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Highlights from this issue

This month we range from Politics to philosophy, from basic science to standards of care. There is a spread of material on the resuscitation of cardiac arrest and lots of pre-hospital care; triage at ‘front’ and ‘rear’, trauma transfer times, airway care in the field and even how to improve ambulance safety. The meaning of words In this month's editorial, Hughes (see page 90) shows how easy it is to become confused with the political language of the performance culture in UK Emergency Medicine and translates some into simple terms that can be understood! On a much simpler and certainly more fundamental level, Body and Foex (see page 91) consider the philosophical difference between pain and suffering. Do we see and try to manage the disease/injury or care for the patient? Try their thought experiments to find out. Real science Tura et al (see...

A&E quality indicators

International readers may need reminding that in April 2011 a new set of clinical quality (A&E) indicators was introduced in the NHS in England to replace the previous 4 h waiting time standard, the new indicators providing a platform with which to measure the quality of care delivered in A&E departments in England. The indicators were developed by the national clinical director for urgent and emergency care, working with the College of Emergency Medicine, the Royal College of Nursing and informed patient representatives. At the beginning of October last year the government released data for May 2011, related to A&E attendances for that month and drawing on just over 1.4 million detailed records of attendances at major A&E departments, single specialty A&E departments (eg, dental), minor injury units and walk-in centres in England.1 Five indicators are reported:left department before being seen for treatment rate; re-attendance rate;...

Optimising well-being: is it the pain or the hurt that matters?

In recent years there has been a commendable focus on patient-centred medicine, with increasing attention being paid to the timely assessment and management of acute pain. 78% of patients who attend the emergency department report pain, the severity of which is often used to determine clinical priority at triage. Clinical guidelines are increasingly including the timely provision of appropriate analgesia as a clinical standard. Pain scoring has been widely adopted, causing pain to be considered as the ‘fifth vital sign’ by some. Interestingly, there remains little evidence to support the benefit of this approach for patients. The aim of this review is to explore some of the assumptions that made in defining and addressing ‘pain’, and to explore whether it is truly ‘nociception’ or ‘suffering’ that ought to be addressed. Through two thought experiments, it is demonstrated that the current approach to pain relies heavily on addressing ‘nociception’ but does little to address the ‘suffering’ that is undoubtedly they key determinant of well-being in patients. It is demonstrated that the current naturalistic approach risks neglecting many ‘non-nociceptive’ sources of suffering, including physical (eg, nausea, vertigo, dyspnoea, pruritus) and mental (anxiety, depression, fear, anger) symptoms. In the humane quest to relieve suffering, there is a clear need to examine current practice. Indeed, the philosophical enquiry presented even questions whether our culture risks overemphasising the importance of pharmacological analgesia and calls for emergency physicians to take a more holistic approach to meeting patient needs.

Comparative quality analysis of hands-off time in simulated basic and advanced life support following European Resuscitation Council 2000 and 2005 guidelines

Aim To compare hands-off time (HOT) in simulated advanced life support (ALS) following European Resuscitation Council (ERC) 2005 guidelines and ERC 2000 and to provide quantitative data on workflow. Subjects and Methods Observations with 18 professional paramedics, performing 39 megacodes (mega-code training; MCT) were videotaped during ALS re-certification. Teams were randomly assigned to train according to ERC 2000 or ERC 2005. HOT, hands-off intervals (HOI) and other variables describing interventions and workflow were analysed. Results In group ERC 2000 17±3 HOI appeared with a mean duration of 17.5±10.8 s (mean±SD). Overall HOT was 382±47 s, equivalent to a mean hands-off fraction (HOF) of 0.45±0.05. 15±5 ventilation-free intervals (VFI) were observed, with a mean duration of 21±10 s. In contrast after ERC 2005 variables resulted in 18±3 HOI with a mean duration of 10.0±4.0 s (p<0.001 vs ERC 2000), overall HOT 196±33 s (HOF 0.23±0.04; p<0.001), 24±12 VFI with a duration of 24±7 s (p<0.05). The first HOI lasted for 60.4±33.1 s in ERC 2000 and 17.6±4.3 s in ERC 2005 (p<0.001). In ERC 2000 6.1±2.6 interruptions for two bag/mask ventilations (BMV) lasted for 5.4±0.8 s, whereas in ERC 2005 9.6±3.1 interruptions for two BMV took 6.5±2.2 s (p<0.001). In both groups HOI were used thoroughly for basic life support/ALS-based interventions. Conclusion The application of ERC guidelines of 2005 markedly reduced the first HOI and mean duration of HOI at the cost of delayed secure airway management and ECG analysis in this MCT model.

Mild hypothermia treatment in patients resuscitated from non-shockable cardiac arrest

Objective Therapeutic hypothermia has proved effective in improving outcome in patients after cardiac arrest due to ventricular fibrillation (VF). The benefit in patients with non-VF cardiac arrest is still not defined. Methods This prospective observational study was conducted in a university hospital setting with historical controls. Between 2002 and 2010 387 consecutive patients have been admitted to the intensive care unit (ICU) after cardiac arrest (control n=186; hypothermia n=201). Of those, in 175 patients the initial rhythm was identified as non-shockable (asystole, pulseless electrical activity) rhythm (control n=88; hypothermia n=87). Neurological outcome was assessed at ICU discharge according to the Pittsburgh cerebral performance category (CPC). A follow-up was completed for all patients after 90 days, a Kaplan–Meier analysis and Cox regression was performed. Results Hypothermia treatment was not associated with significantly improved neurological outcome in patients resuscitated from non-VF cardiac arrest (CPC 1–2: hypothermia 27.59% vs control 18.20%, p=0.175). 90-Day Kaplan–Meier analysis revealed no significant benefit for the hypothermia group (log rank test p=0.82), and Cox regression showed no statistically significant improvement. Conclusions In this cohort patients undergoing hypothermia treatment after non-shockable cardiac arrest do not benefit significantly concerning neurological outcome. Hypothermia treatment needs to be evaluated in a large multicentre trial of cardiac arrest patients found initially to be in non-shockable rhythms to clarify whether cooling may also be beneficial for other rhythms than VF.

'Scurvy': presentation and skin manifestations of a not so uncommon condition

An 84-year-old man attended our emergency department with a 5-month history of poor oral intake since the death of his wife. He complained of lethargy, dyspnoea, epistaxis and myalgic pains. He was severely thin with purpuric skin lesions over his knuckles, elbows and shins (figures 1 and 2).1 Scurvy was suggested and confirmed by dermatology. The patient was started on ascorbic acid (400 mg/24 h) and initially improved, but died later of a nosocomial infection. Scurvy is a state of vitamin C (ascorbic acid) deficiency. Ascorbic acid is used in the synthesis of collagen, neurotransmitters and helps in dietary iron absorption. Deficiency results in poor wound healing, defective capillary walls and anaemia. The UK incidence of clinical scurvy is unknown, but the prevalence of vitamin C deficiency is estimated at 25% in men and 16% in women and is associated with low income, poor diet...

Value of a rigid collar in addition to head blocks: a proof of principle study

Background All trauma patients with a cervical spinal column injury or with a mechanism of injury with the potential to cause cervical spinal injury should be immobilised until a spinal injury is excluded. Immobilisation of the entire patient with a rigid cervical collar, backboard, head blocks with tape or straps is recommended by the Advanced Trauma Life Support guidelines. However there is insufficient evidence to support these guidelines. Objective To analyse the effects on the range of motion of the addition of a rigid collar to head blocks strapped on a backboard. Method The active range of motion of the cervical spine was determined by computerised digital dual inclinometry, in 10 healthy volunteers with a rigid collar, head blocks strapped on a padded spine board and a combination of both. Maximal opening of the mouth with all types of immobiliser in place was also measured. Results The addition of a rigid collar to head blocks strapped on a spine board did not result in extra immobilisation of the cervical spine. Opening of the mouth was significantly reduced in patients with a rigid collar. Conclusion Based on this proof of principle study and other previous evidence of adverse effects of rigid collars, the addition of a rigid collar to head blocks is considered unnecessary and potentially dangerous. Therefore the use of this combination of cervical spine immobilisers must be reconsidered.

Slow infusion metoclopramide does not affect the improvement rate of nausea while reducing akathisia and sedation incidence

Objective To compare the effects of metoclopramide infusion in emergency department (ED) patients complaining of nausea to determine the changes in its therapeutic effect and prevention of side effects such as akathisia and sedation. Methods A prospective, randomised, double blind trial, from 1 March 2007 to 1 May 2008 in the ED of Pamukkale University Faculty of Medicine. Patients with moderate to severe nausea were randomised and divided into two groups: group 1 received 10 mg metoclopramide as a slow intravenous infusion over 15 min plus placebo (SIG); group 2 received 10 mg metoclopramide as an intravenous bolus infusion over 2 min plus placebo (BIG). The whole procedure was observed, and nausea scores, akathisia and vital changes were recorded. Results 140 patients suffering from moderate to severe nausea in the ED were included in the study. There was no significant difference between the groups in terms of mean nausea scores during follow-up (p=0.97). A significant difference in akathisia incidence was observed between the groups (18 (26.1%) in the BIG and 5 (7%) in the SIG) (p=0.002). There was also a significant difference in sedation incidence between the groups (19 (27.5%) in the BIG and 10 (14.5%) in the SIG) (p=0.05). Conclusion Even though slowing the rate of infusion of metoclopramide does not affect the rate of improvement in nausea, it may be an effective strategy for reducing the incidence of akathisia and sedation in patients with nausea.

Serum procalcitonin predicting mortality in exertional heatstroke

Background The aim of this study was to test if Procalcitonin PCT value at the time of admission is a predictor of mortality and/or a diagnostic marker of concomitant infection in exertional heatstroke. Methods 68 patients with exertional heatstroke admitted to the multidisciplinary intensive care unit were studied. Serum PCT was detected by means of a specific and ultrasensitive immunoluminometric assay within 2 h of admission. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was evaluated within 24 h of admission. Results There was no significant difference in PCT levels between concomitant infection and non-infection patients (p=0.712). Elevated PCT level in exertional heatstroke patients was associated with a more critical pathological state. PCT values in patients with multiple organ dysfunction syndrome (MODS) were significantly higher than those without MODS (p=0.007.). PCT values were also positively correlated with APACHE II scores (r=0.588, p=0.016). PCT values in non-survivors were higher than in survivors at univariate regression analysis (p=0.017). After adjusting for confounders, PCT concentration also remained an independent determinant of mortality (OR 2.98; 95% CI 1.02 to 4.41; p=0.039). Receiver operating characteristic curve for PCT concentration was located above the reference line, which shows an association with mortality. The area under the curve for PCT concentration (0.705; 95% CI 0.547 to 0.862) was statistical significantly (p=0.019). As a predictor of mortality, PCT value was inferior to APACHE II score. Conclusions PCT value at the time of admission is an independent predictor of mortality, but maybe not a good indicator of concomitant infection in exertional heatstroke.

Unexpected splenic injury

A 31-year-old man presented to the emergency department at 04:50 complaining of left-sided abdominal and flank pain that started from the previous afternoon. The pain had initially settled but he woke up with a recurrence of the pain. The pain settled with the administration of rectal diclofenac and an intravenous pyelogram was normal. The patient was stable and blood tests were unremarkable. He was admitted by the surgeon, reviewed by senior surgeons in the morning and discharged. After 2 days, he returned with persistent abdominal pain. Abdominal examination was unremarkable. Emergency department ultrasound showed significant intra-abdominal free fluid and a lesion in the spleen (figure 1A,B). A CT scan confirmed the presence of free fluid in the abdomen, intrasplenic laceration together with peri-splenic haematoma. The patient admitted to jet skiing the week before the pain started. He was readmitted. The pain settled over the next few days and...

Recent massive blood transfusion practice in England and Wales: view from a trauma registry

Background Few studies have characterised massive blood transfusion (MBT) practice in UK trauma. This study describes the Trauma Audit and Research Network experience of MBT over a 4-year period, and examines variables predictive of MBT and mortality following MBT. Methods Prospectively collected data between 2005 and 2009 from the Trauma Audit and Research Network database were analysed. MBT incidence was examined, and patient characteristics, blood component usage and mortality compared to non-MBT patients. Clinical and injury features predictive of massive transfusion, and risk factors predictive of death in MBT, were analysed using multivariate logistic regression. Results 157 patients (0.4%) received MBT, with a mortality rate of 40.3%. MBT patients were younger, more likely to be male and to have sustained more severe trauma (median age 39.2 years, median Injury Severity Score 27, 78% male, p<0.01). No patients received platelets and fresh frozen plasma (FFP) in 1:1 ratios with packed red cells. Multivariate analysis showed: age, admission pulse rate, systolic blood pressure, and injury type; thoracic, abdominal, pelvis, were significant predictors of MBT. Injury Severity Score and admission pulse rate were also independent predictors of death in MBT, but level of platelet and FFP use were not found to be statistically significant. Conclusion MBT is a rare event with high mortality in UK trauma. Haemostatic resuscitation is not currently practiced in the UK and the authors were unable to show that FFP and platelet use were significant predictors of survival in MBT.

Theme: Suicide and suicidal behaviours

Question 1 Which of the following are true regarding suicidal intent and suicide? A previous suicide attempt is the best predictor of a future suicide attempt. 10–15% of those attempting suicide succeed, but 60–70% of successful suicides have no prior history of attempts. Patients who attempt suicide have low CSF serotonin levels. Borderline personality disorder is the Axis II diagnosis most closely associated with suicide. Question 2 Which of the following are true regarding assessment of potentially suicidal patients? A ‘SAD PERSONS’ score of <6 has a negative predictive value (NPV) of >95%. No single psychological test can accurately predict suicidal attempts. Scoring systems might help in determining the need for hospitalisation. Suicide is often provoked by a treatable or reversible short-term crisis. Question 3 Which of the following are true regarding treatment of suicidality? Suicidal patients frequently...

Is computer-assisted telephone triage safe? A prospective surveillance study in walk-in patients with non-life-threatening medical conditions

Background Patients often establish initial contact with healthcare institutions by telephone. During this process they are frequently medically triaged. Purpose To investigate the safety of computer-assisted telephone triage for walk-in patients with non-life-threatening medical conditions at an emergency unit of a Swiss university hospital. Methods This prospective surveillance study compared the urgency assessments of three different types of personnel (call centre nurses, hospital physicians, primary care physicians) who were involved in the patients' care process. Based on the urgency recommendations of the hospital and primary care physicians, cases which could potentially have resulted in an avoidable hazardous situation (AHS) were identified. Subsequently, the records of patients with a potential AHS were assessed for risk to health or life by an expert panel. Results 208 patients were enrolled in the study, of whom 153 were assessed by all three types of personnel. Congruence between the three assessments was low. The weighted values were 0.115 (95% CI 0.038 to 0.192) (hospital physicians vs call centre), 0.159 (95% CI 0.073 to 0.242) (primary care physicians vs call centre) and 0.377 (95% CI 0.279 to 0.480) (hospital vs primary care physicians). Seven of 153 cases (4.57%; 95% CI 1.85% to 9.20%) were classified as a potentially AHS. A risk to health or life was adjudged in one case (0.65%; 95% CI 0.02% to 3.58%). Conclusion Medical telephone counselling is a demanding task requiring competent specialists with dedicated training in communication supported by suitable computer technology. Provided these conditions are in place, computer-assisted telephone triage can be considered to be a safe method of assessing the potential clinical risks of patients' medical conditions.

Cardiovascular collapse after return of spontaneous circulation in human out-of-hospital cardiopulmonary arrest

Objective Animal studies describe cardiovascular collapse (CVC; hypotension or reoccurrence of cardiac arrest) after return of spontaneous circulation (ROSC) from cardiopulmonary arrest. Few studies describe CVC in humans. This study aimed to determine the occurrence of CVC in human out-of-hospital cardiopulmonary arrest (OHCA). Methods Using observational data from a site of the Resuscitation Outcomes Consortium, the study analysed treated, non-traumatic OHCA achieving initial ROSC. CVC was defined as post-ROSC hypotension (systolic blood pressure ≤80 mm Hg), post-ROSC administration of epinephrine, vasopressin or dopamine, or post-ROSC recurrent cardiac arrest. The time period from initial ROSC to emergency department (ED) arrival was measured. The prevalence of and elapsed time to post-ROSC CVC was determined, censoring cases at the point of ED arrival and comparing clinical characteristics between CVC and non-CVC cases. Results Of 1081 treated OHCA, ROSC occurred in 58 (5%; 95% CI 4% to 7%). CVC occurred in three cases of 58 ROSC (5%; 95% CI 1% to 14%), all due to recurrent cardiac arrest. The median ROSC to ED arrival time was 6 min (IQR 3–13 min). ROSC to CVC times were 1, 2 and 8 min. Patient sex, age, initial ECG rhythm, endotracheal intubation, bystander cardiopulmonary resuscitation and bystander automated external defibrillation were similar between CVC and non-CVC cases (p=0.11–1.00). Conclusions In this series of treated OHCA, only a small fraction of patients experienced CVC after ROSC.

Effect of an onboard event recorder and a formal review process on ambulance driving behaviour

Background Onboard event recorders in vehicles record external and internal video before and after when preset g-force limits are exceeded. The use of these recorders in a fleet of ambulances, along with formal review, may decrease the number of unsafe driving events. The aim of this study was to evaluate the number of driving events since the inception of DriveCam technology in a fleet. Methods 54 vehicles were outfitted with DriveCam event recorders in 2003. Events were captured and assigned a categorical severity score of 1–4 (1 being the lowest severity) when the vehicle exceeded preset g-force limits. An event was assigned a score of ‘good’ if the review determined that the driver demonstrated good judgement. A review and feedback process was implemented in August 2006 and analysed through June 2008. Results During the study period, 2 979 891 miles were driven for 115 019 ambulance responses, with 6009 events captured. Events were categorised as follows: 2008 (33.4%) level 1; 3726 (62.0%) level 2; 175 (2.9%) level 3; 3 (0.05%) level 4; and 97 (1.6%) good events. The proportion of all events per mile and all events per response decreased over time with use of the recorder and review and feedback. Conclusions The institution of video event recorder technology along with formal review and feedback resulted in a change in driving behaviour. Given that call volumes increased and driving events decreased, these measures may serve as surrogates for improvements in safety and maintenance costs. Economic analysis is necessary for conclusions on fiscal impact.

Prehospital anaesthesia: a survey of current practice in the UK

Aim To establish the national picture of prehospital anaesthesia in the UK and to reference practice against the Association of prior to Anaesthetists of Great Britain and Ireland safety guideline on prehospital anaesthesia. Methods Lead clinicians were identified for all prehospital services in the UK that could potentially be performing prehospital anaesthesia and invited to complete a detailed online survey. The survey requested details on team structure, the process for prehospital anaesthesia, drugs and equipment used and training and governance arrangements. Results 55 responses were received from 63 invitations sent (87.3%) yielding usable data for 47 services. 31 of the 47 services (70%) responded that they performed prehospital anaesthesia. All services performing prehospital anaesthesia utilised a doctor but only 18 services (58%) always utilised a trained assistant. 28 services (90%) maintained a database and over half of services (55%) performed less than 20 prehospital anaesthetics annually. 23 services (74%) had a designated lead clinician for prehospital anaesthesia and 25 (81%) had a written difficult airway plan. 19 services (61%) had mandatory continual training requirements. Conclusions The majority of services are currently complying with the recommendations in the Association of prior to Anaesthetists of Great Britain and Ireland safety guideline. There are still areas of concern, particularly with regard to ongoing training and the high numbers of services that do not use a trained assistant for the process of prehospital anaesthesia.

Inappropriate 999 calls: an online pilot survey

Background Abuse of ambulance services is high, and there is concern among healthcare professionals that misuse of ambulances places stress on services, which may jeopardise patient care. This study aims to determine the proportion of people who correctly identify appropriate situations to call for an ambulance, and determine the characteristics of those most likely to call inappropriately. Methods An online questionnaire presented 12 common scenarios that may require medical attention and required participants to identify when they would request an ambulance. Proportions correctly responding to each scenario were calculated and each respondent was given a total score. t-Tests compared mean scores between groups (with and without first aid (FA) training), and 2 tests compared between-group proportions of correct answers for scenarios. Backwards stepwise logistic regression analyses determined the characteristics of those most likely to call inappropriately. Results 150 respondents completed the questionnaire. 5.2–47.8% responded with an inappropriate answer, depending on the scenario. Almost all participants identified the need for an ambulance in 3/5 scenarios when it was required; however, fewer (74.8%) respondents identified the need for an ambulance to a suspected stroke. The majority correctly identified an ambulance was not required in only 2/7 scenarios. Those with FA training were less likely to call inappropriately in all scenarios (significant in three situations). However, no participant characteristics were predictive of calling an ambulance inappropriately once confounders were taken into account. Conclusions The majority would call for an ambulance appropriately when a real emergency occurred, and most inappropriate classification occurs when an ambulance is not required.

Management of acute allergic reactions by dispatching physicians in a Medical Emergency Dispatch Centre

Background Acute allergic reactions often occur in out-of-hospital settings, and some of these reactions may cause death in the short term. However, initial diagnosis, management and processing of acute allergic reactions by Medical Emergency Dispatch Centres are not documented. The aim of the present study was to describe acute allergic reactions and their management by a Medical Emergency Dispatch Centre. Methods A prospective study was conducted from 20 August 2006 to 5 November 2006 on incoming calls for acute allergic reactions to the Medical Emergency Dispatch Centre for the Hauts de Seine (Paris West suburb, France). The agreement between initial diagnosis (made by dispatching physician) and final diagnosis (made by the physician who later examined the patient), and between initial and final severity, were evaluated using Cohen's weighted coefficient. Results 210 calls were included. The diagnoses made by the dispatching physician were: in 58.1% of cases urticaria, in 23.8% angioedema, in 13.3% laryngeal oedema, and in 1.9% anaphylactic shock. The agreement between initial and final diagnoses was evaluated by a coefficient at 0.44 (95% CI 0.26 to 0.61) and the agreement between initial and final severity was evaluated using a coefficient at 0.37 (95% CI 0.24 to 0.50). Conclusions Only moderate agreement is highlighted between the initial severity assessed by the dispatching physician and the final severity assessed by the physician later examining the patient. This demonstrates the need to develop a tool for assessing severity of acute allergic reactions for dispatching physicians in Medical Emergency Dispatch Centres.

Paramedics and the effects of shift work on sleep: a literature review

Introduction This paper investigates the literature regarding the impact of shift work on prehospital emergency providers. While the issue of shift work has been thoroughly investigated in other health disciplines, this is not the case for the paramedic discipline, particularly in the Australian context. Objective To identify the literature available on prehospital providers regarding the effects of shift work on sleep. Method Electronic databases used were the Cochrane Database of Systematic Reviews, Ovid MEDLINE, Proquest, AMED and CINAHL. The following MeSH terms and keywords with truncation were used in the search strategy: ‘shift work’; ‘sleep disorder’; ‘sleep deprivation’; ‘circadian rhythm’; ‘fatigue’; ‘occupational stress’. Results The electronic databases cited 226 articles, of which nine met the inclusion criteria with another three articles sourced from references in the retrieved papers. There is a lack of literature describing the effect of shift work on sleep in the prehospital arena, with only one paper exploring paramedics in the Australian setting. These findings suggest that further work is required to examine shift hours and workforce health and safety in the prehospital setting. Conclusions Shift work can affect health and well-being on a variety of levels, both physiologically and psychologically, affecting aspects of work and personal life. Further research is warranted to prevent the issues of patient safety, work-related fatigue and the cumulative effects of shift work.

Is direct transport to a trauma centre best for patients with severe traumatic brain injury? A study in south-central Taiwan

Objective This study attempted to identify any differences between the outcomes of patients with severe traumatic brain injury (TBI) who were directly transported to Chang Gung Memorial Hospital and those who were stabilised initially at other hospitals in south-central Taiwan. Methods A retrospective review of the records of 254 patients with isolated severe TBI who visited this hospital's emergency department from July 2003 to June 2008, of whom 167 were referred from other hospitals. Logistic regression was used to assess the effects of transfer and its components on mortality. Results Transfer from another hospital was not significantly correlated with mortality in this study (OR 0.513, 95% CI 0.240 to 1.097). Moreover, neither intubation (OR 1.356, 95% CI 0.445 to 4.133) nor transfer time over 4 h (OR 0.549, 95% CI 0.119 to 1.744) had a significant effect on mortality. Conclusion No differences in outcome were found between patients with isolated severe TBI who were directly transported and those transferred to this hospital's emergency room.

Using 'reverse triage' to create hospital surge capacity: Royal Darwin Hospital's response to the Ashmore Reef disaster

This report analyses the impact of reverse triage, as described by Kelen, to rapidly assess the need for continuing inpatient care and to expedite patient discharge to create surge capacity for disaster victims. The Royal Darwin Hospital was asked to take up to 30 casualties suffering from blast injuries from a boat carrying asylum seekers that had exploded 840 km west of Darwin. The hospital was full, with a backlog of cases awaiting admission in the emergency department. The Disaster Response Team convened at 10:00 to develop the surge capacity to admit up to 30 casualties. By 14:00, 56 beds (16% of capacity) were predicted to be available by 18:00. The special circumstances of a disaster enabled staff to suspend their usual activities and place a priority on triaging inpatients' suitability for discharge. The External Disaster Plan was activated and response protocols were followed. Normal elective activity was suspended. Multidisciplinary teams immediately assessed patients and completed the necessary clinical and administrative requirements to discharge them quickly. As per the Plan there was increased use of community care options: respite nursing home beds and community nursing services. Through a combination of cancellation of all planned admissions, discharging 19 patients at least 1 day earlier than planned and discharging all patients earlier in the day surge capacity was made available in Royal Darwin Hospital to accommodate blast victims. Notably, reverse triage resulted in no increase in clinical risk with only one patient who was discharged early returning for further treatment.

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary

Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again. The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary1 or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere.2 The BETs shown here together with those published previously and those currently under construction can be...

BET 1: Does the 'Seatbelt Sign' predict intra-abdominal injury after motor vehicle trauma in children?

A short cut review was carried out to establish whether the seat belt sign was a significant predictor of intra-abdominal injury in children involved in motor vehicle collisions. 51 papers were found using the reported searches, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that seatbelt sign appears to be associated with an increased risk of intra-abdominal injuries, especially gastrointestinal and pancreatic injuries.

BET 2: Should capnography be routinely used during procedural sedation in the Emergency Department?

A short cut review was carried out to establish whether capnography should be routinely used during procedural sedation in Emergency Departments. 206 papers were found using the reported searches, of which nine presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is that capnography may provide early warning of ventilatory changes that could result in hypoxia.

BET 3: Can pregabalin effectively diminish acute herpetic pain and reduce the incidence of post-herpetic neuralgia?

A short cut review was carried out to establish whether pregabalin can reduce acute herpetic pain and reduce post herpetic neuralgia. 48 papers were found using the reported searches, of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this best paper are tabulated. It is concluded that pregabalin does not seem to decrease the intensity of pain related to acute herpes zoster. Moreover, it does not decrease the incidence of post herpetic neuralgia. More research is.

Massive transfusion: a complex issue

I must comment on the article by Milligan et al regarding massive transfusion in trauma.1 The authors state that ‘standardizing blood transfusion in major trauma to include automatic delivery of appropriate blood products at particular points in resuscitation may be of benefit’. They base this on their survey of 32 emergency medicine doctors to whom they asked questions apparently relating to the definition of massive transfusion (MT), ‘target’ laboratory values and blood product components. The definition of MT is a retrospective one and therefore not of value to the emergency physician faced with a bleeding patient. The ‘target’ laboratory values may be of academic interest but are not the primary relevant point we should be interested in—the authors quite rightly allude to the delay associated with treatment reactionary to laboratory values. A recent data analysis by Brown et al2 noted that, in patients who had...

Short answer question case series: diagnosis and management of glaucoma

Case vignette A 40-year-old woman with history of hypertension and migraines presents with a complaint of headache. Two days prior to presentation she began to experience a left-sided, throbbing headache that radiated to the right and was accompanied by blurring of left eye vision and nausea. The blurred vision and headache were exacerbated by bright light, consistent with prior migraine attacks. She took her usual dose of naproxen with resolution of her nausea but still had a mild headache and blurred left eye vision. Two hours prior to presentation she walked outside and experienced worsening of her headache upon exposure to the sunlight, but without concomitant change in her vision or nausea. Aleve did not improve her symptoms, so she decided to present to the emergency department. Her vital signs were normal. Key questions Which features are consistent with migraine in this patient? What other important...

Highlights from the literature

Prehospital intraosseous access Intraosseous (IO) needles are commonly used to obtain vascular access in children rapidly. Recent studies have shown that IO needles can also be used as a rapid method for obtaining vascular access in adults. A randomised controlled trial attempted to establish whether there was a difference in the frequency of first attempt success between humeral IO, tibial IO and peripheral intravenous access in adult patients experiencing non-traumatic out-of-hospital cardiac arrest. The study found that tibial IO needles had the highest first attempt success and the most rapid time to vascular access. Perhaps IO access should be adopted more widely in the adult population (Annals of Emerg Med 2011;58:509–16). Pigtails for chest trauma There is an increasing trend towards using pigtail catheters (rather than traditional large bore drains) in patients who are found to have a traumatic pneumothorax. A retrospective study from the USA found that...

US Army: Brigadier general has died in Afghanistan

Natural causes. FORT HOOD, Texas (AP) – A 49-year-old brigadier general who died Friday in Afghanistan of apparent natural causes is likely the highest-ranking military officer to die in that conflict, according to military records. via US Army: Brigadier general has died in Afghanistan. At 49. Wow. Condolences to his family. Related posts: Army [...] Related posts: Army seeking troops bitten by stray animals following rabies death – Army – Stripes Wow, that is awful beyond belief. Army seeking troops bitten... Truman CO dies after collapsing – Navy News | News from Afghanistan & Iraq – Navy Times Carrier Command. On the path to Stars. Died at age... Wish comes true for cancer-stricken 10-year-old inducted into Army – Yahoo! News Most kids might hope to get an Xbox or an... Related posts brought to you by Yet Another Related Posts Plugin.

Worker Trapped Under Boeing 787 Tires

EVERETT, Wash. – Officials say emergency crews have rescued a worker who was temporarily trapped beneath the tires of a Boeing 787 jetliner at an Everett, Wash., airfield. via Worker Trapped Under Boeing 787 Tires Is Rescued. Yikes. Best wishes. via Drudge. Related posts: Boeing Providing Facebook Fan With the ‘Opportunity of a Lifetime’ [...] Related posts: Boeing Providing Facebook Fan With the ‘Opportunity of a Lifetime’ — CHICAGO, Feb. 9, 2011 /PRNewswire/ – This weekend, Dr. Jeremy Hampton, an aviation enthusiast and amateur... Related posts brought to you by Yet Another Related Posts Plugin.

The Best Super Bowl ad you won’t see

It’s only on in Canada (eh). It’s good. Yeah, it’s a Budwiser ad, but since they paid for the stunt (I guess), so they get a lot of credit from me. via SFGate Related posts: Volkswagen rolls out full Super Bowl ad – Autoweek Volkswagen rolls out full Super Bowl ad – Autoweek. ... Announcing [...] Related posts: Volkswagen rolls out full Super Bowl ad – Autoweek Volkswagen rolls out full Super Bowl ad – Autoweek. ... Announcing Guess-a-Nobel 2011 MedGadget has an interesting contest going on: Six days from... Related posts brought to you by Yet Another Related Posts Plugin.

Not dead yet

All, Sitemeter tells me people still visit this site. Probably from a sense of nostalgia, and I thank all of you for checking in here from time to time. I’m working a lot of shifts, going to a lot of meetings, and still trying to have a semblance of a life. This leaves no time [...] No related posts. Related posts brought to you by Yet Another Related Posts Plugin.

Volkswagen rolls out full Super Bowl ad – Autoweek

Volkswagen rolls out full Super Bowl ad – Autoweek. No related posts. Related posts brought to you by Yet Another Related Posts Plugin. No related posts. Related posts brought to you by Yet Another Related Posts Plugin.

American Airlines, this is a problem

Dear AA, I appreciate all the good to great service over the years, so this is why, in the spirit of improving our relationship, I offer this constructive criticism: For those unfamiliar with DFW, the gates are always related to the terminal. So the terminal being B and the gate starting with D, that’s a [...] Related posts: My first medical checklist Laugh if you want, this helps my life, at least... Royal wedding’s lone American will guard Queen on horseback – CNN.com Good for him. London (CNN) — Growing up on the... Related posts brought to you by Yet Another Related Posts Plugin.

Doc Fix Just Got More Expensive

Sustainable. They keep using that word. I do not think it means what they think it means… Permanent repeal of the flawed Medicare payment formula known as the Sustainable Growth Rate just got a lot more expensive…. via Doc Fix Just Got More Expensive – Margot Sanger-Katz – NationalJournal.com. Related posts: Medical Apps? There’s a [...] Related posts: Medical Apps? There’s a Doc for That When emergency physician Harvey Castro asked a nurse to start... With explanatory graphics! The Sources of the SGR “Hole” — NEJM This article and its graph (from the NEJM), and its... Related posts brought to you by Yet Another Related Posts Plugin.

Official 2012 Honda CR-V Game Day Commercial – “Matthew’s Day Off” Extended Version – YouTube

Laugh, and enjoy! Official 2012 Honda CR-V Game Day Commercial – “Matthew’s Day Off” Extended Version – YouTube. Related posts: The Canada Party Okay, it’s got an Fword in it, so if you’re... Doctors decry poor ER conditions via YouTube – FierceHealthcare Doctors at LaSalle Hospital in Montreal have turned the cameras... Compression Only [...] Related posts: The Canada Party Okay, it’s got an Fword in it, so if you’re... Doctors decry poor ER conditions via YouTube – FierceHealthcare Doctors at LaSalle Hospital in Montreal have turned the cameras... Compression Only CPR video Okay, it’s kind of amusing, and I hope it induces... Related posts brought to you by Yet Another Related Posts Plugin.

Save 50% at XYScrubs.com

I recommend these. They’re terrific. Get ‘em while they last. XY Scrubs, a premier provider of men’s scrubs and medical work apparel is having a 50% Off Sale on all Men’s Scrubs. Providing eco-friendly, anti- microbial, durable and fashion forward scrubs for Men, XY Scrubs (XYScrubs.com) has established itself as the New Leader in Men’s [...] Related posts: XY SCRUBS | Mens Scrubs – XY SCRUBS XY SCRUBS | Mens Scrubs – XY SCRUBS. A... Colorectal Surgeon’s Song It’s from 2006, but new to me. Enjoy.... Related posts brought to you by Yet Another Related Posts Plugin.

Crime Time: Juror arrested for trying to enter Fort Worth courthouse with loaded gun

This isn’t the part that made me roll my eyes: FORT WORTH — A juror was arrested Tuesday morning as she attempted to enter a courthouse with a loaded handgun and after deputies saw the weapon during a screening, a Tarrant County official said.The incident occurred about 8:30 a.m. at the south entrance to the [...] Related posts: In Fort Worth, MedStar’s Community Health Program cutting costs, improving patients’ well-being … Kudos to MedStar (our Fort Worth EMS provider) for their... Extra Credit: Fort Worth teen wins first Google Global Science Fair Fort Worth teen wins first Google Global Science Fair Shree... Texas budget crunch could delay M.D. program in Fort Worth | Texas Legislature | News fr… AUSTIN — A proposal to add an M.D. program to... Related posts brought to you by Yet Another Related Posts Plugin.

The Not-so-Nice Spice: A Teenage Girl With Palpitations and Dry Mouth

No abstract available

A Case of Functional Asplenia and Pneumococcal Sepsis: Erratum

No abstract available

Clinical Impression: Intussusception: An Abdominal Ultrasound Is Obtained: Surprise: Erratum

No abstract available

Nausea, Vomiting, and Diarrhea in a 9-Year-Old Girl

Cryptosporidiosis is reported in an otherwise healthy child. Her history was significant for playing in natural waters during a camping trip 1 week prior. Several days later, she began improving despite an incorrect diagnosis and inappropriate antibiotic therapy. Nitazoxanide was given once the diagnosis was established. Obtaining a thorough patient history, administering appropriate antibiotics, and counseling patients on preventive measures are critical steps in treating and managing the transmission of this parasite. The case emphasizes the value of stool ova and parasite examination for proper diagnosis of pediatric diarrheal illness in the emergency setting. In addition, the often overlooked diagnosis of cryptosporidiosis is reviewed as an important cause of diarrheal illness in the immunocompetent pediatric population.

Cholelithiasis in a Toddler With Sickle Cell Disease: Erratum

No abstract available

Malrotation With Midgut Volvulus

No abstract available

Return Visits to the Emergency Department Among Febrile Children 3 to 36 Months of Age

Objectives and Methods: The aim of the present retrospective, cross-sectional, descriptive study was to determine the characteristics of febrile 3- to 36-month-old children who were admitted to the emergency department (ED) with the chief complaint of fever and returned with the same complaint within 72 hours (returning group), compared with age-matched children who did not return to the ED (nonreturning group). Demographics and predischarge evaluation extent were focused on. Results: Compared with the nonreturning group (n = 305), the returning group (n = 92) demonstrated higher mean temperature at home (P = 0.008), longer fever duration (P < 0.0001), and greater pain frequency (P = 0.03). Demographics and predischarge evaluation extent were similar in both groups. Within the returning group, fever duration was longer at the time of the second visit (P = 0.004). Conclusions: Higher fever causes higher rate of return visits. Among the investigated groups, pain was the sole differentiating symptom. Further studies should identify patterns that diminish children’s ED readmission.

An Educational Video Improves Technique in Performance of Pediatric Lumbar Punctures

Background: Unsuccessful or traumatic lumbar punctures (LPs) occur commonly and contribute to patient discomfort and to challenges in medical decision making in the pediatric emergency department (ED). Objective: We produced an instructional video demonstrating the best practices in pediatric LP technique. We hypothesized that the performance of LPs would change and the rate of successful LPs would increase after watching the video. Methods: This was a prospective study of LPs performed in an urban, academic pediatric ED before and after an educational intervention. Lumbar punctures performed during year 1 constituted the control arm. During year 2, all medical practitioners working in the ED watched the instructional video, and this constituted the interventional arm. The practitioner performing the LP completed a standardized data collection form after each LP procedure, and medical records were reviewed. Results: Data forms were collected on 668 LPs during the study period, 391 during year 1 and 277 during year 2. There was neither a significant change in overall LP success rate between the 2 years (56.8% year 1 vs 53.4% year 2) nor a significant difference in median number of LP attempts required per patient (P = 0.78). Seventy-eight percent of participants who viewed the LP video during year 2 stated that the video helped increase their comfort level with performing LPs. The odds of using the techniques endorsed in the educational video were significantly higher during year 2 compared to year 1 for use of local anesthetic, early stylet removal, and vertical patient position. Conclusions: The video increased practitioners’ comfort level with the performance of pediatric LPs and adherence to evidence-based best practices. It was not associated with an increased rate of successful LPs.

Cholelithiasis and Its Complications in Children and Adolescents: Update and Case Discussion

Abstract: In recent years, gallbladder disease, primarily in the form of cholelithiasis, has been on the rise among infants and children. Although pediatric gallbladder disease is still less prevalent than adult gallbladder disease, physicians and other clinicians who care for children need to be aware of this underappreciated problem and understand the manifestations of biliary disease in the pediatric population. In this article, case discussions will serve as a platform for discussing the clinical spectrum of cholelithiasis and its complications in children as well as discussing the latest evidence related to diagnosis and treatment.

Initial Location Determines Spontaneous Passage of Foreign Bodies From the Gastrointestinal Tract in Children

Objective: The purpose of this study was to follow the natural course of spontaneous passage (SP) of ingested foreign bodies (FBs) in children. Methods: The medical records of 249 patients who ingested FBs were reviewed. In addition, they were studied by telephone questionnaires to follow up spontaneously passed FB. The factors associated with SP such as age, the type, size, and initial location of the FBs were analyzed. Results: Foreign bodies were spontaneously passed in 145 patients (58.2%), endoscopic removal was performed in 100 patients (40.2%), and operative removal was performed in 4 patients (1.6%). Most SP FBs were passed within 5 days. The SP rates (SPRs) according to the initial location were the following: 12.2% for the esophagus (P < 0.0001), 71.4% for the stomach, 85.7% for the small bowel, and 96.4% for the colon. There was no significant difference in the SPR according to age. When coins and disk batteries that required early endoscopic removal were excluded, the SPR was 63.4% for FBs less than 10 mm, 80.4% for FBs 10 to 20 mm, 72.8% for FBs 20 to 30 mm, and 50.0% for FBs more than 30 mm (P = 0.091). The initial location of the FB (odds ratio, 33.7; 95% confidence interval, 14.4-79.0) and the size of the FB (odds ratio, 3.5; 95% confidence interval, 1.0-11.6) were independent predictors of SP by multivariate analysis. Conclusions: Most FBs in the gastrointestinal tract are spontaneously passed without complication, and the initial location of FBs was found to be the main determining factor for SPR. Ingested FBs, in children, even sharp or relatively large FBs, can be spontaneously passed when they are located below the esophagus.

Apparent Life-Threatening Event Admissions and Gastroesophageal Reflux Disease: The Value of Hospitalization

Background: No standard management plan for infants with an apparent life-threatening event (ALTE) currently exists. These infants are routinely hospitalized. Benefits of hospitalization of ALTE patients with gastroesophageal reflux disease (GERD) need definition. Objectives: The study’s objectives were to determine the accuracy of a working diagnosis of GERD in infants admitted with ALTE and to describe the history and hospital course of infants with both working and discharge diagnoses of GERD. Methods: Authors retrospectively reviewed records from a large children’s hospital of infants aged 1 year old and younger hospitalized from January 1, 2004, to March 1, 2007, with an admission diagnosis of ALTE. Demographics, clinical presentation, testing, hospital course, and 6-month postdischarge visits were abstracted. Intensive care admissions were excluded. Univariate and multivariate analyses identified factors associated with a discharge diagnosis of GERD. Results: Three hundred thirteen infants met inclusion. Mean age was 2.1 months; mean length of stay was 2.5 days. A discharge diagnosis of GERD was most common (n = 154, 49%); 138 (89%) were initially well appearing, 10 (6%) had in-hospital events, and only 20 (13%) had upper gastrointestinal series performed. Concordance of initial working to discharge diagnosis of GERD was 96%. Nonconcordant diagnoses evolved within 24 hours. Rescue breaths and calling 911 were independently associated with a discharge diagnosis of GERD. Within 6 months, 14 patients (9%) with a discharge diagnosis of GERD had recurrent ALTE, and 5 (3%) had significant new diagnoses. Conclusions: Concordance of initial working diagnosis with discharge diagnosis of GERD in ALTE patients is high. However, in hospital events, evolution to new diagnoses and recurrent ALTE suggest that hospitalization of these patients is beneficial. Diagnostic studies should not be routine but should target concerns from the history, examination, and hospital course.

First-Onset Seizure After Use of 5-hour ENERGY: Erratum

No abstract available

Anticoagulation Therapy: Indications, Monitoring, and Complications

Anticoagulation for thromboembolic disease and bleeding, the main complication of anticoagulation therapy, are uncommon but are potentially life- or limb-threatening conditions that may present in the pediatric emergency department. Thromboembolic disease in children usually occurs as a complication of vascular access, primarily in children with congenital heart disease or cancer. However, complications of anticoagulation therapy used in the treatment of venous thromboembolism, pulmonary embolism, and blocked central venous catheter; arterial thromboembolism, including arterial ischemic stroke, Kawasaki disease, and after cardiac surgery, may warrant a visit to n the pediatric emergency department. Anticoagulation therapy may take the form of unfractionated heparin, low-molecular weight heparin, vitamin K antagonists, acetylsalicylic acid, or thrombolytic therapy. Monitoring anticoagulation therapy in children is very important and follows adult guidelines. Anticoagulant dosing may be adjusted based on activated partial thromboplastin time, anti-factor Xa level, and international normalized ratio.

Abusive Head Trauma

Abusive head trauma is a leading cause of morbidity and mortality in infants and young children. These patients will often first present to the emergency department. They may present with dramatic or subtle findings. It is important that pediatric emergency physicians be aware of the possible presentations of abusive head trauma. This article will review the epidemiology, the clinical findings, the diagnosis, the differential diagnosis, and the management of abusive head trauma.

Urban Primary Care Physicians’ Perceptions About Initiation of Controller Medications During a Pediatric Emergency Department Visit for Asthma

Objective: This study aimed to identify the beliefs and attitudes of primary care providers (PCPs) regarding emergency department (ED) physicians’ initiation of controller medications for children with persistent asthma symptoms during an immediate ED visit. Methods: We performed semistructured interviews and a focus group with a purposive sample of PCPs of asthmatic patients to assess attitudes toward the National Asthma and Education Prevention Program recommendations regarding ED-based initiation of controller medications. Interviews and a focus group were digitally recorded, transcribed, and entered into qualitative software for coding and analysis. A multidisciplinary team used content analysis to identify important themes. Results: A total of 22 pediatricians and 1 nurse practitioner participated, and content saturation was achieved. Of all participants, 57% were from hospital-based practices and 43% were from non–hospital-based practices. All agreed with the new guideline recommendation that emergency medicine physicians should consider initiating controller medications during a short-term visit for asthma. Four major themes were identified: (1) the importance of communication and collaboration between primary care and ED practitioners, (2) patients must meet criteria for inhaled corticosteroids and provide a reliable history, (3) the ED visit offers a lost opportunity for education and may represent a teachable moment, and (4) the ED visit provides a chance to capture patients with frequent exacerbations who are noncompliant with follow-up visits. Conclusions: Primary care providers who participated in this study believed that the ED visit offers a valuable opportunity for the initiation of controller medications when ED providers use guideline-based criteria and communicate the intervention to the PCP.

Is a Lumbar Puncture Necessary When Evaluating Febrile Infants (30 to 90 Days of Age) With an Abnormal Urinalysis?

Objectives: Guidelines for the management of febrile infants aged 30 to 90 days presenting to the emergency department (ED) suggest that a lumbar puncture (LP) should be performed routinely if a positive urinalysis is found during initial investigations. The aim of our study was to assess the necessity of routine LPs in infants aged 30 to 90 days presenting to the ED for a fever without source but are found to have a positive urine analysis. Methods: We retrospectively reviewed the records of all infants aged 30 to 90 days, presenting to the Montreal Children's Hospital ED from October 2001 to August 2005 who underwent an LP for bacterial culture, in addition to urinalysis and blood and urine cultures. Descriptive statistics and their corresponding confidence intervals were used. Results: Overall, 392 infants were identified using the microbiology laboratory database. Fifty-seven patients had an abnormal urinalysis. Of these, 1 infant (71 days old) had an Escherichia coli urinary tract infection, bacteremia, and meningitis. This patient, however, was not well on history, and the peripheral white blood cell count was low at 2.9 × 109/L. Thus, the negative predictive value of an abnormal urinalysis for meningitis was 98.2%. Conclusions: Routine LPs are not required in infants (30-90 days) presenting to the ED with a fever and a positive urinalysis if they are considered at low risk for serious bacterial infection based on clinical and laboratory criteria. However, we recommend that judicious clinical judgment be used; in doubt, an LP should be performed before empiric antibiotic therapy is begun.

Case Records of the Children's Mercy Hospital: A 12-Year-Old Girl With a Straddle Injury

Straddle injuries are common in children. At the end of this case presentation, you should be able to describe the approach to the evaluation and treatment of a straddle injury, list indications for gynecologic consultation and/or sedation, plan disposition, and discuss pitfalls to avoid in evaluating patients with straddle injuries.

Safety and Efficacy of Milk and Molasses Enemas Compared With Sodium Phosphate Enemas for the Treatment of Constipation in a Pediatric Emergency Department

Objectives: The purpose of this study was to determine the safety and efficacy of routine milk and molasses enemas (MME) compared with sodium phosphate enemas for the treatment of constipation in the pediatric emergency department (ED). A secondary objective included the identification of factors associated with enema selection in the pediatric ED. Methods: This study was approved by the University of Texas Southwestern Medical Center Institutional Review Board. The study design was a retrospective comparative chart review. Medical records of patients who presented to the ED and received either MME or sodium phosphate enema for constipation between November 1, 2007, and November 1, 2008, were identified and reviewed for data collection. The following data were collected to determine safety and efficacy: baseline demographics, chief complaint, medical history, radiographic imaging, enema type, treatment dose, adverse effects, improvement in symptoms, time until defecation, failure of initial therapy requiring additional intervention, and time from treatment until disposition. Results: Both treatment groups had similar baseline characteristics. No statistically significant differences in treatment effect were noted between MME and sodium phosphate enemas. Several clinically significant trends were noted including the need for additional rectal treatment after administration of sodium phosphate enemas versus oral therapy after MME. In addition, there were 6 cases of treatment failure with sodium phosphate enemas versus 1 case with MME. Conclusions: No statistically significant differences were found between MME and sodium phosphate enemas. Based on our results, the 2 treatment options were found to be equally safe and effective.

Torsion of the Testicle: It Is Time to Stop Tossing the Dice

Abstract: In this review, long-held myths and misperceptions about the evaluation and management of testicular torsion are discussed, and recommendations for the management of patients who present with acute scrotal pain are presented.

Missed Opportunities During Pediatric Residency Training: Report of a 10-Year Follow-Up Survey in Critical Care Transport Medicine

Objectives: The Accreditation Council for Graduate Medical Education requires pediatric residency training programs to provide exposure to the prehospital management and transport of patients. The authors hypothesized that compared with a similar study a decade prior, current pediatric residency training programs have reduced requirements for participation in transport medicine, thus reducing further the opportunities for residents to learn the management of critically ill infants and children. Methods: In 2009, a questionnaire was distributed to 182 pediatric residency program directors. The authors obtained information regarding the neonatal and pediatric transport teams, the training program size, and the pediatric residents’ role in the transport team. Results: Sixty-eight (37%) of the 182 surveyed institutions responded. Residents were involved in neonatal and pediatric transports in 42.8% and 55.0% of programs, respectively. When involved in transports, residents were the neonatal and pediatric team leaders 44.4% and 42.4% of the time, respectively. Evaluation of resident transport performance occurred consistently in only 23.3% (neonatal) and 21% (pediatric) of programs. Most programs (90.3%) endorsed the concept of a curriculum that would uniquely provide an integrated experience in critical care transport to increase resident exposure, competence, and confidence. Conclusions: Pediatric residency participation in neonatal and pediatric critical care transport continued to decline among training programs. Residents participating in transports were less likely to function as team leaders and frequently did not receive performance evaluations. Most respondents welcomed a curriculum that would increase residents’ exposure to the critically ill infants and children transported by neonatal and pediatric teams.

Utility of Laboratory Tests for Children in the Emergency Department With a First Seizure

Objective: The objective of the study was to evaluate the factors associated with abnormal laboratory findings in patients visiting the emergency department (ED) after having their first seizure. Methods: We included ED patients with first seizures and divided them into groups based on normal and abnormal laboratory results for serum levels of sodium, potassium, calcium, and glucose. We evaluated the differences in age, sex, the presence of fever, the presence of gastrointestinal symptoms, the duration and pattern of the seizure, and whether the seizure was still present at the ED. Results: We evaluated 240 patients. Among them, abnormalities were found in 83 (34.8%) of 238 for serum sodium, 16 (6.7%) of 238 for potassium, 11 (6.2%) of 177 for calcium, and 121 (52.3%) of 231 for glucose. In the serum sodium and calcium group, no differences in associated factors between patients with and without abnormal laboratory results were found. However, results revealed differences in seizure duration between patients with and without abnormal laboratory glucose results (P = 0.005) and in age between patients with normal and abnormal potassium results (P = 0.002). Conclusions: There was no significant association among the factors of sex, fever, gastrointestinal symptoms, seizure duration, and seizures in patients who came to the ED with electrolyte abnormalities after a first seizure. However, glucose level abnormalities may have an association with increased seizure duration. We still do not have any suggestions as to which associated factors should be considered when doing common blood examinations in these patients.

ECGs in the ED

No abstract available

Safety of High-Concentration Nitrous Oxide by Nasal Mask for Pediatric Procedural Sedation: Experience With 7802 Cases

Objectives: Nitrous oxide is an effective sedative/analgesic for mildly to moderately painful pediatric procedures. This study evaluated the safety of nitrous oxide administered at high concentration (up to 70%) for procedural sedation. Methods: This prospective, observational study included all patients younger than 18 years who received nitrous oxide for diagnostic or therapeutic procedures at a metropolitan children’s facility. Patients’ age, highest concentration and total duration of nitrous oxide administration, and adverse events were recorded. Results: Nitrous oxide was administered on 7802 occasions to 5779 patients ranging in age from 33 days to 18 years (median, 5.0 years) during the 5.5-year study period. No adverse events were recorded for 95.7% of cases. Minor adverse events included nausea (1.6%), vomiting (2.2%), and diaphoresis (0.4%). Nine patients had potentially serious events, all of which resolved without incident. There was no difference in adverse event rates between nitrous oxide less than or equal to 50% and greater than 50% (P = 0.18). Patients aged 1 to 4 years had the lowest adverse event rate (P < 0.001), with no difference between groups younger than 1 year, 5 to 10 years, and 11 to 18 years. Compared with patients with less than 15 minutes of nitrous oxide administration, patients with 15 to 30 minutes or more than 30 minutes of nitrous oxide administration were 4.2 (95% confidence interval, 3.2–5.4) or 4.9 (95% confidence interval, 2.6–9.3) times more likely to have adverse events. Conclusions: Nitrous oxide can be safely administered at up to 70% concentration by nasal mask for pediatric procedural sedation, particularly for short (<15 minutes) procedures. Nitrous oxide seems safe for children of all ages.

The Price of Perfection: A Teenaged Athlete With Elevated Serum Creatinine

No abstract available

Asymptomatic Complete Atrioventricular Block in a 13-Year-Old Girl

Atrioventricular (AV) block is a delay or an interruption in the transmission of an impulse from atria to ventricles due to an anatomic or a functional impairment in the conduction system. Atrioventricular block may be congenital or acquired. Electrocardiographic screening of asymptomatic school-aged children (median, 12.4 years) in Japan found the prevalence of a third-degree AV block to be 2 per 100,000. We report a case of asymptomatic complete AV block of unknown etiology in a 13-year-old child who did not require pacemaker placement. The importance of recognizing an asymptomatic complete AV block in the pediatric population, the classification and controversies of pacemaker placement, and the complications of pacemaker placement are discussed.

Staphylococcal Infection Mimicking Child Abuse: What Is the Differential Diagnosis and Appropriate Evaluation?

Twins with similar skin lesions are described. Although initially concerning for nonaccidental burn injury, further evaluation led to the diagnosis of bullous impetigo caused by Staphylococcus aureus. Thoughtful assessment is important in such cases to protect the child and prevent misdiagnosis.

Trichobezoar Presenting With Chief Complaints of Chest Pain, Weight Loss, and Gastrointestinal Bleeding

Abdominal pain is a frequent presenting complaint in pediatric patients seeking acute medical care. We report the case of an adolescent female who presented with nonspecific complaints of chest pain, faintness, and weight loss and whose diagnosis was determined only after the disclosure of trichophagia.

Extracorporeal Membrane Oxygenation as Rescue Therapy for Methadone-Induced Pulmonary Edema

Opioid-induced pulmonary edema has been previously reported, but its mechanism remains unclear. The use of extracorporeal membrane oxygenation as rescue therapy for methadone-induced pulmonary edema has not been reported in the literature. We describe 2 cases of methadone ingestion complicated by pulmonary edema, acute respiratory distress syndrome, and circulatory failure successfully managed with venoarterial extracorporeal membrane oxygenation.

An International Fellowship Training Program in Pediatric Emergency Medicine: Establishing a New Subspecialty in the Land of the Dragon

Introduction: The health care system reform in the People’s Republic of China has brought plans for establishment of a universal coverage for basic health services, including services for children. This effort demands significant change in health care planning. Pediatric emergency medicine (PEM) is not currently identified as a specialty in China, and emergency medicine systems suffer from lack of appropriate training. In 2006, the Centre for International Child Health and the Department of Pediatrics, British Columbia Children’s Hospital, Vancouver, Canada, initiated a fellowship training program in PEM for pediatricians working in emergency departments or critical care settings with the Children’s Hospital of Fudan University, China. The main objective was to upgrade the professional and clinical experience of emergency physicians practicing PEM and build PEM capacity throughout China by training the future trainers. Methods: After selecting trainees, the program included a structured curriculum over 2 years of training in China by Canadian and Australian PEM faculty and then practical exposure to PEM in Canada. All trainees underwent a structured evaluation after their final rotation in Canada. Results: A total of 12 trainees completed the first 2 program cycles. The trainees considered the “overall rating of the training experience” as “excellent” (10/12) or “good” (2/12). All trainees considered the program as a relevant training to their practice and felt it will change their practice. They reported the program to be effective, with excellent complexity of content. Discussion: Despite its current success, the program faces challenges in the development of the new subspecialty and ensuring its acceptance among other health care providers and decision makers. Identification and preparation of a capable training force to lead educational activities in China are daunting tasks. Time constraints, funding, and language barriers are other challenges. Future effort should be focused on improving and sustaining resuscitation capacity and enhancing triage systems.

Should a Near-Patient Test Be Part of the Management of Pharyngitis in the Pediatric Emergency Department?

Objective: The study’s objective was to evaluate the efficacy of a rapid streptococcal test as a single diagnostic agent in the diagnosis of streptococcal pharyngitis in patients presenting to a pediatric emergency department. Methods: We performed a rapid streptococcal test as part of the diagnostic workup for patients presenting with clinical findings consistent with streptococcal pharyngitis. In addition to undergoing the study intervention, each patient had a standard throat swab sent to the laboratory for formal culture. A questionnaire detailing the clinical features was to be completed in each case. Results: Two hundred ten near-patient tests were performed. Complete laboratory results were available in 177 cases (77%). Clinical data were available for analysis in 94 patients (53%). In our patient population, the near-patient test had a high specificity (98.6%) but a low sensitivity (71%). The clinical presentation of confirmed group A β-hemolytic streptococcal pharyngitis is very variable. Conclusions: The QuickVue In-Line Strep A test for streptococcal pharyngitis is unreliable in our patient population. Clinical findings are unhelpful in confirming the diagnosis. Formal laboratory culture is the criterion standard for identifying the organism, but the results are not clinically significant in every case. Acute pharyngitis presenting to the pediatric emergency department can be managed in accordance with the recommendations in the Scottish Intercollegiate Guideline Network guideline.

Severe Rhabdomyolysis With Myocarditis in a 2-Year-Old Child

Rhabdomyolysis in children is frequently a complication of a viral infection and typically has a benign course: calf pain and difficulty walking that usually resolve in a few days. Elevated levels of creatine kinase are an indicator of muscle injury. There are few reports of severe rhabdomyolysis in children without underlying metabolic or rheumatologic disease. We describe a case of acute rhabdomyolysis after a viral infection in a previously healthy child. The muscular involvement was so severe that the patient had a respiratory arrest on the second hospital day. The patient also developed cardiac involvement with mild myocardial dysfunction and myoglobinuria, without reduction of renal function.

Calcium Channel Blocker Toxicity

No abstract available

Posterior Reversible Encephalopathy Syndrome in Childhood: Report of Four Cases and Review of the Literature

Background: Posterior reversible encephalopathy syndrome (PRES) is a recently described disorder with typical radiological findings of bilateral gray and white matter abnormalities in the posterior regions of the cerebral hemispheres and cerebellum. Its clinical symptoms include headache, decreased alertness, mental abnormalities such as confusion, diminished spontaneity of speech, and changed behavior ranging from drowsiness to stupor, seizures, vomiting, and abnormalities of visual perception such as cortical blindness. In this study, the clinical and radiological findings of 4 children with this syndrome due to a variety of conditions are reported. Methods: The records of 4 children with a diagnosis of PRES were retrospectively analyzed. Results: PRES is associated with a disorder of cerebrovascular autoregulation of multiple etiologies. Four patients with PRES who had primary diagnoses of severe aplastic anemia, nephritic syndrome, Henoch-Schönlein purpura, and acute poststreptococcal glomerulonephritis are presented. This syndrome has been described in numerous medical conditions, including hypertensive encephalopathy, eclampsia, and with the use of immunosuppressive drugs. Conclusions: Early recognition of PRES as a complication during different diseases and therapies in childhood may facilitate precise diagnosis and appropriate treatment.

Benign Afebrile Convulsions in the Course of Mild Acute Gastroenteritis: A Study of 28 Patients and a Literature Review

Objectives: Since the description of afebrile convulsions in the course of mild acute gastroenteritis (AGE) in 1982 by Morooka in Japan, there have been few reports of further cases outside Asia. The aim of this study was to share our casuistry-from a non-Asian country. Methods: This is a retrospective study of identified cases in our center from January 2002 to December 2007. Results: A total of 28 patients were studied. All were previously healthy patients who experienced convulsions with mild AGE without dehydration and with normal blood analysis. The mean age was 17.25 months (range, 6-48 months), with 93% younger than 24 months. Seizures were generalized tonic-clonic (61%), followed by generalized tonic (31%), and hypotonic (5.2%), with 2 (2.6%) partial. Only 8 patients (28.6%) presented one convulsion, and in 13 patients (46%), the seizures were in clusters from 3 to 6. Eleven patients (39%) presented 2 different types of convulsion. The duration of the crises ranged from 30 seconds to 10 minutes, and all of them occurred within 24 hours of the first. Electroencephalograms, obtained for all patients, were normal. Rotavirus was the main infectious agent in the AGEs, found in 11 patients with 22 determinations. In one patient, Salmonella serotype Enteritidis was isolated. All of the patients developed favorably, with no sequelae or epilepsy during the follow-up period. Conclusions: Afebrile convulsion in the course of mild gastroenteritis exists in our environment. It is a banal symptom in the course of the disease with good prognosis. Recognition of this fact may help avoid needless explorations and treatment in patients of this kind.

Epidemiology and Disposition of Burn Injuries Among Infants Presenting to a Tertiary-Care Pediatric Emergency Department

Objective: The objective of the study was to study the etiology of and factors determining the emergency department disposition of infants sustaining burn injuries. Methods: A retrospective chart review was performed on all patients 12 months or younger with a burn injury presenting to our emergency department over a 5-year period. We collected the chief complaint and diagnosis, patient demographics, and circumstances surrounding the burn injury from the emergency department charts. Univariable statistics, multiple imputation, and multivariable regression were performed to determine differences between races and factors leading to admission. Results: During the study period, 344 patients meeting inclusion criteria were treated in our emergency department. Scalds (53.2%) and contact burns (39.8%) were the most common causes of burns among the study group. Significant differences were observed between races for mechanism of burn, interhospital transport, and total body surface area affected (P < 0.05). White patients were more likely to have higher body surface affected and to be transferred from another facility (P < 0.05). Increased severity of burn, burns located on the hand, and concern for abuse resulted in higher likelihood of admission (P < 0.01). No significant differences in disposition or mechanism of burn were present between English-speaking and non-English-speaking patients. Conclusions: Although most infant burns in our emergency department are due to scalds, burn injuries due to contact with household objects are common. Race plays a significant role in mechanism and severity of burn sustained. Increased severity of burn, concern for abuse, and burn to the hand were all associated with increased odds of admission.

Are Antibiotics Necessary for Pediatric Epididymitis?

Objectives: To determine the percentage of cases of epididymitis in pediatric patients that is of bacterial cause and to identify factors that predict a positive urine culture. Methods: We conducted a retrospective chart review of patients diagnosed with acute epididymitis or epididymo-orchitis in 1 pediatric emergency department for 11 years. Charts were reviewed for historical, physical, laboratory, and radiologic data. A positive urine culture was used to identify patients with a bacterial cause of epididymitis. Results: A total of 160 patient records were initially identified as having a diagnosis of epididymitis; of these, 20 met exclusion criteria or did not have records available for review and 140 cases of epididymitis were reviewed. Patients' age ranged from 2 months to 17 years, with a median age of 11 years. Of these patients, 91% received empiric antibiotic therapy. Also, of these patients, 97 (69%) had a urine culture sent, of whom 4 (4.1%; 95% confidence interval, 1.1%-10.2%) were positive. Of the 4 positive urine cultures, 3 had organisms not sensitive to usual empiric therapy for urinary tract infections. The boys with positive urine cultures were not significantly different from the other patients in age, maximum temperature, or number of white blood cells on urinalysis. Conclusions: Given the low incidence of urinary tract infections in boys with epididymitis, in prepubertal patients, antibiotic therapy can be reserved for young infants and those with pyuria or positive urine cultures. Because it is difficult to predict which patients will have a positive urine culture, urine cultures should be sent on all pediatric patients with epididymitis.

Common Pediatric Fractures Treated With Minimal Intervention

No abstract available

Lumbar Vertebral Fractures in Children: Four Cases and Review of the Literature

Background: Vertebral fractures and severe injuries to the spine cord in children are rare and account for a small proportion of all childhood injuries. Pediatric vertebral and spinal cord injuries have unique characteristics depending on their age. Young children sustain upper cervical spine injuries, which are more serious injuries and have a higher mortality rate. Older children have lower spine injuries and thoracoabdominal injuries. Objectives: This study aimed to present the epidemiology and potential complications from lumbar spine fractures. Cases: There were 4 cases of older children who sustained lumbar vertebral fractures. Conclusions: Fractures of the lumbar spine in children, although relatively rare, are important to understand. Patterns of injury with vertebral and spinal cord injuries in children vary from those of adults. The biologic differences of children make differences in fracture patterns and alter the management necessary for successful treatment. Errors in management can have adverse effects on these injuries.