12,13 more research is needed to guide the practice of pediatric seizure management in the prehospital setting.14

The Institute of Medicine (IOM) and the National Emergency Medical Services (EMS) Research Agenda emphasize the importance of evidence-based guidelines (EBG) to provide systematic aids for making complex medical decisions throughout the health-care continuum, with the potential to enhance health-care quality and outcomes.15a,b,c,d,16,17

However, a review of ten sample statewide protocols for seizure management by the investigator group found substantial overall variation in practice, in terms of both medication selection and mode of administration.

Given the high incidence, potential morbidity, and wide practice variation associated with pediatric prehospital seizures, there is a need for an evidence-based guideline to inform management

Using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) methodology, the National Highway Traffic Safety Administration (NHTSA) and the Emergency Medical Services for Children (EMSC) Program at the Health Resources Services Administration (HRSA) pilot tested the National Prehospital EBG Model for the development of a pediatric seizure guideline.16–19

Guidelines for the management of paediatric patients with epileptic seizures: study conclusions

Using GRADE methodology, we have developed a pediatric seizure guideline that emphasizes the role of capillary blood glucometry and the use of buccal, IM, or intranasal benzodiazepines over IV or rectal routes.

Future research is needed to compare the effectiveness and safety of these medication routes.

Read the full article on seizures in paediatric patients:

An Evidence based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology

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Source:

Emergency Medical Services for Children Innovation and Improvement Center

References:

• Wheless JW. Treatment of status epilepticus in children. Pediatr Ann. 2004;33(6):376–83. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Gausche-Hill M. Pediatric continuing education for out-of-hospital providers: is it time to mandate review of pediatric knowledge and skills? Ann Emerg Med. 2000;36(1):72–74. [Google Scholar]
• Glaeser PW, Linzer J, Tunik MG, Henderson DP, Ball J. Survey of nationally registered emergency medical services providers: pediatric education. Ann Emerg Med. 2000;36(1):33–38. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Gausche-Hill M, Henderson DP, Brownstein D, Foltin GL. The education of out-of-hospital emergency medical personnel in pediatrics: report of a national task force. Prehosp Emerg Care. 1998;2(1):56–61. [Google Scholar]
• Su E, Mann NC, McCall M, Hedges JR. Use of resuscitation skills by paramedics caring for critically injured children in Oregon. Prehosp Emerg Care. 1997;1(3):123–127. [Taylor & Francis Online], [Google Scholar]
• Su E, Schmidt TA, Mann NC, Zechnich AD. A randomized controlled trial to assess decay in acquired knowledge among paramedics completing a pediatric resuscitation course. Acad Emerg Med. 2000;7(7):779–786. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Lammers RL, Byrwa MJ, Fales WD, Hale RA. Simulation-based assessment of paramedic pediatric resuscitation skills. Prehosp Emerg Care. 2009;13(3):345–356. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]
• Shah MN, Cushman JT, Davis CO, Bazarian JJ, Auinger P, Friedman B. The epidemiology of emergency medical services use by children: an analysis of the national hospital ambulatory medical care survey. Prehosp Emerg Care. 2008;12(3):269–76. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]
• Sampalis JS, Lavoie A, Williams JI, Mulder DS, Kalina M. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma. 1993;34(2):252–61. [Crossref], [PubMed], [Google Scholar]
• Lillis KA, Jaffe DM. Prehospital intravenous access in children. Ann Emerg Med. 1992;21(12):1430–4. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Lammers R, Byrwa M, Fales W. Root causes of errors in a simulated prehospital pediatric emergency. Acad Emerg Med. 2012;19(1):37–47. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O”Neil N, Neuhaus JM, Segal MR, Lowenstein DH. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med. 2001;345(9):631–7. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012;366(7):591–600. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Foltin GL, Dayan P, Tunik M, Marr M, Leonard J, Brown K, Hoyle J, Lerner EB; Prehospital Working Group of the Pediatric Emergency Care Applied Research Network. Priorities for pediatric prehospital research. Prehosp Emerg Care. 2010;26(10)773–7. [Google Scholar]
• Institute of Medicine (U.S.) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. [Google Scholar]
• National Highway Traffic Safety Administration. National EMS Research Agenda. US Department of Transportation, Washington, DC, 2001. Available at www.ems.gov/pdf/EMS ResearchAgenda.pdf. Accessed February 4, 2013. [Google Scholar]
• Institute of Medicine (U.S.) Committee on the Future of Emergency Care in the United States Health System. Emergency Medical Services: At the Crossroads. Washington, DC: The National Academies Press; 2006. [Google Scholar]
• Lang ES, Spaite DW, Oliver ZJ, Gotschall CS, Swor RA, Dawson DE, Hunt RC. A National model for developing, implementing and evaluating evidence-based guidelines for prehospital care. Acad Emerg Med. Feb 2012; 19(2): 201–9. [Google Scholar]
• Brozek JL, Akl EA, Alonso-Coello P, Lang D, Jaeschke R, Williams JW, Phillips B, Lelgemann M, Lethaby A, Bousquet J, Guyatt GH, Schunemann HJ; GRADE Working Group. Grading quality of evidence and strength of recommendations in clinical practice guidelines, part 1 of 3: an overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009;64(5):669–77. [Google Scholar]
• Brozek JL, Akl EA, Jaeschke R, Lang DM, Bossuyt P, Glasziou P, Helfand M, Ueffing E, Alonso-Coello P, Meerpohl J, Phillips B, Horvath AR, Bousquet J, Guyatt GH, Schunemann HJ; GRADE Working Group. Grading quality of evidence and strength of recommendations in clinical practice guidelines, part 2 of 3: the GRADE approach to grading quality of evidence about diagnostic tests and strategies. Allergy. 2009;64(8):1109–16. [Google Scholar]
• Guyatt GH, Oxman AD, Kunz R, Jaeschke R, Helfand M, Liberati A, Vist GE, Schunemann HJ; GRADE Working Group. Incorporating considerations of resources use into grading recommendations. BMJ. 2008;336(7654):1170–3. [Google Scholar]
• Schünemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, Williams JW, Kunz R, Craig J, Montori VM, Bossuyt P, Guyatt GH; GRADE Working Group. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ. 2008; 336(7653):1106–10. [Google Scholar]
• Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490–4. [Google Scholar]
• Jaeschke R, Guyatt GH, Dellinger P, Schunemann H, Levy MM, Kunz R, Norris S, Bion J; GRADE Working Group. Use of GRADE grid to reach decisions on clinical practice guidelines when consensus is elusive. BMJ. 2008;337:327–30. [Crossref], [Web of Science ®], [Google Scholar]
• Brown KM, Macias CG, Dayan PS, Shah MI, Weik TS, Wright JL, Lang ES. The development of evidence-based prehospital guidelines using GRADE-based methodology. Prehosp Emerg Care. 2014; in press. [Google Scholar]
• Vilke GM, Castillo EM, Ray LU, Murrin PA, Chan TC. Evaluation of pediatric glucose monitoring and hypoglycemic therapy in the field. Pediatr Emerg Care. 2005;21(1):1–5. [Google Scholar]
• Funk DL, Chan L, Lutz N, Verdile VP. Comparison of capillary and venous glucose measurements in healthy volunteers. Prehosp Emerg Care. 2001;5(3):275–7. [Taylor & Francis Online], [Google Scholar]
• Desachy A, Vuagnat AC, Ghazali AD, Baudin OT, Longuet OH, Calvat SN, Gissot V. Accuracy of bedside glucometry in critically ill patients: influence of clinical characteristics and perfusion index. Mayo Clin Proc. 2008;83(4):400–5. [Google Scholar]
• Holstein A, Kuhne D, Elsing HG, Thiessen E, Plaschke A, Widjaja A, Vogel MY, Egberts EH. Practicality and accuracy of prehospital rapid venous blood glucose determination. Am J Emerg Med. 2000;18(6):690–4. [Google Scholar]
• Kulkarni A, Saxena M, Price G, O”Leary MJ, Jacques T, Myburgh JA. Analysis of blood glucose measurements using capillary and arterial blood samples in intensive care patients. Intensive Care Med. 2005;31(1):142–5. [Google Scholar]
• Kumar G, Sng BL, Kumar S. Correlation of capillary and venous glucometry with laboratory determination. Prehosp Emerg Care. 2004;8(4):378–83. [Taylor & Francis Online], [Google Scholar]
• Jones JL, Ray VG, Gough JE, Garrison HG, Whitley TW. Determination of prehospital blood glucose: a prospective, controlled study. J Emerg Med. 1992;10(6):679–82. [Google Scholar]
• Holstein A, Plaschke A, Vogel MY, Egberts EH. Prehospital management of diabetic emergencies –a population-based intervention study. Acta Anaesthesiol Scand. 2003;47(5):610–5. [Google Scholar]
• Roberts K, Smith A. Outcome of diabetic patients treated in the prehospital arena after a hypoglycemic episode, and an exploration of treat and release protocols: a review of the literature. Emerg J Med. 2003;20(3):274–6. [Google Scholar]
• Sporer KA, Johnson NJ. Detailed analysis of prehospital interventions in medical priority dispatch system determinants. West J Emerg Med. 2011;12(1):19–29. [Google Scholar]
• Cain E, Ackroyd-Stolarz S, Alexiadis P, Murray D. Prehospital hypoglycemia: the safety of not transporting treated patients. Prehosp Emerg Care. 2003;7(4)458–65. [Taylor & Francis Online], [Google Scholar]
• Richard J, Osmond MH, Nesbitt L, Stiell IG. Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system. Can J Emerg Med. 2006;8(1):6–12. [Crossref], [Google Scholar]
• Deasy C, Ryan D, O”Donnell C, Cusack S. The impact of a pre-hospital medical response unit on patient care and emergency department attendances. Ir Med J. 2008;101(2):1–2. [Google Scholar]
• Babl FE, Vinci RJ, Bauchner H, Mottley L. Pediatric pre-hospital advanced life support care in an urban setting. Pediatr Emerg Care. 2001;17(1):5–9. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Schwartz D, Amir L, Dichter R, Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience. J Trauma. 2008;64(3):650–5. [Google Scholar]
• Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma. 2000;49(4):584–99. [Google Scholar]
• Hartholt KA, van Lieshout EM, Thies WC, Patka P, Schipper IB. Intraosseous devices: a randomized controlled trial comparing three intraosseous devices. Pediatr Emerg Care. 2010;14(1):6–13. [Taylor & Francis Online], [Google Scholar]
• Gerritse BM, Scheffer GJ, Draaisma JM. Prehospital intraosseous access with the bone injection gun by a helicopter-transported emergency medical team. J Trauma. 2009;66(6):1739–41. [Google Scholar]
• Gerritse BM, Schalkwijk A, Pelzer BJ, Draaisma JM. Advanced medical life support procedures in vitality compromised children by a helicopter emergency medical service. BMC Emerg Med. 2010;10:6. [Google Scholar]
• Zarate L, Mandleco B, Wilshaw R, Ravert P. Peripheral intravenous catheters started in prehospital and emergency department settings. J Trauma Nurs. 2008;15(2):47–52. [Google Scholar]
• Frascone RJ, Jensen J, Wewerka SS, Salzman JG. Use of the pediatric EZ-IO needle by emergency medical services providers. Pediatr Emerg Care. 2009;25(5): 329–32. [Google Scholar]
• de Caen A. Venous access in the critically ill child. Pediatr Emerg Care. 2007;23(6):422–7. [Google Scholar]
• Tobias JD, Ross AK. Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesth Analg. 2010;110(2):391–401. [Google Scholar]
• Nicholl J, Hughes S, Dixon S, Turner J, Yates D. The costs and benefits of paramedic skill in pre-hospital trauma care. Health Technol Assess. 1998;2(17):1–72. [Google Scholar]
• De Lorenzo RA, Abbott CA. Effect of a focused and directed continuing education program on prehospital skill maintenance in key resuscitation areas. J Emerg Med. 2007;33(3): 293–7. [Google Scholar]
• Lamhaut L, Dagron C. Comparison of intravenous and Intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment. Resuscitation. 2010;81(1):65–8. [Google Scholar]
• Arya R, Gulati S, Kabra M, Sahu JK, Kalra V. Intranasal versus intravenous lorazepam for control of acute seizures in children: a randomized open-label study. Epilepsia. 52(4):788–93. [Google Scholar]
• Muchohi SN, Kokwaro GO, Ogutu BR, Edwards G, Ward SA, Newton CR. Pharmacokinetics and clinical efficacy of midazolam in children with severe malaria and convulsions. Br J Clin Pharmacol. 2008;66(4):529–38. [Google Scholar]
• Muchohi SN, Obiero K, Newton CR, Ogutu BR, Edwards G, Kokwaro GO. Pharmacokinetics and clinical efficacy of lorazepam in children with severe malaria and convulsions. Br J Clin Pharmacol. 65(1):12–21. [Google Scholar]
• Mahmoudian T, Zadeh MM. Comparison of intranasal midazolam with intravenous diazepam for treating acute seizures in children. Epilepsy Behav. 2004;5(2):253–5. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Talukdar B, Chakrabarty B. Efficacy of buccal midazolam compared to intravenous diazepam in controlling convulsions in children: a randomized control trial. Brain Dev. 2009;31(10):744–9. [Google Scholar]
• Vilke GM, Sharieff GQ, Marino A, Gerhart AE, Chan TC. Midazolam for the treatment of out-of-hospital pediatric seizures. Prehosp Emerg Care. 2002;6(2):215–7. [Taylor & Francis Online], [Google Scholar]
• Lahat E, Goldman M, Barr J, Bistritzer T, Berkovitch M. Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomized study. Br Med J. 2000;321(7253):83–6. [Google Scholar]
• Shah I, Deshmukh CT. Intramuscular midazolam vs. intravenous diazepam for acute seizures. Indian J Pediatr. 2005;72(8):667–70. [Crossref], [PubMed], [Google Scholar]
• McMullan J, Sasson C, Pancioli A, Silbergleit R. Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: a meta-analysis. Acad Emerg Med. 2010;17(6):575–82. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Chin RF, Neville BG, Peckham C, Wade A, Bedford H, Scott RC. Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study. Lancet Neurol. 2008;7(8):696–703. [Google Scholar]
• Mittal P, Manohar R, Rawat AK. Comparative study of intranasal midazolam and intravenous diazepam sedation for procedures and seizures. Indian J Pediatr. 2006;73(11): 975–8. [Google Scholar]
• Chamberlain JM, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, Waisman Y. A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children. Pediatr Emerg Care. 1997;13(2):92–4. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• McIntyre J, Robertson S, Norris E, Appleton R, Whitehouse WP, Phillips B, Martland T, Berry K, Collier J, Smith S, Choonara I. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomized controlled trial. Lancet. 2005;366(9481):205–10. [Google Scholar]
• Mpimbaza A, Ndeezi G, Staedke S, Rosenthal PJ, Byarugaba J. Comparison of buccal midazolam with rectal diazepam in the treatment of prolonged seizures in Ugandan children: a randomized clinical trial. Pediatrics. 2008;121(1):e58–e64. [Google Scholar]
• Rainbow J, Browne GJ, Lam LT. Controlling seizures in the prehospital setting: diazepam or midazolam? J Paediatr Child Health. 2002;38(6):582–6. [Google Scholar]
• Fisgin T, Gurer Y, Tezic T, Senbil N, Zorlu, Okuyaz C, Akgun D. Effects of intranasal midazolam and rectal diazepam on acute convulsions in children: prospective randomized study. J Child Neurol. 2002;17(2):123–6. [Google Scholar]
• Bhattacharyya M, Kalra V, Gulati S. Intranasal midazolam vs rectal diazepam in acute childhood seizures. Pediatr Neurol. 2006;34(5):355–9. [Google Scholar]
• Holsti M, Dudley N, Schunk J, Adelgais K, Greenberg R, Olsen C, Healy A, Firth S, Filloux F. Intranasal midazolam vs rectal diazepam for the home treatment of acute seizures in pediatric patients with epilepsy. Arch Pediatr Adolesc Med. 2010;164(8):747–53. [Google Scholar]
• Yoshikawa H, Yamazaki S, Abe T, Oda Y. Midazolam as a first-line agent for status epilepticus in children. Brain Dev. 2000;22(4):239–42. [Google Scholar]
• Galvin GM, Jelinek GA. Midazolam: an effective intravenous agent for seizure control. Arch Emerg Med. 1987;4(3):169–72. [Google Scholar]
• Papavasiliou AS, Kotsalis C, Paraskevoulakos E, Karagounis P, Rizou C, Bazigou H. Intravenous midazolam in convulsive status epilepticus in children with pharmacoresistant epilepsy. Epilepsy Behav. 2009;14(4):661–4. [Google Scholar]
• Hayashi K, Osawa M, Aihara M, Izumi T, Ohtsuka Y, Haginoya K, Kato I, Kaneko K, Sugai K, Takahashi T, Hamano S, Matsukura M, Miura H, Minagawa K, Yamano T, Yamamoto H, Yamanouchi H, Yoshikawa H; Research Committee on Clinical Evidence of Medical Treatment of Status Epilepticus in Childhood. Efficacy of intravenous midazolam for status epilepticus in childhood. Pediatr Neurol. 2007;36(6):366–72. [Google Scholar]
• Galustyan SG, Walsh-Kelly CM, Szewczuga D, Bergholte J, Hennes H. The short-term outcome of seizure management by prehospital personnel: a comparison of two protocols. Pediatr Emerg Care. 19(4);221–5. [Google Scholar]
• Alldredge BK, Wall DB, Ferriero DM. Effect of prehospital treatment on the outcome of status epilepticus in children. Pediatr Neurol. 12(3):213–6. [Google Scholar]
• Appleton R, Sweeney A, Choonara I, Robson J, Molyneux E. Lorazepam versus diazepam in the acute treatment of epileptic seizures and status epilepticus. Dev Med Child Neurol. 1995;37(8):682–8. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Sreenath TG, Gupta P, Sharma KK, Krishnamurthy S. Lorazepam versus diazepam-phenytoin combination in the treatment of convulsive status epilepticus in children: a randomized controlled trial. Eur J Paediatr Neurol. 14(2):162–8. [Google Scholar]
• Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O”Neil N, Neuhaus JM, Segal MR, Lowenstein DH. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med. 345(9);631–7. [Google Scholar]
• Leppik IE, Derivan AT, Homan RW, Walker J, Ramsay RE, Patrick B. Double-blind study of lorazepam and diazepam in status epilepticus. JAMA. 249(11);1452–4. [Google Scholar]
• Holliman CJ, Wuerz RC, Vazquez-de Miguel G, Meador SA. Comparison of interventions in prehospital care by standing orders versus interventions ordered by direct (on-line) medical command. Prehsop Disaster Med. 1994;9(4):202–9. [Google Scholar]
• Wuerz RC, Swope GW, Holliman J, Vazquez-de Miguel G. On-line medical direction: a prospective study. Prehosp Disaster Med. 1995;10(3):51–4. [Google Scholar]
• Atkins D, Eccles M, Flottorp S, Guyatt GH, Henry D, Hill S, Liberati A, O”Connell D, Oxman AD, Phillips B, Schunemann H, Edejer TT, Vist GE, Williams JW; GRADE Working Group. Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group. BMC Health Serv Res. 2004;4(1):38. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]
• Lewena S, Pennington V, Acworth J, Thornton S, Ngo P, McIntyre S, Krieser D, Neutze J, Speldewinde D. Emergency management of pediatric convulsive status epilepticus: a multicenter study of 542 patients. Pediatr Emerg Care. 2009;25(2):83–7. [Google Scholar]
• Martin-Gill C, Hostler D, Callway CW, Prunty H, Roth RN. Management of prehospital seizure patients by paramedics. Prehosp Emerg Care. 2005;21(1):1–5. [Google Scholar]
• Balas EA, Boren SA. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000: Patient-centered Systems. Stuttgart, Germany: Schattauer; 2000:65–70. [Google Scholar]
• Chumpitazi CE, Barrera P, Macias CG. Diagnostic accuracy and therapeutic reliability in pediatric emergency medicine: the role of evidence-based guidelines. Clin Pediatr Emerg Med. 2011;12(2):113–20. [Google Scholar]