Journals RSS : Gourt

[Primary survey] Primary survey

[Editorial] Mid Staffordshire: where to from here?

[Miscellanea] See page 545 for answers

[Review] Improving post-hypoglycaemic patient safety in the prehospital environment: a systematic review

To determine the extent to which post-hypoglycaemic patients with diabetes, who are prescribed oral hypoglycaemic agents (OHA) are at risk of repeat hypoglycaemic events (RHE) after being treated in the prehospital environment and whether they should be transported to hospital regardless of their post-treatment response, a systematic literature review was carried out using an overlapping retrieval strategy that included both published and unpublished literature. Retrieved papers were reviewed by each author for inclusion. Disagreements regarding inclusion were resolved through discussion. Ninety-eight papers and other relevant material were retrieved using the developed search strategy. Twenty-three papers and other relevant material were included in the final review. A narrative synthesis of the findings is presented. Although several case reports demonstrate the risks associated with repeat or prolonged hypoglycaemia, the review was unable to locate any specific high quality research in this area. Consequently, caution is required in interpreting the findings of the studies. Post-hypoglycaemic patients treated in the prehospital environment have a 2–7% risk of experiencing a RHE within 48 h. The literature retrieved in this study recognises the potential for OHA to cause RHE. However, the extent to which this occurs in practice remains unknown. This lack of evidence has led to the recommendation that conservative management, through admission to hospital, is appropriate. The review concludes with recommendations for both practice and research.

[Original articles] Effect of a pathway bundle on length of stay

Background: Pathways to guide clinical care are well accepted and used in many emergency departments. We wanted to introduce a number ("bundle") over a short space of time and involve the whole patient stay in the pathway. It was hypothesised that a more efficient process would result with an overall reduction in length of stay (LoS). Methods: A "bundle" of 14 evidence-based pathways of care was introduced into a medium-sized district general hospital (DGH) in late 2006/early 2007. These pathways covered emergency department care and acute medical care for a period of up to 48 h. A total of 8184 acute emergency admission episodes were audited, 3852 in the 8 months before introduction of the new pathways and 4332 in the 8 months after their introduction. Results: The overall effect of introducting the pathway bundle had a trend towards reduction in LoS by 0.2 days (95% CI –0.2 to 0.5), but this was not statistically significant (p>0.1). However, in those patients with <=2 diagnoses, the introduction of the pathway bundle had an independent effect in reducing LoS by 0.4 days (95% CI 0.04 to 0.7, p<0.01). In patients with <=2 diagnoses (63.0% of all pre-pathway cases and 63.4% of all post-pathway cases), the reduction in LoS equates to a saving of 2154 (CI 215 to 3769) bed days per annum or 5.9 (CI 0.6 to 10.3) beds saved each day. This reduced LoS represents an improvement of 2.5% (CI 0.25% to 4.38%) in medical bed usage. As this benefit occurs in the uncomplicated group of patients without multiple co-morbidities, such pathways would have the most effect in the type of patients who may be looked after by an emergency or acute physician. They are much less likely to be effective in those who require specialist intervention due to a more complicated presentation and possibly those with multiple co-morbidities. Conclusion: The introduction of a bundle of evidence-based care pathways can modestly reduce LoS for certain types of acute medical patients in a DGH setting.

[Original articles] The Manchester Triage System provides good reliability in an Australian emergency department

Background: The Australasian Triage Scale is a simple five-point system of triage that forms the basis of triage in most emergency departments in Australia. The Manchester Triage System (MTS) is an algorithmic aid to the process of triage. It utilises a series of flow charts that lead the triage nurse to a logical choice of triage category also using a five-point scale. Objective: To evaluate the inter-rater reliability of the MTS in an Australian emergency department. Methods: 50 triage scenarios were derived from the notes of 50 consecutive patients who had presented to the emergency department. All available nurses who had been trained to use the MTS were invited to participate in the study. The nurses were asked to assign a triage category to each scenario using the MTS. Weighted kappas were calculated for all pairs of raters. Results: 20 nurses participated in the study. The range of kappas was 0.4007 to 0.8018, with a median of 0.6304. Conclusion: The MTS is a reliable system of triage in the emergency department.

[Original articles] Amethocaine versus EMLA for successful intravenous cannulation in a children's emergency department: a randomised controlled study

Background: Topical anaesthetics reduce the pain of venous cannulation. The emergency department at the Starship Children’s Hospital in Auckland uses EMLA (an eutectic mixture of 25 mg/g lidocaine and 25 mg/g prilocaine) for topical anaesthesia. Amethocaine has recently been shown to be a more effective topical anaesthetic. It is suggested that, because amethocaine does not vasoconstrict veins, it may increase the success of cannulation. Aim: The primary aim was to determine if amethocaine improves the success of cannulation compared with EMLA. The secondary aim was to determine if amethocaine is a more effective topical anaesthetic in a children’s emergency department. Methods: A parallel, randomised, double-blind controlled study was performed in children aged 3 months to 15 years who were offered topical anaesthesia for venous cannulation. Caregivers gave verbal consent at triage, followed by written consent. Children were randomised into amethocaine or EMLA groups. Those who went on to have an intravenous cannula were analysed on an intention-to-treat basis. The primary outcome was a successful first attempt at cannulation. A convenience cohort was also observed for distress using a visual analogue scale and the Faces, Legs, Activity, Cry and Consolability Score. Results: From November 2006 to June 2007, 2837 children were enrolled and 809 were known to have had intravenous cannulation. 679 complete data and consent forms were returned. There was no significant difference between the first attempt success rates (75.8% amethocaine vs 73.9% EMLA) or between pain scores for the 65 observed cannulations. Conclusion: Amethocaine is not more successful than EMLA for first attempt intravenous cannulation in a children’s emergency department. Trial registration number: Australian New Zealand Clinical Trials Register ACTRN12606000409572.

[Original articles] Comparison of neurological outcomes following witnessed out-of-hospital ventricular fibrillation defibrillated with either biphasic or monophasic automated external defibrillators

Background: Biphasic waveform defibrillation results in higher rates of termination of fibrillation than monophasic waveform defibrillation but has not been shown to improve survival outcomes. Objective: To compare the effectiveness of a biphasic automated external defibrillator (AED) with a monophasic AED for witnessed out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF). Methods: In a prospective population-based cohort study, adults with witnessed VF OHCA were treated with either monophasic or biphasic waveform AED shocks. The primary outcome measure was neurologically favourable 1-month survival, defined as a Cerebral Performance Categories score of 1 or 2. Results: Of 366 adults with witnessed OHCA of presumed cardiac aetiology, 74 (20%) had VF. Termination of VF with the first shock tended to occur more frequently after biphasic AED shocks (36/44 (82%) vs 20/30 (67%), p = 0.14). Return of spontaneous circulation (ROSC) occurred more frequently after biphasic AED shocks (29/44 (66%) vs 8/30 (27%), p = 0.001). Neurologically favourable 1-month survival was also more frequent in the biphasic group (10/44 (23%) vs 1/30 (3%), p = 0.04). The median time interval from the first shock to the second shock was 67 s in the monophasic group and 24 s in the biphasic group (p = 0.001). Conclusions: Treatment with biphasic AED shocks improved the likelihood of ROSC and neurologically favourable 1-month survival after witnessed VF compared with monophasic AED shocks. In addition to waveform differences, a shorter time interval from the first shock to the second shock could account for the better outcomes with biphasic AED.

[Original articles] Ten things your emergency department should consider to prepare for pandemic influenza

Pandemic influenza remains a potential major threat to global public health. It is essential for emergency departments to be involved in planning for the management of such a major event. It is also important for emergency departments to be clear on their internal arrangements for staff and for patient care. This paper outlines 10 suggestions for UK emergency departments based on the recent experience of emergency departments in Hong Kong and elsewhere.

[Original articles] Comparison of powered and conventional air-purifying respirators during simulated resuscitation of casualties contaminated with hazardous substances

Background: Advanced life support of patients contaminated with chemical, biological, radiological or nuclear (CBRN) substances requires adequate respiratory protection for medical first responders. Conventional and powered air-purifying respirators may exert a different impact during resuscitation and therefore require evaluation. This will help to improve major incident planning and measures for protecting medical staff. Methods: A randomised crossover study was undertaken to investigate the influence of conventional negative pressure and powered air-purifying respirators on the simulated resuscitation of casualties contaminated with hazardous substances. Fourteen UK paramedics carried out a standardised resuscitation algorithm inside an ambulance vehicle, either unprotected or wearing a conventional or a powered respirator. Treatment times, wearer mobility, ease of communication and ease of breathing were determined and compared. Results: In the questionnaire, volunteers stated that communication and mobility were similar in both respirator groups while breathing resistance was significantly lower in the powered respirator group. There was no difference in mean (SD) treatment times between the groups wearing respiratory protection and the controls (245 (19) s for controls, 247 (17) s for conventional respirators and 250 (12) s for powered respirators). Conclusions: Powered air-purifying respirators improve the ease of breathing and do not appear to reduce mobility or delay treatment during a simulated resuscitation scenario inside an ambulance vehicle with a single CBRN casualty.

[Original articles] Predicting admission and mortality with the Emergency Severity Index and the Manchester Triage System: a retrospective observational study

Objective: To compare the degree to which the Emergency Severity Index (ESI) and the Manchester Triage System (MTS) predict admission and mortality. Methods: A retrospective observational study of four emergency department (ED) databases was conducted. Patients who presented to the ED between 1 January and 18 July 2006 and were triaged with the ESI or MTS were included in the study. Results: 37 974 patients triaged with the ESI and 34 258 patients triaged with the MTS were included. The likelihood of admission decreased significantly with urgency categories in both populations, and was greater for patients triaged with the ESI than with the MTS. Mortality rates were low in both populations. Most patients who died were triaged in the most urgent triage categories of both systems. Conclusion: Both the ESI and MTS predicted admission well. The ESI was a better predictor of admission than the MTS. Mortality is associated with urgency categories of both triage systems.

[Short report] Predictors of the need for rapid sequence intubation in the poisoned patient with reduced Glasgow coma score

Aim: In patients presenting to the emergency department (ED) with significant poisoning and reduced Glasgow coma score (GCS), the decision to proceed with rapid sequence intubation can be a difficult one. Traditionally, patients with a GCS of 8 or less are thought to require airway protection. It has been found that a number of these patients can be managed safely without advanced airway support in a well-monitored ward environment. The objective of this study was to define the key physiological indicators of intubation requirement in this complex group of patients. Method: Prospective parallel group comparison. The study was conducted in the ED of a Scottish teaching hospital over a 12-month period. Group 1 included all poisoned patients admitted to the ED with a GCS of 8 or less who were not intubated and managed conservatively in the short-stay ward. Group 2 included all poisoned patients with a reduced GCS who were intubated. Demographics and physiological parameters were analysed in both groups (intubated vs non-intubated). Results: 12 patients were identified in the intubated group and 14 in the non-intubated group. Demographics were similar in both groups. Analyses of means and medians of physiological parameters indicated minimal predominance of oxygenation/ventilatory failure in the group requiring intubation. This correlated with the physician’s perception of inadequate airway protection or ventilatory failure. Conclusion: Clinical assessment by experienced medical staff rather than physiological variables are the key to determining intubation requirements in the poisoned patient with reduced GCS. GCS alone is not a good predictor of intubation.

[Critical care series] Critical care in the emergency department: traumatic brain injury

Head injury outcome is influenced by the initial insult and the various pathophysiological changes that take place in the posttraumatic phase, some of which may be amenable to intervention. Appropriate measures taken during initial emergency department management and subsequently in the intensive therapy unit can significantly improve outcome. The primary goal is to limit secondary brain injury. Early imaging, rather than admission and observation for neurological deterioration, reduces the time to the detection of life-threatening complications. This paper discusses the current management of severe head injury, some prognostic indicators and methods used to rule out an associated spinal injury.

[Best Evidence Topic reports] Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary

[Best Evidence Topic reports] BET 1. NEBULISED HYPERTONIC SALINE SIGNIFICANTLY DECREASES LENGTH OF HOSPITAL STAY AND REDUCES SYMPTOMS IN CHILDREN WITH BRONCHIOLITIS

[Best Evidence Topic reports] BET 2. HEART FATTY ACID BINDING PROTEIN FOR RAPID DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION IN THE EMERGENCY DEPARTMENT

[Best Evidence Topic reports] BET 3. HONEY FOR THE SYMPTOMATIC RELIEF OF COUGH IN CHILDREN WITH UPPER RESPIRATORY TRACT INFECTIONS

[Prehospital care] Emergency ambulance transport induces stress in patients with acute coronary syndrome

Background: Trials with healthy volunteers have shown that emergency ambulance transportation induces stress, which becomes evident by an increase in heart rate, blood pressure and plasma levels of stress hormones such as adrenaline, noradrenaline, cortisol and prolactin. A study was undertaken to test the hypothesis that emergency ambulance transportation may also lead to stress in patients with acute coronary syndrome. Methods: Venous plasma levels of epinephrine, norepinephrine and lactate as well as visual analogue scale (VAS) scores for pain and anxiety were measured in 32 patients with defined clinical signs of acute coronary syndrome before and after transportation. Heart rate, blood pressure and transcutaneous oxygen saturation levels were recorded every 3 min. Results: Mean (SD) plasma levels of epinephrine and norepinephrine increased significantly (p<0.01) during transportation (159.29 (55.34) ng/l and 632.53 (156.32) ng/l before transportation vs 211.03 (70.12) ng/l and 782.93 (173.95) ng/l after transportation), while lactate levels, heart rate and mean blood pressure remained almost stable. There was no significant change in mean (SD) VAS scores for pain and anxiety (3.79 (3.70) and 2.89 (3.01) vs 2.13 (3.30) and 1.57 (2.78)). Conclusion: Emergency ambulance transportation induces a rise in plasma catecholamine levels and therefore stress in patients with acute coronary syndrome, but does not result in cardiac shock as lactate levels and haemodynamic parameters remain normal.

[Prehospital care] Construction of an adaptable and specific severity score for prehospital emergencies

The aim of this study was to design a severity score specific to mobile emergency and resuscitation services (MERS). A prospective, multicentre cohort study including 17 868 patients was performed. The severity reference criterion was determined by multiple correspondence analysis. A multiple linear regression was used for the construction of the severity score. The score performances were analysed in terms of area under the receiver operating characteristics curves (AUC). Twelve variables were identified for the construction of the severity score. The multiple regression (r2 = 0.947; p<0.001) provided a severity score that took on values from 8 to 68. The score performs well in distinguishing the various patient outcomes in terms of AUC. This study develops the first adaptable and specific severity score of MERS activities.

[Prehospital care] Use of prehospital dressings in soft tissue trauma: is there any conformity or plan?

Background: Acute soft tissue wounds are commonly seen in the prehospital setting. It was hypothesised that there is a lack of consistency in early management of trauma wounds, particularly in the dressings used. Methods: In January 2007 a questionnaire-based study was undertaken to evaluate the early management of such injuries. All 13 UK ambulance services were contacted, as well as 2 voluntary ambulance services. The questionnaire considered the implementation of a wound treatment policy and staff training, immediate wound management including haemostasis, cleansing, analgesia, dressings and the use of antibiotics. Results: The response rate was 100%. Only 27% of services had a wound treatment policy in place, but all services implemented staff training. All services regularly achieved haemostasis of wounds using a combination of pressure and elevation. Regular cleansing was performed by 47% of services and those that did so used normal saline or water. All ambulance services administered analgesics. The most commonly used analgesics were Entonox and intravenous morphine. Other analgesics administered were paracetamol and ibuprofen. No local anaesthesia was used. Dressings were applied regularly by all services; 13 different types of dressings were in regular use. Conclusions: This study confirmed that there is currently no national standard protocol for early acute wound management in the prehospital care setting. The key areas for improvement are cleansing, simplification of dressings and the introduction of standardised protocols and teaching.

[Prehospital care] Sepsis: a need for prehospital intervention?

Prehospital staff have made a significant contribution in recent years to improving care for patients with acute coronary syndrome, multiple trauma and stroke. There is, however, another group of patients that is not currently being targeted, with a similar time-critical condition. This group of patients is those with severe sepsis and septic shock and they could also benefit greatly from timely prehospital care. This article will consider how prehospital staff can improve the outcome of patients with severe sepsis, and in particular how they can aid emergency departments in identifying and initiating treatment in patients with severe sepsis.

[Emergency casebooks] Importance of the log roll

Immobilisation is a crucial part of the management of a trauma patient. This case describes the importance of stabilisation and early imaging in preventing long-term disability. The patient presented with no history or symptoms suggestive of spinal instability, but was under the influence of alcohol and had signs which were difficult to explain. After deterioration in his vital signs, he was found to have a rare and spectacular assembly of injuries which could have proved devastating had immobilisation been compromised. A comprehensive literature search was undertaken to establish the current consensus on the timing of mobilisation and imaging.

[Emergency casebooks] Early administration of thrombolysis can prevent myocardial necrosis: time is myocardium

A case is presented in which a 66-year-old man received thrombolysis for an acute ST elevation myocardial infarction (STEMI) within 6 minutes of developing chest pain. An ECG performed 10 minutes after thrombolysis showed complete resolution of the ST segment elevation and showed no other abnormality. An echocardiogram showed normal left ventricular function and there was no detectable myocardial necrosis, as evidenced by two negative troponin assays. The case clearly reinforces the benefits of the rapid delivery of thrombolysis when appropriate for patients with STEMI. Clinicians need to be aware of the benefits of early thrombolysis as laid out in the national service framework. Evidence for the early administration of thrombolysis, data from the Myocardial Infarction National Audit Project and the future with regard to improving thrombolysis times are discussed.

[Emergency casebooks] Calcific tendonitis of the medial collateral ligament

The case is presented of a woman with a gradual onset of knee pain due to calcific tendonitis of the medial collateral ligament (MCL). The diagnosis was made based on clinical findings, plain radiography and magnetic resonance imaging. Her symptoms improved with non-operative measures. Calcific tendonitis is a common pathology of the shoulder, but has not previously been described to involve the MCL of the knee. Different treatment options are considered in the paper.

[PostScript] Dissociation of mortality at high levels of overcrowding (the death plateau)

[PostScript] The Livingston paediatric calculator, revision needed

[PostScript] Training for acute care common stem trainees

[PostScript] The utility of nitrous oxide

[PostScript] CORRECTION

[Miscellanea] For questions on page 471

[Miscellanea] Sophia

The Michael Jackson autopsy | The Sun |News

Update 6/29/09 @ 12:36 This may all be a hoax. NOPE. APPARENTLY THIS IS REAL. British Media and News Reporting may actually not be related. The shock findings of the Michael Jackson autopsy | The Sun |News 8st 1oz, no food just pills in his stomach, bald, bruised, his ribs broken by CPR, 4 needle wounds near [...]

Treatment difference between Bird and Swine Flu

Via Dr. Val on Twitter: RT @Doctor_V RT @bobfinn: CDC’s Cox: “What’s the diff btwn bird & swine flu? 4 bird flu U need tweetment, 4 swineflu U need oinkment.” [Ugh] Hahaha. Here’s hoping I can deliver both!

Michael Jackson, King of Pop dies

My first thought: I’m willing to bet drugs (legal, clean, prescribed by a doctor) were involved, and that a review of the records will show some questionable prescribing. First Do No Harm, unless it’s a celebrity? Why are docs willing to engage in this kind of horrible, destructive prescribing? It’s reprehensible. If it is doc-assisted, please [...]

Better Health » Some of My Best Friends Are Doctors

Better Health » Some of My Best Friends Are Doctors Dr. Val does a nice Fisk! Yes, docs make a decently good living. No, it’s not why the health care system is in trouble.

Dead Blogs, Medical Edition.

Yes, it’s that time. As a general rule either no posting for 3 months or an intentional abandonment will get you added to the heap of Dead Blogs (right sidebar, near the bottom). Adventures in Medicine Blogborygmi (this one hurts, and I suspect he’ll be back soon, but dead is dead) decided he wants to live! Canadianmedicine, now [...]

A Happy Hospitalist: You Are Living In The Medicare Tomato

A Happy Hospitalist: You Are Living In The Medicare Tomato You want to know what the process is like for a physician to make a living as a physician. Look only toward the Medicare Tomato. Imagine for the moment that you have been taken out of reality and into the alternate bizarro world of the Medicare [...]

Running a hospital: What a public plan is really for

Running a hospital: What a public plan is really for by Paul Levy of BIDMC. Surprise: it’s not about access for patients. Where have I heard that before….?

Day by Day: Don’t Mess with Texas

Mr. Muir at Day by Day… Don't Mess with Texas

What my end of Hospital Credentialling looks like

Bad news? At least 47 different signatures. Good news? It arrived mostly prefilled. Over 100 pages.

NYT Opinion: “Doctors’ Pay, a Key to Health Care Reform”

The by-line reads “The Editors” but it’s actually a compilation of Short editorials, two of which are by medical bloggers! One is the usual suspect, Kevin, MD, and the other is Shadowfax from Movin’ Meat (his real name and a picture with hair is at the NYT). They’re all good, and all presuppose that the system [...]

Chronic Retropharyngeal Abscess Presenting as Obstructive Sleep Apnea

Chronic retropharyngeal abscess (RPA) in children is an unusual condition that has rarely been reported in the literature. Pediatric obstructive sleep apnea (OSA) has many etiologies that have been well described, but there have been no reports of a chronic RPA presenting with severe OSA. We describe an infant who presented with severe OSA due to oropharyngeal narrowing by a chronic abscess. An intraoperative magnetic resonance imaging study confirmed the presence of a RPA. Treatment included tracheostomy, surgical drainage, and intravenous followed by oral antibiotics. Physicians evaluating children with recent onset severe OSA after a respiratory infection should include suppurative oropharyngeal pathology in the differential diagnosis. A recent drainage of a head or neck abscess should strengthen that suspicion. (C) 2008 Lippincott Williams & Wilkins, Inc.

Iatrogenic Metoclopramide Toxicity in An Infant Presenting To A Pediatric Emergency Department

No abstract available

The Bruised Premobile Infant: Should You Evaluate Further?

Three premobile infants with unexplained bruising are described. Although, they were asymptomatic otherwise, evaluation led to the recognition of inflicted rib fractures in two and hemophilia A in one. Although such bruises are inconsequential themselves, they may provide the opportunity to recognize serious problems before major injury or morbidity occurs. (C) 2009 Lippincott Williams & Wilkins, Inc.

Serious Adverse Events During Procedural Sedation With Ketamine

Objectives: Compare the frequency of respiratory adverse events between patients who received intramuscular (IM) versus intravenous ketamine. Methods: Case control study from 1997 to 2005 at a large urban pediatric emergency department. Adverse events were defined as apnea, hypoxemia (oximetry <93%), hypoventilation, laryngospasm, and other upper airway obstruction. Serious adverse events were defined by the level of intervention and included those cases that required positive pressure ventilation, insertion of oral or nasal airway, or endotracheal intubation. Minor adverse events were respiratory events requiring minimal intervention (stimulation, supplemental O2, airway repositioning). Controls (2:1) were selected by the next chronological patient in the data set who received ketamine but had no respiratory adverse event. Results: Four thousand two hundred fifty-two patients received ketamine; 102 cases (2.4%) had respiratory adverse events, including 38 patients with severe adverse events (0.9%). Interventions for the cases included supplemental O2 (59/102, 58%), airway repositioning (36/102, 35%), continuous positive airway pressure (7/102, 7%), positive pressure ventilation (33/102, 32%), nasal airway (2/102, 2%), oral airway (1/102, 1%), stimulation (11/102, 11%), and intubation (1/102, 1%). Overall, 33% of all subjects received IM ketamine including 47% of cases and 27% of controls. Intramuscular IM ketamine was associated with increased likelihood of adverse events (odds ratio [OR] 2.1, 95% CI, 1.3-3). Twenty (69%) of the 29 patients with laryngospasm received IM ketamine (OR, 5.2; 95% CI, 2.3-11.9) and 20 (53%) of the 38 patients who had severe events were administered IM (OR, 2.4; 95% CI, 1.2-4.9). Use of pre-sedation morphine or combined administration with midazolam and/or atropine was not associated with adverse events. Specific procedures were not associated with increased adverse events. Conclusions: Respiratory adverse events with ketamine are uncommon. Serious events, like laryngospasm, are rare but occur more commonly with IM administration. This increased risk associated with IM administration should be considered in the sedation plan. (C) 2009 Lippincott Williams & Wilkins, Inc.

Alternatives to Sedation for Painful Procedures

Conscious sedation is used frequently to perform procedures that may be undertaken with or without minimal sedation. Fracture manipulation can be performed with minimal discomfort in the awake patient using various techniques-for example, intravenous regional anesthesia, nerve blocks, and hematoma blocks. These have been used for many years and are very safe. They may require some specific equipment (eg, automatic tourniquet) to perform the anesthesia but patients have the same results and are able to go home much quicker because sedation is not used. Use of topical anesthesia for both intact skin and wounds has been used over many years. Its use now should be standard. Nerve blocks can also be used to anesthetize specific areas which may be difficult to use topical anesthesia (eg, lip, hand, etc) or are painful because of injection directly into the wound. These may include infraorbital nerve blocks for lip lacerations, ulna or median nerve blocks for hand injuries, and so on. Other novel approaches to topical anesthesia have seen the use of iontophoresis (again requires specific expensive equipment), jet injection of lidocaine, or "freeze sprays." Each has its own advantages and disadvantages. Femoral nerve block is a useful intervention for analgesia in patients with femoral fractures and can obviate the need for parenteral analgesia and allows excellent analgesia particularly during x-ray examination. Thus, it is important to remember that there are alternatives to conscious sedation which gives good analgesia during the procedure and allows the patient to be discharged sooner. (C) 2009 Lippincott Williams & Wilkins, Inc.

Management of Anaphylaxis in Children

Anaphylaxis is a severe, life-threatening immunoglobulin E (IgE)-mediated hypersensitivity reaction. The key to successful management of anaphylaxis involves rapid diagnosis, assessment, and early initiation of therapy. Epinephrine is the undisputed initial therapy for anaphylaxis, and its administration should never be delayed. In most cases, additional interventions such as oxygen therapy, fluid resuscitation, [beta]-agonists, antihistamines, and corticosteroids should be strongly considered. Although hospital course must be individualized to meet each patient's needs, a minimum of 4 to 6 hours of observation period after complete symptom resolution may be reasonable to monitor for recurrence of symptoms and biphasic reaction. Before discharge, every patient should receive patient education about anaphylaxis, a prescription for self-injectable epinephrine, and instructions for follow-up care. (C) 2008 Lippincott Williams & Wilkins, Inc.

Procedural training for pediatric and neonatal transport nurses: Part 1-Training methods and airway training

No abstract available

Newer Agents for Rapid Sequence Intubation: Etomidate and Rocuronium

The emergency airway management of children and adolescents with critical illnesses may necessitate rapid sequence intubation with a sedating and a neuromuscular blocking agent. Etomidate and rocuronium have become increasingly popular for the sedation and paralysis, respectively, of pediatric patients in rapid sequence intubation, and there are many advantages to the use of both agents. Both etomidate and rocuronium have a rapid onset of action, and both agents are relatively free of hemodynamic adverse effects. Etomidate does, however, suppress adrenal function, and consequently, its use in patients with septic shock is controversial. Rocuronium can produce optimal intubating conditions without the serious complications that can accompany succinylcholine. The available evidence supports the safety of etomidate and rocuronium in rapid sequence intubation but also suggests that more prospective studies are needed in pediatric patients. (C) 2009 Lippincott Williams & Wilkins, Inc.

The Utility of Bedside Ultrasonography in Identifying Fractures and Guiding Fracture Reduction in Children

Objective: To compare bedside ultrasonography (BUS) to radiography for identifying long bone fractures, the need for reduction, and the adequacy of reduction. Methods: Children aged 2 to 17 years presenting to a pediatric emergency department with long bone injuries were prospectively enrolled. Bedside ultrasonography was performed before ordering initial radiographs. If a fracture was identified, measurements of angulation and displacement were made based on BUS images. Radiographs were used to guide management. Patients who had a fracture identified on radiograph underwent standard care. Later, agreement between BUS and radiography for fracture identification, the need for reduction, and the adequacy of reduction were determined. Results: Thirty-three patients were enrolled, the mean age was 9.1 years (+/-3.1 years). Sixty six bones were studied; 56 (84.8%) involved the upper extremity. Fractures were identified in 59.1% of all bones; 13 (33.3%) required reduction. The agreement between BUS and radiography for fracture identification was 95.5%, for the need for reduction 92.3%, and for the adequacy of reduction 92.3%. The sensitivity and specificity of BUS for fracture identification, need for reduction and reduction adequacy was 0.97 (95% confidence interval [CI], 0.85-1.00), 0.93 (95% CI, 0.74-0.99), and 1.00 (95% CI 0.79-1.00), and 0.85 (95% CI, 0.61-0.96), 1.00 (95% CI, 0.59-1.00) and 0.80 (95% CI, 0.30-0.99), respectively. Conclusions: These data suggest that BUS evaluation of upper extremity injuries not involving joints maybe comparable to radiography for identifying fractures, the need for reduction, and the adequacy of reduction in children. If further investigations which include a larger number of lower extremity, growth plate, and joint injuries support our findings, BUS may gain a more prominent role in managing children with all long bone injuries. (C) 2009 Lippincott Williams & Wilkins, Inc.

Use of the Pediatric EZ-IO Needle by Emergency Medical Services Providers

Objective: The aim of this study was to examine emergency medical services providers' use of a new intraosseous needle designed for pediatric patients. Methods: This prospective pilot study was conducted between May 2006 and October 2007. After completing an initial training session, the EZ-IO PD was deployed for use on patients. Emergency medical services (EMS) providers completed a telephone data collection process after each insertion attempt. Data regarding insertion failure or success (insertion of needle into the bone with subsequent fluid flow), time to fluid flow, provider comfort with the device, device performance assessment, and recommendation for future use were collected. Results: Two hundred forty-six EMS providers (EMT-P and registered nurses) from 14 EMS agencies consented to participation. Nineteen insertions were completed by 19 different providers during the study period. Successful insertion was achieved in 18 (95%) of 19 patients (95% confidence interval [CI], 85%-100%). Successful insertion was achieved in less than 60 seconds by 13 (72%) of 15 providers (95% CI, 60%-94%; 4 providers, no response). Fourteen out of 17 providers (82%) reported feeling very comfortable (59%) or comfortable (23%) with the device (95% CI, 64%-100%; 2 non-responses). Fourteen (82%) of 17 providers (95% CI, 64%-100%) with a successful insertion felt that the device worked very well, and the remaining 3 (18%) felt that it worked well. Thirteen (78%) of 17 providers (95% CI, 56%-96%) recommended future use of the EZ-IO needle over the Illinois needle. Two providers (11%) recommended the use of both needles, and 2 providers (11%) were unsure if they would recommend one of the intraosseous needles over the other. A total of 5 complications were reported by the providers: infiltration during use (2); slow flow rate (2); and needle dislodgement (1) when moving the patient into the ambulance. Conclusions: This device has a high insertion success rate with our provider group. Most of our EMS providers also felt comfortable using the device and recommend the device for future use. (C) 2009 Lippincott Williams & Wilkins, Inc.

Sedation After Intubation Using Etomidate and a Long-Acting Neuromuscular Blocker

Background: Etomidate is an imidazole hypnotic which is commonly used by emergency medicine physicians during rapid sequence intubation. Etomidate's duration of action is significantly shorter than that of commonly used long-acting paralytic medications (3-12 minutes vs 25-73 minutes). If additional sedative medications are not administered in the paralyzed patient before the conclusion of etomidate's duration of action, patients are at risk for experiencing paralysis without adequate sedation. Objective: To evaluate the frequency of the administration of additional sedation in pediatric emergency department patients undergoing endotracheal intubation with etomidate and a long-acting paralytic agent. Methods: This study was a retrospective review of pediatric patients undergoing endotracheal intubation in a tertiary pediatric emergency department between July 2001 and December 2005. All patients intubated with etomidate and rocuronium or vecuronium were eligible for inclusion; patients with seizures were excluded. Data elements included the following: demographic variables, presenting complaint, intubation indication, medications used, time from etomidate administration to the administration of an additional sedative, Glasgow Coma Scale (GCS) score, and patient disposition. Results: During the study period, 276 pediatric intubations were reviewed with 104 patients receiving etomidate and rocuronium or vecuronium. Twenty cases were excluded, 15 cases with documented seizures and 5 incomplete/missing charts. Eighty-four records were included in the final analysis. The mean age is 84 +/- 65 months; 62 (73.8%) patients were male; the mean GCS was 8.44 +/- 3.9, with a median GCS of 8 (interquartile range 6,11), and 41 (48.8%) of patients presented with blunt trauma. The mean time from etomidate to the administration of additional sedation was 46 +/- 49 minutes. Eleven (13.1%) patients received no additional sedative after etomidate administration, whereas only 20 (23.8%) patients were given a sedative within 15 minutes of the administration of etomidate. Fifty-three (63.1%) patients received an additional sedative more than 15 minutes after the administration of etomidate. Conclusions: A significant proportion of pediatric patients receiving etomidate and rocuronium or vecuronium during endotracheal intubation are likely experiencing ongoing paralysis without adequate sedation. Emergency medicine physicians should be cognizant of this when using these medications for facilitating intubation. (C) 2009 Lippincott Williams & Wilkins, Inc.

Review of New and Newly Discovered Respiratory Tract Viruses in Children

Respiratory tract viral infection continues to be among the most common reasons for emergency department visits and hospitalization of children, particularly infants younger than 1 year, in the United States. Throughout the years, clinicians have considered respiratory syncytial virus followed by influenza as the most common pathogens responsible. Over the past decade, new viruses have been discovered through both more specific testing and the finding of new agents causing infection. This includes human metapneumovirus, which leads to similar but often epidemiologically more severe clinical symptoms than respiratory syncytial virus. Other agents responsible for lower respiratory tract infection include Coronavirus (severe acute respiratory syndrome), Bocavirus, and others. This review serves to focus on some of the recent literature on these agents and the clinical impact they have on pediatric lung infection. (C) 2009 Lippincott Williams & Wilkins, Inc.

Confirming Nasogastric Tube Position in the Emergency Department: pH Testing Is Reliable

Objective: The aim of this study was to determine whether pH testing is an accurate method of confirming nasogastric tube (NGT) position in children with and without gastroenteritis in the emergency department. Methodology: A prospective observational study of NGT insertions was conducted at a tertiary pediatric emergency department, during a 9-month period in 2006. We evaluated methods of NGT position confirmation, pH of nasogastric aspirates from patients with and without gastroenteritis, and adverse events. Results: A total of 404 patients were enrolled. For 393 patients (97.3%), NGT aspirates could be obtained to assess pH. Of these patients, 294 (74.8%) had a diagnosis of gastroenteritis and 99 (25.2%) did not. There was no difference in median pH between the patients with gastroenteritis (pH, 2; interquartile range, 2-4) and those without gastroenteritis (pH, 2; interquartile range, 2-4; P = 0.09). Overall, 341 patients (86.8%) had a pH of 4 or lower. The patients with gastroenteritis were more likely to have a pH of 4 or lower than the patients without gastroenteritis (P = 0.018). Tube position was confirmed by pH alone in 332 patients (84.5%). Nine (2.6%) of the 341 patients with a pH of 4 or lower also had radiography (7 for causes other than confirmation of NGT position) indicating correct placement of all NGTs. Fifty-two patients (13.2%) had a pH higher than 4, and 18 (34%) of these had the tube position confirmed by radiography, of which 3 had tubes misplaced in the distal esophagus. Irrespective of pH level, there were no respiratory placements clinically or by radiography. Overall, 22 patients (5.6% 95% CI 3.5%-8.3%) required more than 1 attempt for NGT insertion. There were 13 minor adverse events (3.3% 95% CI 1.8%-5.6%) and no major adverse events. Conclusions: Testing of gastric pH is a reliable way of confirming NGT position when the pH is 4 or lower. When the pH is higher than 4, a radiograph may be necessary. (C) 2008 Lippincott Williams & Wilkins, Inc.

Emergency Management of Pediatric Convulsive Status Epilepticus: A Multicenter Study of 542 Patients

Objective: To perform a multicenter study examining the presentations and emergency management of children with convulsive status epilepticus (CSE) to sites within the Paediatric Research in Emergency Departments International Collaborative. Methods: Retrospective review of children presenting to emergency departments (EDs) with convulsive seizures of at least 10 minutes' duration. Eight sites within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand participated. Patients were identified through a search of ED electronic records for the period January 2000 to December 2004. Results: Data were obtained from 542 eligible episodes of CSE. Demographics and seizure history were similar across all sites. One third of children with CSE presented with their first seizure. A preexisting diagnosis that predisposed to seizures was present in 59%. Median duration of seizures before hospitalization was 45 minutes, and median duration of treatment in ED before termination was 30 minutes. Prehospital duration did not seem to influence the timing of key ED interventions such as the administration of second-line anticonvulsants or progression to rapid sequence induction (RSI) of anesthesia and intubation. Convulsive status epilepticus was terminated after first-line treatment in 42%, second-line treatment in 35%, and RSI in 22%. One third of the patients had persistent seizure activity beyond 40 minutes of ED treatment. Marked variation in the use of RSI for refractory seizures was observed between sites. Conclusions: Convulsive status epilepticus is an important neurological emergency, with many children experiencing prolonged seizures in both the prehospital and hospital phases. Persistent seizure activity beyond 40 minutes contrasts with current published guidelines. There is a need to adopt a widely accepted approach to the management of children who fail to respond to standard anticonvulsant therapy. (C) 2009 Lippincott Williams & Wilkins, Inc.

Development and Validation of a Risk Score for Predicting Hospitalization in Children With Influenza Virus Infection

Objective: Influenza virus infections cause significant morbidity and often result in hospitalization in children. Many children with influenza seek care in emergency settings during seasonal influenza epidemics. We hypothesized that certain features could predict the need for hospitalization in children with influenza. Methods: Retrospective cohort study of all children 18 years or younger seen at a children's hospital with laboratory-confirmed influenza infection between July 2001 and June 2004. Medical records of children with confirmed influenza virus infection were reviewed. Predictors of admission were identified using logistic regression models. An influenza risk score system was created and validated based on 4 predictors. Results: We identified 1230 children with laboratory proven influenza virus infection, 541 were hospitalized. Multivariate logistic regression demonstrated that 4 predictors were independently strongly associated with hospitalization. In the clinical prediction rule for children with influenza who were hospitalized, history of a high-risk medical condition (odds ratio [OR], 4.06; 95% confidence interval [CI], 2.91-5.68) was worth 2 points. Respiratory distress on physical examination (OR, 2.33; 95% CI, 1.61-3.38) was worth 1 point. Radiographic evidence of focal pneumonia (OR, 7.82; 95% CI, 3.62-16.92) was worth 3 points and influenza B infection (OR, 3.99; 95% CI, 2.57-6.21) was worth 2 points. High-risk children with influenza with a total risk score of 3 to 8 had an 86% probability of hospitalization. Conclusions: The presence of a high-risk medical condition, respiratory distress on physical examination, radiographic evidence of focal pneumonia, and influenza B infection were the 4 strongest predictors of hospitalization. The risk score assigned to a child with influenza may provide a disposition tool for predicting hospitalization in children in seasonal influenza epidemics. (C) 2009 Lippincott Williams & Wilkins, Inc.

The Use of White Blood Cell Count and Left Shift in the Diagnosis of Appendicitis in Children

Background: The use of white blood cell (WBC) count and left shift in the diagnosis of appendicitis in pediatric patients is unproven. It is commonly thought that children with appendicitis have an elevated WBC count with a left shift; however, most data supporting this belief stem from studies conducted on appendicitis in adults, not children. The purpose of this investigation was to determine the value of WBC count and differential in the diagnosis of appendicitis in children presenting to the emergency department (ED) with acute abdominal pain. Methods: Seven hundred twenty-two pediatric ED patients with a primary complaint of nontraumatic abdominal pain were identified by prospective and retrospective methods. White blood cell count with differential was performed on patients with history and physical examination findings that were felt to warrant laboratory investigation. Results of WBC counts were determined as low, normal, or high, with or without a left shift, based on normal age-related values per laboratory protocol for pediatric patients. Results: The diagnosis of appendicitis was made in 10.2% of all patients presenting to the ED with acute abdominal pain. Thirty percent of toddlers (1-3.9 years) with high WBC counts had appendicitis, whereas 0% of toddlers with low WBC counts and 4.8% of toddlers with normal WBC counts had appendicitis ([chi]2 = 6.5, P = 0.04). A normal WBC count did not rule out appendicitis in toddlers; however, the negative predictive value (NPV) for normal or low WBC count was high (NPV = 95.6%). In the child age group (4-11.9 years), high WBC count was both sensitive and specific for the diagnosis of appendicitis in children (sensitivity = 71%, specificity = 72%), and the NPV for normal or low WBC count was high (NPV = 89.5%). Lastly, 43.9% of adolescents (12-19 years) with high WBC counts had appendicitis, whereas 0% of adolescents with low WBC counts and 8.3% of adolescents with normal WBC counts had appendicitis ([chi]2 = 37.3, P < 0.001). The NPV for a low or normal WBC count was also high in the adolescent group (NPV = 91.9%). Left shift was also strongly associated with appendicitis. Among toddlers, 40% of patients with a left shift had appendicitis, whereas 1.8% of toddlers without a left shift had appendicitis ([chi]2 = 25.7, P < 0.001, NPV = 98.2%). Similarly, left shift was strongly associated with appendicitis in children and adolescents. Among children, 54.3% of patients with a left shift had appendicitis, whereas 5.4% of children without a left shift had appendicitis ([chi]2 = 67.8, P < 0.001, NPV = 90.5%). Among adolescents, 53.5% of patients with a left shift had appendicitis, whereas 6.1% of adolescents without a left shift had appendicitis ([chi]2 = 72.3, P < 0.001, NPV = 93.9%). In patients with a left shift, 51.2% had appendicitis, whereas 3.7% of patients without a left shift had appendicitis ([chi]2 = 226.2; P < 0.001, NPV = 96.3%). In all patients with appendicitis, elevated WBC counts had a sensitivity of 67% and a specificity of 80%. Using left shift alone as an indicator for appendicitis was associated with a sensitivity of 59% and a specificity of 90%. However, when a high WBC count and left shift were combined, the sensitivity climbed to 80%, and specificity remained at 79%. The sensitivity fell to 47% when both a high WBC count and left shift were analyzed, and specificity climbed to 94%. The positive likelihood ratio for a high WBC count and left shift was 9.8. Conclusions: The determination of WBC count and differential is useful in the diagnosis of appendicitis in children presenting to the ED with nontraumatic acute abdominal pain, regardless of age. High WBC counts and left shift are independently, strongly associated with appendicitis in children aged 1 to 19 years. In fact, for this subset of patients older than 4 years, the most common diagnosis in the setting of an elevated WBC count was appendicitis. The presence of an increased WBC count or left shift carries with it a high sensitivity (79%), and the presence of both high WBC count and left shift has the highest specificity (94%). These values are, therefore, helpful in the diagnosis and exclusion of appendicitis. Although not absolute, the WBC count and left shift can be helpful in the diagnosis and exclusion of appendicitis. (C) 2007 Lippincott Williams & Wilkins, Inc.

Swallowed Coke Can Tab: Is It Still Stuck in the Esophagus?

No abstract available

Jumped off the Trampoline: Fell on Knee: Pain

No abstract available

Rehydration: Role for Early Use of Intravenous Dextrose

Acute gastroenteritis is a common reason for children to seek health care. Among the potential complications of acute gastroenteritis, the most common is dehydration. For mild to moderate dehydration, treatment options include oral and intravenous rehydration. Outpatient treatment failure for either method, when it occurs, is often due to persistent nausea and vomiting. Some authorities have suggested that the early administration of dextrose to patients receiving intravenous rehydration may help terminate vomiting and result in fewer outpatient treatment failures. The purpose of this report was to review the evidence supporting the effectiveness of early intravenous dextrose administration in the outpatient management of dehydration in children with acute gastroenteritis. (C) 2009 Lippincott Williams & Wilkins, Inc.

Enema-Reduced Intussusception Management: Is Hospitalization Necessary?

Objectives: To describe the demographic and clinical characteristics of hospitalized children with enema-reduced intussusception and to determine the necessity of hospitalization. Methods: Retrospective cross-sectional study of patients (0-17 years of age) with enema-reduced intussusception hospitalized at a 110-bed urban children's hospital. For this study, potential necessity of hospitalization was defined as the presence of associated dehydration, persistent symptoms and signs of intussusception requiring repeated radiographic studies, and/or enema-reduced serious complications (bowel perforation and/or sepsis). Results: For a 12-year period (January 1995 to December 2006), 45 patients who had enema-reduced intussusception were hospitalized. There were 32 males (71%). Three (6.7%) of the 45 patients had recurrent episodes of intussusception occurring at 2, 7, and 45 months after the initial episode. The initial episode for only 1 of these 3 was an enema-reduced hospitalization event. Thus, the following results include 46 episodes among 45 patients. The mean (SD) age at the time of intussusception was 19.6 (25.4) months, and the median age was 10 months (range, 2-135 months). There were 27 episodes (59%) of patients 12 months or younger. The types of intussusception were ileocolic, 44 and ileoileum, 2. In 13 episodes (28%), patients were described as dehydrated and/or having an abnormal basic metabolic panel test result and meeting one of the study criteria for potential necessity of hospitalization. During the hospitalization, enema was repeated in 1 patient (2%) who had recurrent pain. The repeated enema was normal. No patient had a recurrent intussusception or developed signs of bowel perforation or sepsis while hospitalized. The mean (SD) hospital length of stay was 25.6 (9.9) hours, and the median time was 23 hours (range, 12-60 hours). Conclusions: Hospitalized children with enema-reduced intussusception required minimal interventions, had a low rate of signs and symptoms requiring further radiographic studies, and had no enema-reduced serious complications during hospitalization. These results support outpatient management as an acceptable alternative. (C) 2009 Lippincott Williams & Wilkins, Inc.

Hemorrhagic Shock Resulting From Post-Coital Vaginal Bleeding in an Adolescent With Ehlers-Danlos Type IV

Multiple cases of obstetric-related vaginal bleeding exist in the medical literature pertaining to affected people with Ehlers-Danlos syndrome. We present a novel case of a 16-year-old female with vascular Ehlers-Danlos syndrome (formerly Ehlers-Danlos type IV) who was brought to the emergency department with brisk vaginal bleeding after her first episode of sexual intercourse. (C) 2009 Lippincott Williams & Wilkins, Inc.

Hypertensive Emergency Successfully Treated With Metoprolol: A Case Report

It has been estimated that up to 27% of all medical emergencies presenting to emergency departments are due to hypertension, predominantly in the adult population. Although this often is an insidious process, acutely, a hypertensive emergency occurs when a patient presents with severe hypertension and evidence of end organ damage. We discuss the case of a 12-year-old female with spastic cerebral palsy and global developmental delay secondary to neonatal asphyxia who presented to the emergency department after having a seizure at home. On arrival to the emergency department, she was found to have a heart rate (HR) of 170 and a left upper extremity blood pressure of 174/112. Initial electrocardiogram revealed a HR of 163, with significant ST segment elevations in leads I, II, and minimal elevations in V4, 5, and 6. Intravenous Metoprolol 2.5 mg was administered 3 times with 5 minutes interval between doses, which resulted in a decline in HR (106) and blood pressure (128/86), and subsequent resolution of the electrocardiogram changes. An extensive workup revealed the patient had gallstones, however, her hypertension did not resolve with pain control and, ultimately, cholecystectomy. The remainder of her evaluation confirmed the diagnosis of poststreptococcal glomerulonephritis, and her blood pressure was, eventually, controlled with 3 medications: clonidine, isradipine, and amlodipine. Over the ensuing 2 years, these were weaned with no recurrent hypertensive episodes. Although studies have shown extended release Metoprolol to be a safe and effective treatment in children with established hypertension, to the best of our knowledge, it has not been studied in a pediatric emergency setting. (C) 2009 Lippincott Williams & Wilkins, Inc.

Anticonvulsant Medications in the Pediatric Emergency Room and Intensive Care Unit

Seizures are common in pediatric emergency care units, either as the main medical issue or in association with an additional neurological problem. Rapid treatment prolonged and repetitive seizures or status epilepticus is important. Multiple anti-convulsant medications are useful in this setting, and each has various indications and potential adverse effects that must be considered in regard to individual patients. This review discusses new data regarding anticonvulsants that are useful in these settings, including fosphenytoin, valproic acid, levetiracetam, and topiramate. A status epilepticus treatment algorithm is suggested, incorporating changes from traditional algorithms based on these new data. Treatment issues specific to complex medical patients, including patients with brain tumors, renal dysfunction, hepatic dysfunction, transplant, congenital heart disease, and anticoagulation, are also discussed. (C) 2008 Lippincott Williams & Wilkins, Inc.

The importance of cultural and linguistic issues in the emergency care of children

Background: Rapid growth in the diversity of the US population makes it increasingly likely that emergency clinicians will encounter greater numbers of patients from different cultures, but little is known about the importance of culture and language in the emergency care of children. Objective: To conduct a critical review and synthesis of published studies on culture and language in the emergency care of children. Methods: PubMed was used to perform a literature search (using 17 search terms) of all articles on culture, language, and the emergency care of children published in English or Spanish from 1966 to 1999. Results: More than 2000 citations initially were identified; consensus review yielded 400 papers that were photocopied. A final database of 117 articles revealed the following: certain normative cultural values, such as the Navajo hozhooji (the importance of thinking and speaking positively), can have profound effects on informed consent and discussions of medical risk. For limited English proficient children and their families, studies document that medical interpreters frequently are not used, there is a lack of trained interpreters, there are more access barriers, and those who need but do not get interpreters have poor understanding of their diagnosis and treatment. Numerous folk illnesses, such as empacho among Latinos, can affect care, because symptoms often overlap with important biomedical conditions, the first clinical contact may be with folk healers, and certain folk remedies are harmful or even fatal. Certain parent beliefs and practices can result in serious morbidity and fatalities (from lead poisoning, liver failure, and other causes), costly or unnecessary medical evaluations (eg, Fenugreek teas), and clinical findings easily confused with child abuse (eg, coining). Biased provider attitudes and practices can have profound clinical consequences, including ethnic disparities in prescriptions, analgesia, test ordering, sexual history taking, asthma care quality, and diagnostic evaluations. Conclusions: Failure to appreciate the importance of culture and language in pediatric emergencies can result in multiple adverse consequences, including difficulties with informed consent, miscommunication, inadequate understanding of diagnoses and treatment by families, dissatisfaction with care, preventable morbidity and mortality, unnecessary child abuse evaluations, lower quality of care, clinician bias, and ethnic disparities in prescriptions, analgesia, test ordering, and diagnostic evaluations. (C) 2002 Lippincott Williams & Wilkins, Inc.

Glass Table-Related Injuries in Children

Objectives: To investigate the patterns of injury sustained from glass table-related accidents to estimate whether tempered glass would prevent injuries. Methods: We conducted a retrospective cohort analysis of all patients in an urban pediatric emergency department between October of 1995 and May for 2007 for glass table-related accidents. Data collected included age, sex, injury characteristics, examination findings, radiographic imaging, interventions, and disposition. We used a preventability score ranging from I (fully preventable injury with safety glass) to IV (unlikely to be preventable with safety glass). Results: We identified 174 eligible patients during the study period. The median age was 3.4 years (interquartile range, 2.0-6.6 years); 62.1% were boys. The face was most commonly involved (45.6%) followed by lower (23.8%) and upper extremities (18.9%). Patients younger than 5 years were associated with more facial injuries (odds ratio, 6.0; 95% confidence interval, 2.9-12.6). Radiographs were obtained in 68 patients, and computed tomographic scans in 3 (total, 40.1%). Surgical repair was needed in 143 patients (82.1%), of whom 15 (10.5%) underwent procedural sedation and 8 (5.6%) required operative management. Reviewers ranked 74 patients (42.5%) as grade I, 20 patients (11.5%) as grade II, 64 patients (36.8%) as grade III, and 16 patients (9.2%) as grade IV. Conclusions: Glass table injuries are associated with significant morbidity. More than half of the injuries may have been prevented or mitigated with the use of tempered glass. Pediatricians are advised to discourage families from the purchase of nontempered glass tables, while advocating for legislation mandating the use of tempered glass. (C) 2009 Lippincott Williams & Wilkins, Inc.

Management of Occult Fractures in the Skeletally Immature Patient: Cost Analysis of Implementing a Limited Trauma Magnetic Resonance Imaging Protocol

Study Objective: Fractures in children may not be visible in the result of initial radiography, and undertreatment and overtreatment of such fractures routinely occur. The purpose of this study was to evaluate the potential cost of implementing limited magnetic resonance imaging (MRI) at initial encounter, when radiographs are unrevealing. Methods: This was a retrospective review of 204 emergency department pediatric patients presenting between January 1, 2005 and February 28, 2006 with appendicular trauma, with initially negative radiographic result and follow-up. Emergency department treatment categorization of (1) no treatment, (2) ACE wrap, (3) brace, (4) splint, or (5) casting was evaluated. Final determination of presence or absence of fracture was based on follow-up. Patients with fractures were considered undertreated when they received categories 1 to 3 care; patients without fractures were considered overtreated when they received categories 4 and 5 care. The percentage of patients undertreated or overtreated and direct and total costs were determined and analyzed in conjunction with the cost of a limited MRI at initial encounter. Total costs include direct and indirect costs (lost wages for each day off work for the parent). Cost estimates assume patients determined to be without fractures at follow-up will not return for follow-up clinical care or obtain additional imaging after MRI at initial encounter. Results: Twenty-eight (13.7%) of the 204 patients had fractures at follow-up. Fifty one percent of patients without fractures were overtreated; 29% with fractures were undertreated. Mean direct cost for all patients and cost estimation with limited MRI protocol were $843.81 and $891.79, respectively (P = 0.365). However, mean total cost for all patients and cost estimation with limited MRI protocol was $1059.49 and $929.10, respectively (P = 0.02). Conclusions: Based on clinical grounds and initially negative radiographic results, slightly more than half of patients without fractures can be overtreated, and nearly one third of patients with fractures can be undertreated. Instituting a protocol that includes limited trauma MRI lowers the total cost of care without increasing direct cost, and appropriate care may be instituted at the outset. (C) 2009 Lippincott Williams & Wilkins, Inc.

Parental Preference for Rehydration Method for Children in the Emergency Department

Objective: To determine which rehydration method, oral or intravenous, parents would choose for their child when given the opportunity to make an informed decision and to determine factors influencing preference. Methods: Parents of children, aged 6 months to 5 years, who presented to a pediatric emergency department with a chief complaint of vomiting and/or diarrhea were eligible. After triage evaluation and before physician assessment, research assistants presented educational materials regarding the method, risks, and benefits of both oral and intravenous rehydration. Parents were then asked to complete a survey asking them their preference, reasons for their preference, questions about their child's current illness, and demographic information. Results: Two hundred sixty parents completed the study. Ninety eight (38%) preferred oral rehydration, and 162 (62%) preferred intravenous rehydration. Time of day, presence of siblings in the ED requiring parental attention, presence of another adult to provide support, parental age, educational attainment, and employment status were not statistically associated with the stated preference. Of those parents who selected intravenous rehydration, 53% stated that they would choose oral rehydration if there was an oral medication available that would significantly decrease vomiting. Of those parents who selected oral rehydration, 32% stated that they would choose intravenous rehydration if there was a topical medication available that would significantly decrease the pain of intravenous catheter placement. Conclusions: When given the opportunity to make an informed decision, more parents chose intravenous rehydration. However, the prospect of an effective oral antiemetic medication might lead more parents to choose oral rehydration. (C) 2009 Lippincott Williams & Wilkins, Inc.

Management of Primary Herpetic Gingivostomatitis in Young Children

Objective: To review the treatment of primary herpetic gingivostomatitis at a children's hospital. Methods: A review of charts from 1999 to 2003. Results: Forty-eight cases were identified. They ranged in age from 8 months to 12 years, with a median age of 2 years 7 months. All children were treated with fluids and analgesics; 11 children were treated with fluids and analgesics exclusively. Thirty-five children were treated with a mixture of Maalox and diphenhydramine, 8 with acyclovir, and 7 with viscous lidocaine; 11 children were treated with 2 or more of these regimens. Both the Maalox and diphenhydramine mixture and the viscous lidocaine were administered as swish and swallow, swish and spit, or by application with a swab as frequently as every hour or as infrequently as every 8 hours. Conclusions: Topical therapy with Maalox and diphenhydramine or viscous lidocaine was administered to 73% and 15% of the patients, respectively, whereas acyclovir was administered to only 17%. Dosing and administration of topical agents in the treatment of primary herpetic gingivostomatitis in preschoolers were problematic. Acyclovir was not being used as often as it could have been. (C) 2006 Lippincott Williams & Wilkins, Inc.

Randomized Controlled Trial of Ultrasound-Guided Peripheral Intravenous Catheter Placement Versus Traditional Techniques in Difficult-Access Pediatric Patients

Objectives: We hypothesized that the use of ultrasound guidance would improve the success rate of peripheral intravenous catheter placement in pediatric patients with difficult access in a pediatric emergency department (ED). Our secondary hypotheses were that ultrasound guidance would reduce the number of attempts, the number of needle redirections, and the overall time to catheter placement. Methods: This was a prospective randomized study of pediatric ED patients younger than 10 years old requiring intravenous access, presenting between August 2006 and May 2007. Inclusion criteria were 2 unsuccessful traditional attempts at peripheral intravenous access or history of difficult access. Exclusion was critical illness or instability. Patients were randomized to undergo peripheral intravenous catheter placement using continued traditional approaches or real-time, dual-operator ultrasound-guided technique. Measured outcomes were success of cannulation, number of attempts, number of needle redirections, and overall time to catheter placement. Results: Fifty patients were enrolled, with 25 patients randomized to each group. The overall success rates for the ultrasound-guided group were 80% and for the traditional-attempts group, 64%, with a difference in proportions of 16% (95% confidence interval, -9% to 38%, P = 0.208). The ultrasound-guided group required less overall time (6.3 vs 14.4 minutes, difference of -8.1 minutes [95% confidence interval, -12.5 to -3.6], P = 0.001), fewer attempts (median, 1 vs 3; P = 0.004), and fewer needle redirections (median, 2 vs 10; P < 0.0001) than traditional approaches. Conclusions: In a sample of pediatric ED patients with difficult access, ultrasound-guided intravenous cannulation required less overall time, fewer attempts, and fewer needle redirections than traditional approaches. (C) 2009 Lippincott Williams & Wilkins, Inc.

Pediatric Emergency Medicine Fellowship Programs

No abstract available

Rapid sequence intubation for pediatric emergency airway management

Objectives: To characterize current practice with respect to pediatric emergency airway management using a multicenter data set. Methods: A multicenter collaboration was undertaken to gather data prospectively regarding emergency intubation. Analysis of data on adult emergency department (ED) intubations clearly demonstrated that rapid sequence intubation (RSI) was the method used most often. We then conducted an observational study of the prospectively collected database of pediatric ED intubations (EDIs) using the National Emergency Airway Registry Phase One data, gathered in 11 participating EDs over a 16-month time period. A data form completed at the time of EDI enabled analysis of patients' ages, weights, and indications for EDI; personnel; methods employed to facilitate EDI; success rates; and adverse events. Data forms were analyzed regarding the methods of intubation employed, and frequencies, success rates, and adverse event rates among various intubation modalities were compared. Results: Of 1288 EDIs, there were 156 documented pediatric patients. Initial intubation attempts were all oral, including rapid sequence intubation in 81%, without medications (NOM) in 13%, and sedation without neuromuscular blockade (SED) in 6%. Older children and trauma patients were more likely to be intubated with RSI compared to younger children and patients presenting with medical illnesses. Intubation using RSI was more successful on the first attempt (78%) compared with either NOM (47%, P < 0.01) or SED (44%, P < 0.05), though this finding is likely explainable by the age differences among groups. Intubation was successfully performed by the initial intubator in 85% of RSI, 75% of NOM, and 89% of SED attempts (P = NS for both comparisons vs RSI). Overall, successful intubation occurred in 99% of RSI and 97% of non-RSI intubation attempts (P = NS). Only one of 156 patients required surgical airway management. True complications occurred in 1%, 5%, and 0% of RSI, NOM, and SED attempts, respectively (P = NS for both comparisons vs RSI). The majority of initial intubation attempts were by emergency medicine residents (59%), pediatric emergency medicine fellows (17%), and pediatrics residents (10%). These groups were 77%, 77%, and 50% successful, respectively, on the first laryngoscopy attempt, and 89%, 89%, and 69% successful overall. Conclusions: A large, prospective, multicenter observational study of pediatric EDIs was conducted at university-affiliated EDs. RSI is the method of choice for the majority of pediatric emergency intubations; it is associated with a high success rate and a low rate of serious adverse events. Pediatric intubation as practiced in academic EDs, with most initial attempts by emergency and pediatrics residents and fellows under attending physician supervision, is safe and highly successful. (C) 2002 Lippincott Williams & Wilkins, Inc.

Ventriculoperitoneal shunt migration presenting with vaginal discharge and hydrosalpinx in a 16-year-old patient

No abstract available

Frena Tears and Abusive Head Injury: A Cautionary Tale

Tears of the lingual and labial frena have been associated with accidental and nonaccidental injury. Three cases of infants are presented who were evaluated in the hospital with frena tears which were not recognized as manifestations of abuse, discharged home, and subsequently returned with manifestations of severe abusive head injury. (C) 2007 Lippincott Williams & Wilkins, Inc.

Pediatric Procedural Sedation by a Dedicated Nonanesthesiology Pediatric Sedation Service Using Propofol

Objectives: To evaluate the success and dosing requirements of propofol in children for prolonged procedural sedation by a nonanesthesiology-based sedation service. Methods: The pediatric sedation service at this institution uses propofol as its preferred sedative, and the local guideline suggests using 3 mg/kg for induction and 5 mg kg-1 h-1 for maintenance sedation. Doses can be adjusted as needed to individualize successful sedation. A retrospective analysis of patients sedated for 30 minutes or longer was conducted. Patients were stratified into 4 cohorts based on age (7 years [n = 55]) and dosing patterns, success, and adverse effects were investigated. Results: Two hundred forty-nine patients met the inclusion criteria. Mean age was 4.8 years (SD, 4.1). The mean induction dose was 3.2 mg/kg (range, 0.9-9.7), and the mean maintenance infusion was 5.2 mg kg-1 h-1 (range, 0.14-21.3). No differences were seen in the induction doses in the different age cohorts, yet the SD was largest in the youngest cohort compared to any other. Although no differences were seen in maintenance rates by age, the greatest SD for dosing was seen in the oldest cohort. For all ages, all sedations were successful (100%) and unanticipated adverse effects rare (<1%). Conclusions: Although it seems that the mean dosing of propofol does not vary significantly with age, there is greater variability in induction dosage for those younger than 1 year and in maintenance dosing for those 7 years or older. The results and general dosing parameters may assist pediatric subspecialists in using propofol for prolonged procedural sedation. (C) 2009 Lippincott Williams & Wilkins, Inc.

Simple Febrile Seizures: Are the AAP Guidelines Regarding Lumbar Puncture Being Followed?

Background: In 1996, the American Academy of Pediatrics (AAP) published a practice parameter recommending that lumbar puncture (LP) be strongly considered in infants younger than 12 months presenting with a first febrile seizure. Objective: We sought: (1) to determine if the recommendations of the AAP are being followed by pediatric emergency medicine-trained physicians at our institution; (2) to describe the rate of meningitis among patients with febrile seizure who underwent LP; and (3) to determine if there were differences in performance of LP if children were younger or pretreated with antibiotics. Methods: A retrospective chart review of patients aged 6 to 12 months presenting with first simple febrile seizure to the emergency department (ED) at Miami Children's Hospital was conducted between January 2001 and November 2005. Results: A total of 242 ED records with a discharge diagnosis including the term "febrile seizure," "seizure," or "meningitis" were identified. Of those, 56 met inclusion criteria for first simple febrile seizure. Lumbar puncture was performed in 28 patients (50%) that met inclusion criteria. Younger patients were no more likely to have LP performed than older patients (P = 0.15). Ten children (17.8%) received antibiotics before the ED visit; of these, 4 (40%) underwent LP in the ED. Children who presented with first simple febrile seizure to our institution who were pretreated with antibiotics were no more likely to have LP performed than those who were not receiving antibiotics (P = 0.48). All cerebrospinal fluid cultures were sterile. Conclusion: The AAP recommendations regarding LP in patients 6 to 12 months of age with first simple febrile seizure are not being strictly adhered to. The AAP recommendations regarding simple febrile seizures were conceived in a different epidemiologic era of disease pathology with data not representative of current prevalence and etiologic issues and need to be revisited. (C) 2009 Lippincott Williams & Wilkins, Inc.

Intraosseous Infusion: A Review of Methods and Novel Devices

Bathing Suit Mesh Entrapment: An Unusual Case of Penile Injury

colon; Penile injury is a rare chief complaint in the pediatric emergency department. The most common penile injuries are iatrogenic or postsurgical complications, blunt trauma, tourniquet injuries, fractures, and zipper injuries. We report a series of 3 cases of penile foreskin entrapment within the mesh lining of bathing suits as a new, recognized form of penile injury. (C) 2006 Lippincott Williams & Wilkins, Inc.

Strategies to Improve Flow in the Pediatric Emergency Department

As emergency departments (EDs) experience overcrowding, there is ever-growing pressure to improve patient flow. We present a review of strategies to increase efficiency of patient inflow, throughput, and output in the ED, with an emphasis on approaches that are under greater control of the ED itself and therefore more amenable to implementation without major institutional changes. (C) 2007 Lippincott Williams & Wilkins, Inc.

Chlorine-related Inhalation Injury from a Swimming Pool Disinfectant in a 9-year-old Girl

colon; Chlorine is a potential respiratory hazard in both occupational and household settings. The clinical sequelae of inhalation are variable in severity and timing, and subacute presentation is a concern. We report the case of a 9-year-old girl who developed dyspnea, hypoxemia, and pneumonitis approximately 12 hours after exposure to chlorine released from aerosolized swimming pool purification tablets. Her course was characterized by improvement with supplemental oxygen and bronchodilator therapy. Follow-up pulmonary testing at 4 months after the episode revealed the presence of mild obstructive reactivity of the airways, but she was able to perform normal activities without requiring medications. We discuss the pathophysiology, symptoms, therapy, and long-term follow-up of chlorine inhalation injuries. (C) 2006 Lippincott Williams & Wilkins, Inc.

Pediatric Emergency Medicine: Legal Briefs

No abstract available

Effect of High-Fidelity Simulation on Pediatric Advanced Life Support Training in Pediatric House Staff: A Randomized Trial

Objectives: To assess the effect of high-fidelity simulation (SIM) on cognitive performance after a training session involving several mock resuscitations designed to teach and reinforce Pediatric Advanced Life Support (PALS) algorithms. Methods: Pediatric residents were randomized to high-fidelity simulation (SIM) or standard mannequin (MAN) groups. Each subject completed 3 study phases: (1) mock code exercises (asystole, tachydysrhythmia, respiratory arrest, and shock) to assess baseline performance (PRE phase), (2) a didactic session reviewing PALS algorithms, and (3) repeated mock code exercises requiring identical cognitive skills in a different clinical context to assess change in performance (POST phase). SIM subjects completed all 3 phases using a high-fidelity simulator (SimBaby, Laerdal Medical, Stavanger, Norway), and MAN subjects used SimBaby without simulated physical findings (ie, as a standard mannequin). Performance in PRE and POST was measured by a scoring instrument designed to measure cognitive performance; scores were scaled to a range of 0 to 100 points. Improvement in performance from PRE to POST phases was evaluated by mixed modeling using a random intercept to account for within-subject variability. Results: Fifty-one subjects (SIM, 25; MAN, 26) completed all phases. The PRE performance was similar between groups. Both groups demonstrated improvement in POST performance. The improvement in scores between PRE and POST phases was significantly better in the SIM group (mean [SD], 11.1 [4.8] vs. 4.8 [1.7], P = 0.007). Conclusions: The use of high-fidelity simulation in a PALS training session resulted in improved cognitive performance by pediatric house staff. Future studies should address skill and knowledge decays and team dynamics, and clearly defined and reproducible outcome measures should be sought. (C) 2009 Lippincott Williams & Wilkins, Inc.

Jet Injection of 1% Buffered Lidocaine Versus Topical ELA-Max for Anesthesia Before Peripheral Intravenous Catheterization in Children: A Randomized Controlled Trial

Background: Peripheral intravenous (PIV) catheter insertion is a frequent, painful procedure that is often performed with little or no anesthesia. Current approaches that minimize pain for PIV catheter insertion have several limitations: significant delay for onset of anesthesia, inadequate anesthesia, infectious disease exposure risk from needlestick injuries, and patients' needle phobia. Objective: Comparison of the anesthetic effectiveness of J-Tip needle-free jet injection of 1% buffered lidocaine to the anesthetic effectiveness of topical 4% ELA-Max for PIV catheter insertion. Methods: A prospective, block-randomized, controlled trial comparing J-Tip jet injection of 1% buffered lidocaine to a 30-minute application of 4% ELA-Max for topical anesthesia in children 8 to 15 years old presenting to a tertiary care pediatric emergency department for PIV catheter insertion. All subjects recorded self-reported visual analog scale (VAS) scores for pain at time of enrollment and pain felt following PIV catheter insertion. Jet injection subjects also recorded pain of jet injection. Subjects were videotaped during jet injection and PIV catheter insertion. Videotapes were reviewed by a single blinded reviewer for observer-reported VAS pain scores for jet injection and PIV catheter insertion. Results: Of the 70 children enrolled, 35 were randomized to the J-Tip jet injection group and 35 to the ELA-Max group. Patient-recorded enrollment VAS scores for pain were similar between groups (P = 0.74). Patient-recorded VAS scores were significantly different between groups immediately after PIV catheter insertion (17.3 for J-Tip jet injection vs 44.6 for ELA-Max, P < 0.001). Blinded reviewer assessed VAS scores for pain after PIV catheter insertion demonstrated a similar trend, but the comparison was not statistically significant (21.7 for J-Tip jet injection vs 31.9 ELA-Max, P = 0.23). Conclusion: J-Tip jet injection of 1% buffered lidocaine provided greater anesthesia than a 30-minute application of ELA-Max according to patient self-assessment of pain for children aged 8 to 15 years undergoing PIV catheter insertion. (C) 2008 Lippincott Williams & Wilkins, Inc.

Megacolon: Constipation or Volvulus?

colon; Pediatric abdominal complaints are common presentations in emergency departments, and emergency physicians are challenged every day with a vast array of gastrointestinal disorders. Differentiating the child with a benign abdominal process from the child with a more serious condition can be difficult. We report a case of massive dilatation of the colon due to fecal impaction. Means for distinguishing constipation from alternative diagnoses are discussed. (C) 2006 Lippincott Williams & Wilkins, Inc.

Randomized Controlled Comparison of Cosmetic Outcomes of Simple Facial Lacerations Closed With Steri Strip(TM) Skin Closures or Dermabond(TM) Tissue Adhesive

Objective: To compare the short-term complications and long-term cosmetic outcomes of simple facial lacerations closed with 3M Steri Strip(TM) Skin Closures or Dermabond(TM). Methods: Prospective, randomized controlled trial of children ages 1 to 18 presenting to a pediatric emergency department with simple low-tension lacerations of the face. After standard wound care, patients received wound closure with either Steri Strip Skin Closure or Dermabond. Pain associated with closure was evaluated on a 100-mm visual analogue scale (0 = no pain, 100 = worst pain). A follow-up telephone call was made a week after enrollment to determine short-term complications. Patients returned 2 months after would closure for wound photography. Cosmetic outcomes were evaluated by 2 plastic surgeons blinded to the method of wound closure on a 100-mm visual analogue scale (0 = best scar, 100 = worst scar). Results: One hundred children aged 1 to 18 were enrolled. Ninety-seven patients had results analyzed. Forty-eight received Steri Strip Skin Closures and 49 received Dermabond. Patient demographics and wound characteristics were similar between groups. Pain scores on a 100-mm visual analogue scale were 9.0 mm for the Steri Strip group and 6.2 mm for the Dermabond group (P = ns). At short-term follow-up, there was one wound complication in the Steri Strip group and 7 complications in the Dermabond group (P = 0.06). Eighty-nine patients received 2-month evaluation (41 Steri Strip, 45 Dermabond). There was no difference in the mean visual analogue scale cosmesis scores: 37.2 mm (95% CI = 30.8-43.7) versus 43.8 mm (95% CI = 38.4-49.2) (P = 0.12). Conclusions: Steri Strip Skin Closures and Dermabond provide similar cosmetic outcomes for closure of simple facial lacerations. Steri Strip Skin Closure may represent a low-cost alternative for closure of simple facial lacerations. (C) 2004 Lippincott Williams & Wilkins, Inc.

Final Evaluation of the 2005 to 2007 National Pediatric Emergency Medicine Fellows' Conferences

Objective: Evaluate the effectiveness of the 2005 to 2007 National Pediatric Emergency Medicine (PEM) Fellows Conference series in achieving predefined objectives in the domains of scholarship, leadership, and partnership. Methods: Conference attendees included fellows in the existing PEM fellowship programs. Self-administered preconference and postconference questionnaires measured knowledge, research-related confidence, beliefs about institutional support for Emergency Medical Services for Children (EMSC) research, and intentions to engage in 7 specific behaviors relating to scholarship, leadership, and partnership. Pearson product-moment correlations measured relationships among continuous variables. Repeated-measures analysis of variance measured change between preconference and postconference measures. Hierarchical multiple linear regression models identified predictors of postconference intentions to engage in each of the 7 specific behaviors, controlling for preconference intention. Results: Approximately one third of all PEM fellows attended the conference each year. Preconference and postconference questionnaires were completed by at least 70% of attendees each year. Because several fellows attended more than one conference, data were analyzed from the first conference that a fellow attended. In each year, we observed significant increases in attendees' conference-specific knowledge, confidence, and intentions to continue in EMSC research, join national collaborative research networks, and establish national mentoring relationships. Conclusions: The National PEM Fellows' Conference is an effective means to increasing fellows' knowledge about scholarship, leadership, and partnership in EMSC and increasing their confidence and intentions to conduct research in EMSC. (C) 2009 Lippincott Williams & Wilkins, Inc.

Epidemiology of Admissions in a Pediatric Resuscitation Room

Objective: Describe the epidemiology of a pediatric resuscitation room (PRR). Methods: A prospective study was performed in a pediatric emergency department (PED) from June 17, 2004 to March 19, 2006. Collected data were date and time of admission in the unit and, in the PRR, age and sex, geographical origin, mode of transportation, PED referral mode, diagnosis, evolution, and resuscitation techniques. Statistical analysis included a univariate analysis of hypothetical links between variables and their relation to the risk of death or transfer to the pediatric intensive care unit, then a multivariate analysis by logistical regression where the dependant variable was this risk. Results: Three hundred sixty-one patients totaled 370 admissions. The male-female ratio was 1.3. Mean (SD) age was 5.5 (5.2) years. A quarter of the population was recommended for admission by a physician. Main causes were cardiocirculatory (32%), neurological (26%), respiratory (23%), and traumas (18%), and 17% were hospitalized in an intensive care unit and 4 died. Sixteen technical resuscitation procedures were performed. Children from 0 to 2 years old were more often admitted for cardiocirculatory insufficiency (P < 0.001). The children who were at higher risk for pediatric intensive care unit transfer or death were children from 0 to 2 years old (P < 0.001), an admission for respiratory insufficiency (P < 0.001), and an arrival by medicalized transport (P = 0.003). Conclusions: In addition to national guidelines for PRR management, the teaching and knowledge of the different diagnosis admitted in the PRR and their resuscitation technical procedures warranty a serener approach of those stressful situations. (C) 2009 Lippincott Williams & Wilkins, Inc.

Just Another Case of Diarrhea and Vomiting?

Chronic intussusception is a treatable cause of failure to thrive. It is an uncommon condition often diagnosed late. The presenting features differ from acute intussusception. Chronic intussusception presents with a varying combination of abdominal pain, vomiting, weight loss/failure to thrive, diarrhea, and blood per rectum. An abdominal mass may or may not be palpable. The classic triad of abdominal pain, vomiting, and blood per rectum is uncommon. The purpose of this report is to present a small series of 3 cases and review 19 previously reported cases of chronic intussusception. Considering the diagnosis of chronic intussusception in children who present with failure to thrive and recurrent nonspecific abdominal symptoms is emphasized. (C) 2009 Lippincott Williams & Wilkins, Inc.

Diagnosis and management of pediatric conjunctivitis

No abstract available

Drowning and Near-Drowning in Children and Adolescents: A Succinct Review for Emergency Physicians and Nurses

No abstract available

ECGs in the ED

No abstract available