Journals RSS : Gourt

Primary survey

USA health reforms and the NHS

Prehospital paediatric emergency care: paediatric triage

The practice of triage was conceived during the Napoleonic wars, with the aim of salvaging those soldiers whose injuries were readily treatable, returning them to the battlefield at the earliest opportunity. Literally, the word triage means "to sieve" or "to sort" (French trier), and those earlier battlefield principles have been refined and expanded to now encompass trauma and medical emergencies, with triage practiced in prehospital and hospital settings. To address the anatomical, physiological and developmental differences encountered when dealing with children, specific paediatric triage systems have also been developed, and this article discusses their merits.

Organisation of traumatic head injury management in the Nordic countries

Objective: The aim of this study is to map and evaluate the available resources and the premises of traumatic head injury management in the Nordic countries, before the implementation of a Nordic adaption of the Brain Trauma Foundation guidelines for prehospital management. Methods: The study is a synthesis of two cross-sectional surveys. Questionnaires were used to collect data on the annual number of acute head injury operations, the infrastructure, the level of education, the use of trauma protocols and the management of traumatic head injury at Nordic hospitals. Results: The proportion of acute head injury operations performed outside a neurosurgical department was 0% in Denmark, 16% in Finland, 19% in Norway and 33% in Sweden. Eighty-four per cent of Nordic hospitals had written protocols for the assessment and treatment of trauma patients and 78% had regular training in trauma management; 67% had specific protocols for the treatment of traumatic head injury. Computed tomography (CT) was available in 93% of the hospitals, and 59% of the hospitals could link CT scans to the regional neurosurgical department. Conclusions: Most Nordic hospitals are well prepared to manage patients with acute traumatic head injury. A substantial proportion of the operations are performed at local and central hospitals without neurosurgical expertise, despite an efficient pre and interhospital transport system. The Nordic adaption of the Brain Trauma Foundation guidelines recommends that this practice is terminated.

Qualitative research: specific designs for qualitative research in emergency care?

This article follows our description of generic qualitative approaches, focusing on the specific designs of ethnography, grounded theory and phenomenology. Distinguishing features are described, including methodological approaches and methods for enhancing rigour. The use of these designs in emergency care is unusual but informative, and important work has been produced. Whether used in a pure or applied manner, it is likely that such approaches will add to our understanding of the emergency world.

Introduction of the Liverpool Care Pathway for end of life care to emergency medicine

Aim: To improve the care of patients presenting to the emergency department who are acutely dying or those in whom further disease-modifying treatment is not appropriate. Design: A quality improvement report on the implementation of a modified Liverpool Care Pathway for the Dying Patient (LCP) in an emergency medicine department. Setting: The emergency medicine department of Ninewells Hospital, Dundee. Ninewells Hospital is the tertiary referral and teaching hospital for the east coast of Scotland and North East Fife. Key measures for improvement: The pathway was introduced after a 2001 study and a 2003 audit showed that the department had an increasing role in the care of the acutely dying, but some inconsistency in approach. Key measures for improvement were to improve communication between staff, improve the consistency of care and improve the perceived quality of care given. Senior decision making remains a crucial element of the pathway. Strategies for change: A modified LCP was developed and launched in November 2005. Change was managed via a series of meetings and a pilot process. Serial review and audit allowed ongoing quality review of the pathway and improvements. Results: The care of the dying patient has become a more consistent and positive endeavour. Nursing staff are very satisfied with its use, and it is hoped that the LCP pathway can be developed further within the organisation. Conclusions: It has been a rewarding undertaking to improve the care of dying patients, but one which has taken time and has required consistent management of change to promote the positive outcomes.

DNW--"Did Not Wait" or "Demographic Needing Work": a study of the profile of patients who did not wait to be seen in an Irish emergency department

Background: Patients who fail to wait for medical assessment in the emergency department (ED) have been referred to in the international literature as "did not wait" (DNW) or "left without being seen" (LWBS) patients or, indeed, simply as "walkouts". This is taken as a performance indicator internationally. In common with many countries, Ireland has very considerable problems in the delivery of ED care due largely to inadequate resources and the inappropriate use of EDs as holding bays for admitted patients. This is the first study of this size to profile the DNW phenomenon in Ireland. Methods: The charts of DNW patients were identified and the DNW status was entered into the ED computer record. Data concerning age, sex, time of arrival, date of arrival, triage category and presenting complaint were recorded. Results: In the study period there were 11 662 patient attendances, of whom 871 patients (7.47%) did not wait for assessment. Triage category was highly statistically significant, with those in the lowest triage category having the highest numbers not waiting to be seen (p<0.001). Those attending at night (p<0.001) and at the weekend (p = 0.03) were most likely to leave without being assessed. Conclusion: Failure to provide the service in a timely manner gives rise to patients leaving without receiving the medical assessment they came to obtain. This is a serious clinical problem and puts both those requiring care and those providing it at risk of adverse outcomes.

Magnesium sulphate in the treatment of acute asthma: evaluation of current practice in adult emergency departments

Background: A recent meta-analysis showed that intravenous and nebulised magnesium sulphate have similar levels of evidence to support their use in the treatment of acute asthma in adults. This consisted of weak evidence of effect on respiratory function and hospital admissions, with wide confidence intervals ranging from no effect to significant positive effects. Current BTS/SIGN guidelines suggest an equivocal role for intravenous magnesium sulphate and no role for nebulised magnesium sulphate. A study was performed to assess what emergency physicians currently do in their management of acute asthma. Method: A postal survey was undertaken of all adult emergency departments within the UK. A structured questionnaire was sent to all clinical leads in emergency medicine about their current usage of both intravenous and nebulised magnesium sulphate in the treatment of acute asthma. Results: 180 of the 251 emergency departments in the UK responded (72%). Magnesium sulphate was used in 93%, mostly because it was expected to relieve breathlessness (70%) or reduce HDU/ITU admissions (51%). It was predominantly given to those patients with acute severe asthma (84%) and life-threatening exacerbations (87%), with most stating they would give the drug if there was no response to repeated nebulisers (68%). In comparison, nebulised magnesium sulphate was only used in two emergency departments (1%). The main reason for not administering the drug via a nebuliser was insufficient evidence (51%). Conclusions: Intravenous magnesium sulphate is widely used for acute asthma, usually for patients with severe or life-threatening asthma who have not responded to initial treatment. Nebulised magnesium sulphate, by contrast, is hardly used at all. The use of intravenous magnesium sulphate is more extensive than current guidelines or available evidence would appear to support.

EMQs: Paediatrics

Relationship between equipment and infrastructure for pandemic influenza and performance in an avian flu drill

Background: Effective preparedness for pandemic influenza necessitates acquisition and maintenance of vital equipment and infrastructure. The aim of this study was to investigate the relationship between the level of hospital preparedness relating to infrastructure and equipment and performance of the hospital in an avian flu drill. Methods: The levels of preparedness of the infrastructure and equipment for pandemic influenza of all 24 general hospitals were evaluated using a tool developed for this purpose. The hospital evaluation scores were then compared with the scores obtained by the hospitals in a simulated avian flu drill. Results: The overall scores of equipment and infrastructure for pandemic influenza of general hospitals ranged from 67% to 100%. Comparison of the overall level of preparedness of equipment and infrastructure for pandemic influenza with the overall scores achieved in the avian flu drill revealed a medium correlation. A medium correlation was also found between stockpiling of medications and performance in the avian flu drill. No correlations were found between operating infrastructure, availability of protective measures and medical forms and performance in the avian flu drill. Conclusions: This study has identified benchmarks of infrastructure and equipment required for managing a pandemic influenza event and evaluating the level of emergency preparedness of the hospital. The significant relationship between maintaining stockpiles of antiviral medications for patients and staff and performance in an avian flu drill emphasises its importance in the process of maintaining emergency preparedness for a pandemic influenza outbreak.

Winged scapula as the presenting symptom of Guillain-Barre syndrome

Derivation and validation of a sensitive IMA cutpoint to predict cardiac events in patients with chest pain

Objectives: In patients with acute chest pain, we derived a cutpoint for ischaemia-modified albumin (IMA) and prospectively validated this cutpoint to predict 30-day major adverse cardiac events (MACEs). Methods: We prospectively recruited a derivation cohort (18-month period) to establish a serum IMA cutpoint targeting 80% sensitivity. This was followed by a prospective validation cohort study of emergency department patients with acute chest pain at two university hospitals over a 3-month period. A MACE was defined as myocardial infarction, revascularisation or death at 30-day follow-up. Results: In the derivation cohort of 151 patients, the IMA cutpoint that achieved 80% sensitivity for MACEs was 75 KU/litre. The sensitivity was prospectively validated in 171 patients consecutively enrolled, of whom 106 underwent multiple-biomarker analysis (19.8% MACE rate, 81% sensitivity of IMA). Furthermore, IMA by itself (81%, p<0.01) and in combination with initial highly sensitive cardiac troponin T (hsTnT) (90%, p<0.001) had significantly higher sensitivity than initial hsTnT (29%) for prediction of MACEs. Conclusions: We prospectively validated the sensitive IMA cutpoint of 75 KU/litre with 80% sensitivity for MACEs in patients with acute chest pain. Our data suggest that IMA alone and in combination with initial hsTnT are more sensitive than the initial hsTnT for MACEs.

Pulmonary artery pseudoaneurysm

The toddler refusing to weight-bear: a revised imaging guide from a case series

Background: The previously mobile child who refuses to walk or weight-bear is a common presentation to the accident and emergency department, for which there are a number of causes. One uncommon cause is discitis, an inflammatory process of the intervertebral disc, which is easily diagnosed with spinal magnetic resonance imaging (MRI). A case series of three patients is presented of non-weight-bearing children in whom there was a delay in making the diagnosis of lumbosacral discitis. None presented with back pain, spinal symptoms or abnormal neurological findings, and a full range of movement of both hips was found. Methods: All patients underwent conventional radiography and ultrasound, but diagnoses were made on spinal MRI, with two patients undergoing bone scintigraphy before this. Results: The mean delay was 15.6 days (range 13–20) from presentation at the hospital to MRI. All three patients made a good clinical recovery with intravenous antibiotics. Conclusion: These cases are presented in order to heighten the awareness of this disease entity and its imaging findings, and suggest new guidelines for the appropriate radiological investigations in this clinical setting.

Predicting the complicated neutropenic fever in the emergency department

Objectives: The purpose of this study was to identify independent factors that can be used to predict whether febrile neutropenic patients who appear healthy at presentation will develop subsequent complications, using variables that are readily available in the emergency department (ED). Method: The medical records of 192 episodes in which the patients presented to the ED with neutropenic fever resulting from chemotherapy, with an alert mental state and haemodynamic stability were retrospectively reviewed. Endpoints examined were fever response to administered antibiotics, death or severe medical complications during hospitalisation. Results: Thirty-eight episodes of neutropenic fever with complicated outcomes were identified from among a total of 192 episodes. Three parameters emerged as independent factors for the prediction of neutropenic fever with complications in the multivariate regression analysis: platelet count (130–450 x 103 cells/mm3) <50 000 cells/mm3, serum C-reactive protein (CRP, 0.1–1 mg/dl) >10 mg/dl and pulmonary infiltration on chest x ray. Conclusions: Platelet count, CRP and pulmonary infiltration on chest x ray at presentation could be used to identify febrile neutropenic patients who will develop complications, and these factors may be useful in making treatment-related decisions in the ED.

Pain in the leg after jogging

Effects of bed height on the performance of chest compressions

Objectives: The correct chest compression technique was emphasised to enhance the result of cardiopulmonary resuscitation in the 2005 guidelines. The present study compared the effects of different bed heights, including a bed at knee height, on the performance of chest compressions. Methods: Twenty-four healthcare providers participated in this study. Knee height was defined as the baseline bed height. Bed heights were adjusted to 10 and 20 cm above the baseline and 10 and 20 cm below the baseline. At the five bed heights, chest compressions were performed for 2 minutes, and the compression rate was maintained at 100 per minute, with audible feedback. Results: The mean compression depths (MCD) were 28.3 mm (SD 10.7; knee height +20 cm), 32.3 mm (SD 9.2; knee height +10 cm), 32.7 mm (SD 8.5; knee height), 32.3 mm (SD 9.0; knee height –10 cm) and 31.1 mm (SD 8.5; knee height –20 cm). The MCD was significantly lower at knee height plus 20 cm (p<0.001). Conclusion: The performance of chest compressions decreased when the bed height was 20 cm higher than the knee height of the rescuer.

Use of a control test to aid pH assessment of chemical eye injuries

Chemical burns of the eye represent 7.0%–9.9% of all ocular trauma. Initial management of ocular chemical injuries is irrigation of the eye and conjunctival sac until neutralisation of the tear surface pH is achieved.We present a case of alkali injury in which the raised tear film pH seemed to be unresponsive to irrigation treatment. Suspicion was raised about the accuracy of the litmus paper used to test the tear film pH. The error was confirmed by use of a control litmus pH test of the examining doctor’s eyes. Errors in litmus paper pH measurement can occur because of difficulty in matching the paper with scale colours and drying of the paper, which produces a darker colour. A small tear film sample can also create difficulty in colour matching, whereas too large a sample can wash away pigment from the litmus paper. Samples measured too quickly after irrigation can result in a falsely neutral pH measurement. Use of faulty or inappropriate materials can also result in errors. We advocate the use of control litmus pH test in all patients. This would highlight errors in pH measurements and aid in the detection of the end point of irrigation.

The mark of the dragon

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

BET 1: STEROIDS FOR PATIENTS WITH VESTIBULAR NEURONITIS

BET 2: ECCENTRIC EXERCISE IN THE TREATMENT OF ACHILLES TENDINOPATHY

BET 3: DO BUCKLE FRACTURES OF THE PAEDIATRIC WRIST REQUIRE FOLLOW UP?

BET 4: THE USE OF ULTRASOUND IN THE DIAGNOSIS OF PAEDIATRIC WRIST FRACTURES

The Tough Guy prehospital experience: patterns of injury at a major UK endurance event

Background: Data from mass gathering events help when planning allocation of resources and in setting standards of care. There is currently a lack of data from the UK. Aim: To determine the frequency of injuries and hospital transfer rates at a large outdoor endurance event. Methods: 251 patient attendances from four consecutive events over 2 years (two summers two winters; 2006–2007) were analysed. Results: 1%–2% of contenders required medical help. Hypothermia (n = 84), soft tissue problems (n = 71) and musculoskeletal problems (n = 51) were the most common conditions encountered. 4% of patients required immediate transfer to the hospital. The medical team was able to prevent 31 hospital transfers, which represents a reduction of 78%. 13% of cases specifically required a doctor who was able to prevent more immediate hospital transfers than other care givers. The majority of injuries were classified as minor (n = 228), with the remaining as intermediate (n = 23); there were no life-threatening injuries or deaths. No patient required intravenous fluid. Overall, in winter, more patients were treated when compared with summer (157 vs 94). There were significantly more retirements in winter (69 vs 22, p<0.001), although hospital transfer rates were similar. Conclusions: Medical teams should plan for casualty rates of 1%–2% of competitors and hospital transfer rates of ~5% of patients treated. Outdoor events in winter create more casualties than in summer and require greater resources. Trauma and exposure injuries are common; critical illness is uncommon. An adequately equipped and skilled medical team reduces hospital admissions.

Answers

An evaluation of an educational intervention to reduce inappropriate cannulation and improve cannulation technique by paramedics

Background: Intravenous cannulation enables administration of fluids or drugs by paramedics in prehospital settings. Inappropriate use and poor technique carry risks for patients, including pain and infection. We aimed to investigate the effect of an educational intervention designed to reduce the rate of inappropriate cannulation and to improve cannulation technique. Method: We used a non-randomised control group design, comparing two counties in the East Midlands (UK) as intervention and control areas. The educational intervention was based on Joint Royal Colleges Ambulance Liaison Committee guidance and delivered to paramedic team leaders who cascaded it to their teams. We analysed rates of inappropriate cannulation before and after the intervention using routine clinical data. We also assessed overall cannulation rates before and after the intervention. A sample of paramedics was assessed post-intervention on cannulation technique with a "model" arm using a predesigned checklist. Results: There was a non-significant reduction in inappropriate (no intravenous fluids or drugs given) cannulation rates in the intervention area (1.0% to 0%) compared with the control area (2.5% to 2.6%). There was a significant (p<0.001) reduction in cannulation rates in the intervention area (9.1% to 6.5%; OR 0.7, 95% CI 0.48 to 1.03) compared with an increase in the control area (13.8% to 19.1%; OR 1.47, 95% CI 1.15 to 1.90), a significant difference (p<0.001). Paramedics in the intervention area were significantly more likely to use correct hand-washing techniques post-intervention (74.5% vs. 14.9%; p<0.001). Conclusion: The educational intervention was effective in bringing about changes leading to enhanced quality and safety in some aspects of prehospital cannulation.

Spontaneous intraparenchymal tension pneumocephalus triggered by compulsive forceful nose blowing

The case is described of a 50-year-old man, treated for 10 years in an outpatient psychiatric clinic for an obsessive compulsive disorder, who presented with acute loss of consciousness after forceful nose blowing. A CT scan revealed an intraparenchymal air collection with tension signs in the left frontal lobe and a bone defect in the roof of the ethmoid sinus. After emergency left frontal craniotomy and dura opening, the gaseous collection was evacuated by a ventricular catheter inserted into the brain and the bone defect was repaired with pericranium flap and muscle. The postoperative course was uneventful with neurocognitive improvement and regained motility. Spontaneous tension pneumocephalus is a rare life-threatening condition which is often caused by a bone defect near the tegmen tympani. This case illustrates both an unusual cause and a unique surgical treatment for spontaneous tension intraparenchymal pneumocephalus. It can be a dangerous entity with potential for early mortality and long-term morbidity if not promptly decompressed. The pathogenesis, diagnosis and surgical strategies for spontaneous tension pneumocephalus are briefly discussed.

Bullet embolisation from the right subclavian vein to the right ventricle: a case report

Bullet embolism to the heart is an unusual complication of penetrating gunshot injuries. A bullet may reach the heart by direct cardiac penetration or entry into the peripheral venous system with embolisation to the heart, which must be differentiated. This is a report of an unusual case of bullet embolism to the heart that was extracted by direct cardiotomy without cardiopulmonary bypass.

Subclavian vein thrombosis following clavicular fracture

A very rare case is presented of a woman with subclavian vein thrombosis that resulted from a fragment of her fractured clavicle impinging on the subclavian vein.

Is propofol a safe and effective sedative for relocating hip prostheses?

Original author's response to e-letter

Sophia

Korean HBP Reaction: Seeing is Believing | The Dugout Doctors

Korean HBP Reaction: Seeing is Believing | The Dugout Doctors Watch the video. I look forward to your explanation… Related posts:Dr. Wes: Are Doctors Sheeple? Dr. Wes: Are Doctors Sheeple? …Meanwhile, the politicians and lawyers...Better Health » Some of My Best Friends Are Doctors Better Health » Some of My Best Friends Are Doctors...Doctors Still Talk About [...] Related posts:Dr. Wes: Are Doctors Sheeple? Dr. Wes: Are Doctors Sheeple? …Meanwhile, the politicians and lawyers...Better Health » Some of My Best Friends Are Doctors Better Health » Some of My Best Friends Are Doctors...Doctors Still Talk About ‘The House of God’ Novel – NYTimes.com Doctors Still Talk About ‘The House of God’ Novel –... Related posts brought to you by Yet Another Related Posts Plugin.

Fort Hood Shooting

From the Austin American Statesman: Scott & White in Temple receives 10 patients. By Joshunda Sanders and Steven Kreytak AMERICAN-STATESMAN STAFF Friday, November 06, 2009 The Fort Hood shooting victims were dispersed to hospitals throughout Central Texas, where few details of their injuries or prognoses were released Thursday evening. The first stop for many of those injured [...] Related posts:Fort Worth soldier’s, um, boxers make him famous | Fort Worth | Star-Telegram.com Fort Worth soldier’s, um, boxers make him famous | Fort...You’ve got to be alive to be inconvenienced That’s one of my favorite medical aphorisms, taught to me...‘City of Fort Worth’ debuts at Pima From the Star Telegram: The final B-36 Peacemaker off the... Related posts brought to you by Yet Another Related Posts Plugin.

6,000 dollars a minute for your deceased son in the UC Davis Trauma Center

Wow. Just wow: Hospital bill stuns slain student’s parents By Sam Stanton “It was just devastating and insulting,” Gerald Hawkins said Monday. “It’s just hard to grasp for words. My wife and I were near collapse.” On Saturday, 10 days after Scott Hawkins was beaten to death inside his dormitory at California State University, Sacramento, his parents got a [...] Related posts:Aggravated DocSurg: Four Horsemen of a Trauma Death Aggravated DocSurg: Four Horsemen of a Trauma Death An excellent...Fort Hood Shooting From the Austin American Statesman: Scott & White in Temple...Doctor’s death ‘tremendous loss’ for UTHSC Doctor’s death ‘tremendous loss’ for UTHSC Dr. Michael Sanchez, who... Related posts brought to you by Yet Another Related Posts Plugin.

Todays’ Words of Wisdom

Try never to alienate someone who can give you a kidney. Related posts:Wisdom from the wide, weird world of the emergency room… at edwinleap.com Wisdom from the wide, weird world of the emergency room…...Words fail « Dr. Ottematic Words fail « Dr. Ottematic This past week, I got... Related posts brought to you by Yet Another Related [...] Related posts:Wisdom from the wide, weird world of the emergency room… at edwinleap.com Wisdom from the wide, weird world of the emergency room…...Words fail « Dr. Ottematic Words fail « Dr. Ottematic This past week, I got... Related posts brought to you by Yet Another Related Posts Plugin.

Bumped: Project Valour-IT Today through November 11th

Bumped to the top. Still a good idea. Give Here. Pick any team (but I’m on the Marine team…) Here’s a worthy project, supporting wounded troops with technology to help their recovery. Soldiers’ Angels has been running this for at least the past 3 years (and somehow I didn’t participate last year, for which I am duly [...] Related posts:A commotio cordis survivor NORTH RICHLAND HILLS — Austin Miller has no memory of...Addicted to Medblogs: Dr. November is . . . Dr. Anonymous Addicted to Medblogs: Dr. November is . . . Dr....You’ve got to be alive to be inconvenienced That’s one of my favorite medical aphorisms, taught to me... Related posts brought to you by Yet Another Related Posts Plugin.

Tulane surgeon stabbed to death in French Quarter home that was set fire

By Ramon Antonio Vargas, The Times-Picayune October 31, 2009, 4:50PM A Tulane University plastic surgeon — known for healing the disfigured limbs and facial features of trauma victims and skin cancer patients with his scalpel — was knifed to death inside of his French Quarter home early Saturday. An arsonist then lit his home on fire [...] Related posts:Aggravated DocSurg: Four Horsemen of a Trauma Death Aggravated DocSurg: Four Horsemen of a Trauma Death An excellent...Doctor’s death ‘tremendous loss’ for UTHSC Doctor’s death ‘tremendous loss’ for UTHSC Dr. Michael Sanchez, who...Sudden cardiac death in a teen athlete prevented with AED (and a smart team) Sudden cardiac death prevented: Coaches, trainer honored for saving teen... Related posts brought to you by Yet Another Related Posts Plugin.

CNN Political Ticker: Senate confirms Benjamin as surgeon general

CNN Political Ticker: All politics, all the time Blog Archive – Senate confirms Benjamin as surgeon general « – Blogs from CNN.com Posted: October 30th, 2009 10:13 AM ET WASHINGTON (CNN) – The Senate has formally confirmed Dr. Regina Benjamin to be the U.S. surgeon general, making her only the third African American to hold the position [...] Related posts:Better Health » What Does The Surgeon General Do? Better Health » What Does The Surgeon General Do? Dr....Senate Democrats Opt for Regressive Mandates – James C. Capretta – The Corner on National Review Online The Corner seems unhappy with the latest bill to be...Tulane surgeon stabbed to death in French Quarter home that was set fire By Ramon Antonio Vargas, The Times-Picayune October 31, 2009,... Related posts brought to you by Yet Another Related Posts Plugin.

Tim Schickedanz Day

It’s October 31st, 2009, and it’s officially Tim Schickedanz Day in Saginaw, TX. Well deserved, unfortunately it’s Posthumous. I was fortunate enough to know Tim for about eight years, as a nurse in our ED. Hard working, friendly, funny and competent, we were nearly instant work-friends due to our military backgrounds. We weren’t really close, [...] Related posts:The Family I didn’t think existed I take care of a of of patients with dialysis. ...Another Horrible ED Sign The patient with a Loving Family, a Job, Good Insurance...Better Health » Some of My Best Friends Are Doctors Better Health » Some of My Best Friends Are Doctors... Related posts brought to you by Yet Another Related Posts Plugin.

Do not text while driving

Seems very simple: concentrate on what you’re doing, and you lessen (but not eliminate) the risk of car crash. How much higher is the risk of accidents from texting? Twenty Three times, that’s how much (VTTI, .pdf). That’s just not worth the risk. Unfortunately, apparently it’s hard to resist… Related posts:BBC NEWS | Health | Steaming hot tea [...] Related posts:BBC NEWS | Health | Steaming hot tea linked to cancer From the ‘life causes cancer’ files: BBC NEWS | Health...State Helicopters Are Flying Much Less After Fatal Crash in Pr. George’s – washingtonpost.com State Helicopters Are Flying Much Less After Fatal Crash in... Related posts brought to you by Yet Another Related Posts Plugin.

Locked iPhone ICE information: an App to fix

Recently I asked if people were still putting ICE (In Case of Emergency) information in their cellphones. (The surprising answer was yes, showing that it’s an idea that resonates, at least with my audience). I lamented that I have that information in my iPhone, but since it’s passcoded no rescuer would be able to access my [...] Related posts:iPhone display of this blog I have installed a plugin for WordPress that displays the...iPhone Medical App Review iPhone Medical App Review is a new site that reviews...iPhone weirdness, ATT & wrong numbers I’m throwing this out there hoping someone has a solution.... Related posts brought to you by Yet Another Related Posts Plugin.

Risk of Bacterial or Herpes Simplex Virus Meningitis/Encephalitis in Children With Complex Febrile Seizures

Objective: To estimate the rates of bacterial meningitis and herpes simplex virus (HSV) encephalitis in children presenting with complex febrile seizures. Methods: Health records from 2002 to 2006 of all children 6 months to 6 years with a discharge diagnosis from the Hospital for Sick Children (Toronto, ON) of febrile convulsion, meningitis, or encephalitis were reviewed. Rates of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures were calculated. Results: There were 390 encounters of complex febrile seizures in 366 children. Of these encounters, 75 (19%) were transferred from an outlying hospital. A history of febrile convulsions was noted in 140 (36%). Lumbar puncture was performed in 146 (37%) patients. Six patients (all but one transferred) were diagnosed with bacterial meningitis (all due to Streptococcus pneumoniae). One transferred patient was diagnosed with HSV encephalitis. In patients initially presenting to our emergency department the rates of bacterial meningitis and HSV encephalitis were 0.3% (95% confidence interval, 0.0-1.8) and 0.0% (95% confidence interval, 0.0-1.2), respectively. Conclusions: Given the low rate of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures, routine lumbar puncture in these patients may be unnecessary. (C) 2009 Lippincott Williams & Wilkins, Inc.

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.

Atypical Presentation of Henoch-Schonlein Purpura

Henoch-Schonlein purpura (HSP) is the most common form of vasculitis found in the pediatric population. The most common presenting complaint for children with HSP is a purpuric rash on the lower extremities. Many other organ systems beyond the skin can be involved for children with HSP. We report a case of a 7-year-old girl with HSP who presented with status epilepticus and onset of rash 2 weeks after her initial symptoms. (C) 2009 Lippincott Williams & Wilkins, Inc.

Ipratropium Bromide for Acute Asthma Exacerbations in the Emergency Setting: A Literature Review of the Evidence

Since the 1970s, when inhaled anticholinergic agents were first introduced as adjunct therapies for the immediate treatment of pediatric asthma exacerbations, several trials have shown varying degrees of benefit from their use as bronchodilators in combination with inhaled short-acting [beta]-adrenergic agonists and systemic corticosteroids. Although other anticholinergics exist, ipratropium bromide (IB) specifically has emerged as the overwhelming choice of pulmonologists and emergency physicians because of its limited systemic absorption from the lungs when given as an inhaled preparation. However, although the varying trials, predominantly in the emergency department setting, have typically shown a trend toward improved outcomes, none has set forth clear dosing protocol recommendations for use by practicing physicians. It is our goal in this review of the available literature on the use of IB, as an adjunct to inhaled short-acting [beta]-adrenergic agonists, to summarize practical, evidence-based recommendations for use in the pediatric emergency department setting for acute asthma exacerbations. We also hope to better delineate the most effective dosing regimen in those patients who might benefit most from the addition of IB and to explore proposed additional benefits it may have as a modulator of cholinergic-induced effects from high-dose [beta]-agonist therapy and viral triggers. (C) 2009 Lippincott Williams & Wilkins, Inc.

Conservative Treatment of Stable Volar Plate Injuries of the Proximal Interphalangeal Joint in Children and Adolescents: A Prospective Study

Objectives: The purpose of this study was to assess a standard conservative management for stable volar plate injuries of the proximal interphalangeal joint in children and adolescents. No study is available regarding this subject for this age group. Methods: A prospective study was performed on 37 consecutive patients (aged between 9 and 15 years; mean, 13 years) with stable acute volar plate injuries of the proximal interphalangeal joints, including 22 avulsion fractures without dislocation. All patients had a standardized conservative treatment consisting of a dorsal aluminum extension block splinting at a 15-degree flexion for 10 days, followed by a spontaneous mobilization and taping to adjacent fingers for sports only. At follow-up visits, active and passive ranges of motion, swelling of the affected joints, analgesic intake, and pain perception by the patient were recorded. Regular follow-up consisted of standardized assessments at 2, 6, and 12 weeks, with additional consultations if symptoms persisted. Results: Healing was uneventful, and hand therapy was not necessary to regain full range of motion in 32 of 33 children with a regular follow-up. The only flexion contracture observed responded well to splinting. Of the 33 patients, 31 had an excellent outcome and 2 had a good outcome. Conclusions: Dorsal extension block splinting was an efficient, simple, well-tolerated treatment for stable volar plate injuries of the proximal interphalangeal joint in a preliminary series of patients younger 16 years. Flexion contractures were rare and responded well to dynamic splinting. (C) 2009 Lippincott Williams & Wilkins, Inc.

Fever, Cough, and Abdominal Pain

No abstract available

Pediatric Ingestions of Hand Sanitizers: Debunking the Myth

Objective: Poison centers frequently receive calls concerning children who are exposed to hand sanitizers. These exposures can occur while the product is being used correctly or when a child has unsupervised access to the container. In 2007, the use of ethanol-containing hand sanitizers in the pediatric population came under media scrutiny owing to an Internet urban legend that resulted in a greater awareness of the potential toxicity of these sanitizers based on their high ethanol content. Methods: A retrospective review of all exposures to hand sanitizers in children younger than 6 years reported to a regional poison information center from January 1, 2000 to March 30, 2007 was performed. Data reviewed included substance, age, sex, and outcome. Data were analyzed using descriptive statistics. Results: Six hundred forty-seven cases were identified including 324 females and 323 males. Ages ranged from 1 month to 5 years with a mean of 1.89 years and a median of 2 years. Outcome data included 31 patients (4.8%) with no effect, 26 (4%) with a minor effect, 372 cases (57.5%) coded as nontoxic - expect no effect, 208 cases (32.1%) with minimal clinical effects possible, and 10 cases (1.6%) where the symptoms were judged to be unrelated to the exposure. There were no moderate or major outcomes and no fatalities. Conclusions: Children in this age group have frequent hand-to-mouth activity and environmental curiosity making the application or availability of a hand sanitizer the perfect situation for an exposure to occur. Although ethanol-based hand sanitizers have the potential to cause toxicity, the benefits of prevention of illness outweigh the hazards when used in a supervised situation. (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.

Effectiveness of Fever Education in a Pediatric Emergency Department

Objective: This study was designed to assess the impact of a brief educational video shown to parents during an emergency department visit for minor febrile illnesses. We hypothesized that a video about home management of fever would reduce medically unnecessary return emergency department visits for future febrile episodes. Methods: A convenience sample of 280 caregivers presenting to one urban pediatric emergency department was enrolled in this prospective, randomized cohort study. All the caregivers presented with a child aged 3 to 36 months with complaint of fever and were independently triaged as nonemergent. A pretest and posttest were administered to assess baseline knowledge and attitudes about fever. One hundred forty subjects were randomized to view either an 11-minute video about home management of fever or a control video about child safety. Subjects were tracked prospectively, and all return visits for fever complaints were independently reviewed by 3 pediatric emergency physicians to determine medical necessity. Results: There were no differences between the fever video and the control groups in baseline demographics (eg, demographically comparable). The fever video group had a significant improvement in several measures relating to knowledge and attitudes about childhood fever. There was no statistical difference between the intervention and control groups in subsequent return visits or in the determination of medical necessity. Conclusions: A brief standardized video about home management of fever improved caregiver knowledge of fever but did not decrease emergency department use or increase medical necessity for subsequent febrile episodes. (C) 2009 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.

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

No abstract available

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.

The Red Reflex

colon; Eliciting the red reflex is a useful clinical test that can be easily performed in the pediatric emergency room. A direct ophthalmoscope is the only tool needed to perform this test. The test is non-invasive, making it a quick screening tool for even the most apprehensive child. A normal red reflex can rule out intraocular pathology; an abnormal reflex can indicate need for urgent ophthalmologic referral. The differential diagnoses for an absent (or black) reflex; an abnormally sized, shaped or positioned reflex; leukocoria; as well as a non-homogenous reflex are listed. (C) 2006 Lippincott Williams & Wilkins, Inc.

Update on Sexually Transmitted Infections, 2008

Sexually transmitted infections (STIs) continue to be a great concern in the adolescent population and of particular concern to the pediatric emergency medicine physician. The Centers for Disease Control and Prevention reports that rates of gonorrheal and chlamydial infections are greatest in female adolescents, aged 15 to 19 years, and many people acquire human papilloma virus and human immunodeficiency virus infections during their teenage years. Adolescents continue to be at a higher risk for acquiring STIs because of multiple factors, including being more biologically susceptible, more likely to engage in unprotected sex with multiple partners, as well as facing various obstacles to their use of the health care system. The pediatric emergency medicine physician must be aware of the various presentations of STIs in their patients, as well as how to adequately treat and offer counseling to this vulnerable population. (C) 2009 Lippincott Williams & Wilkins, Inc.

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.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Consequence of Treatment of an Emerging Pathogen

We report a case of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) secondary to trimethoprim-sulfamethoxazole (TMP-Sx) therapy for presumed community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection. Although the association between SJS/TEN and the sulfonamide class of antibiotics is well established, the increasing prevalence of CA-MRSA has left practitioners with limited regimens to effectively treat skin and soft tissue infections (SSTIs) in the outpatient setting. In the case of SSTIs, alternative treatment of these infections should be considered, especially when the bacterial pathogen is unknown. Future investigations evaluating the efficacy of adjunctive antibiotics for purulent SSTIs and monitoring the incidence of SJS/TEN in the era of CA-MRSA are necessary to reduce unnecessary use of sulfonamide drugs. The potential development of SJS/TEN, a severe life-threatening illness, emphasizes the need for judicious use of TMP-Sx and close monitoring and follow-up for patients who were given TMP-Sx for SSTIs. (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.

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.

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.

Subgaleal Hematoma Secondary to Hair Braiding in a 31-Month-Old Child

A 31-month-old African American girl who presented with subgaleal hematoma (SGH) a day after having her hair braided. This hematoma was managed conservatively with resolution in 2 weeks. Subgaleal hematoma secondary to hair braiding is very uncommon. Being aware that hair braiding is a potential cause of SGH is very important so as to avoid unnecessary investigations, interventions, and reports to child protective services. A review of the literature, potential complications, and management of SGH has been described here. (C) 2009 Lippincott Williams & Wilkins, Inc.

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.

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.

Swollen and painful left testicle

No abstract available

Hematoma of the Labia Majora in an Adolescent Girl

This is a case report of a 19-year-old woman who presented with a large hematoma of her labia majora after consensual sexual intercourse that required surgical intervention. To our knowledge, this is the first case report of such an entity. The following is a summary of the patient's clinical presentation and management, as well as a review of the literature regarding genital injuries in adolescent girls. (C) 2007 Lippincott Williams & Wilkins, Inc.

Factors Associated With Longer Emergency Department Length of Stay for Children With Bronchiolitis: A Prospective Multicenter Study

Objectives: Emergency department (ED) length of stay (LOS) is a quality of care measure and, when prolonged, contributes to ED crowding. Bronchiolitis, a common seasonal illness of infants, provides an opportunity to examine factors affecting ED LOS. Methods: We analyzed data from a 30-center prospective cohort study of ED patients younger than 2 years with an attending physician diagnosis of bronchiolitis to determine what factors affect LOS. Researchers conducted a structured interview and chart review. Results: Among 1459 children enrolled, ED LOS was available for 1416 children (97%). The median ED LOS was 3.3 hours (interquartile range, 2.3-4.8 hours). Multivariate analysis demonstrated that factors significantly (P =62,421 [[beta] = 0.63]), Hispanic race/ethnicity (reference, white race, [beta] = 1.43), lack of primary care provider ([beta] = 1.28), duration of symptoms of 4 to 7 days (reference, <1 day; [beta] = 0.58), presentation of midnight to 7 am (reference, 4:00-11:59 pm; [beta] = 1.07), decreasing lowest oxygen saturation in ED ([beta] = 0.07), fewer number of [beta]-agonists during the first hour ([beta] = 0.74), unknown oral intake (reference, adequate; [beta] = 0.69), performance of chest x-ray ([beta] = 0.62), and hospital admission ([beta] = 1.11). Conclusions: In this prospective multicenter study of children younger than 2 years with bronchiolitis, multiple factors were associated with longer ED LOS. These factors suggest the following steps to help shorten ED LOS: optimizing translation services, improving primary care provider rates, enhancing overnight patient flow, forgoing chest x-rays, and developing evidence-based admission criteria. (C) 2009 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.

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.

Comparison of the Temporal Artery and Rectal Thermometry in Children in the Emergency Department

Objective: Rectal thermometry, the criterion standard of temperature measurement in young children, has numerous disadvantages. This study examined the agreement between rectal versus a new temporal artery professional model (TAPM) thermometer and rectal versus a home device temporal artery consumer model (TACM) thermometer, investigated if the TAPM can safely screen for rectal fever, and determined if parents can detect rectal fever using the TACM. Design, Outcome Measures, and Subjects: In this cross-sectional agreement emergency department study, 327 children =38.0[degrees]C and >=38.3[degrees]C with sensitivities of >=90% and >=95%, respectively, was determined for the TAPM. Results: The mean difference between the rectal minus TAPM was -0.19[degrees]C +/- 0.66[degrees]C, and minus the TACM home device, it was +0.11[degrees]C +/- 0.66[degrees]C. The sensitivities of TAPM temperature of >=37.7[degrees]C to detect rectal fever >=38.0[degrees]C and >=38.3[degrees]C were 90% (95% confidence interval: 0.83; 0.94) and 97% (95% confidence interval: 0.92; 0.99), respectively. The parents detected 67% and 73% of rectal fevers 38.0[degrees]C and >=38.3[degrees]C, respectively. Conclusions: The TAPM thermometer cannot replace the rectal. However, TAPM temperature of =38.3[degrees]C in infants 3 to 24 months of age. The TACM home device has insufficient ability to detect rectal fever. A multicenter trial is needed to validate these results across multiple emergency departments and numerous observers. (C) 2004 Lippincott Williams & Wilkins, Inc.

A Transatlantic Caterpillar

Background: Saddleback caterpillar sting has been very rarely reported in European countries. We report a French case of a stung toddler. Case: A 2-year-old girl was brought to the pediatric emergency department after being stung by a caterpillar in a furniture store. The emergency department physical examination revealed an inflammatory edema of the stung finger, normal vital signs, and no fever. Three hours after presentation, she was discharged with local ointment prescription. The caterpillar brought in by the parents was unusual compared to common French caterpillar species. The regional poison center was unable to identify it. With the help of the Internet, we succeeded in its identification as a saddleback caterpillar. Tracing its transatlantic importation was the most difficult. Conclusions: Saddleback caterpillars can be imported to France and carried across the Atlantic Ocean on house or garden plants especially Areca trees. French garden store owners should be informed about this risk and should check and treat host plants (especially Areca trees) at the arrival time. (C) 2009 Lippincott Williams & Wilkins, Inc.

Dacryocystitis: Diagnosis and Initial Management in Pediatric Emergency Medicine

Complications of dacryocystoceles can be life-threatening in neonates. Dacryocystitis is a common complication of dacryocystoceles. The following case report illustrates the clinical characteristics of dacryocystitis in a 4-day-old infant. The pathophysiology, associated anatomical abnormalities, differential diagnosis, complications, and management of dacryocystoceles are reviewed. (C) 2009 Lippincott Williams & Wilkins, Inc.

Pain Management Practices in a Pediatric Emergency Room (PAMPER) Study: Interventions With Nurses

Background and Aim: Children's pain in emergency departments (EDs) is poorly managed by nurses, despite evidence that pain is one of the most commonly presenting complaints of children attending the ED. Our objectives were 2-fold: to verify if tailored educational interventions with emergency pediatric nurses would improve nurses' knowledge of pain management and nurses' pain management practices (documentation of pain, administration of analgesics, nonpharmacological interventions). Methods: This intervention study with a pre-post design (baseline, immediately after the intervention [T-2], and 6 months after intervention [T-3]) used a sample of nurses (N = 50) and retrospective chart reviews of children (N = 450; 150 charts reviewed each at baseline, T-2, and T-3) who presented themselves in the ED with a diagnosis known to generate moderate to severe pain (burns, acute abdominal pain, deep lacerations, fracture, sprain). Principal outcomes: nurses' knowledge of pain management (Pediatric Nurses Knowledge and Attitudes Survey [PNKAS] on pain) and nurses' clinical practices of pain management (Pain Management Experience Evaluation [PMEE]). Results: Response rate on the PNKAS was 84% (42/50) at baseline and 50% (21/42) at T-2. Mean scores on PNKAS were 28.2 (SD, 4.9; max, 42.0) at baseline and 31.0 (SD, 4.6) at T-2. Results from paired t test showed significant difference between both times (t = -3.129, P = 0.005). Nurses who participated in the capsules improved their documentation of pain from baseline (59.3%) to T-2 (80.8%; [chi]2 = 12.993, P < 0.001) as well as from baseline (59.3%) to T-3 (89.1%; [chi]2 = 29.436, P < 0.001). In addition, nurses increased their nonpharmacological interventions from baseline (16.7%) to T-3 (31.9%; [chi]2 = 8.623, P = 0.003). Finally, we obtained significant differences on pain documentation between the group of nurses who attended at least 1 capsule and the group of nurses who did not attend any capsule at both times (T-2 and T-3; [chi]2 = 20.424, P < 0.001; [chi]2 = 33.333, P < 0.001, respectively). Conclusions: The interventions contributed to the improvement of the nurses' knowledge of pain management and some of the practices over time. We believe that an intervention tailored to nurses' needs and schedule has more impact than just passive diffusion of educational content. (C) 2009 Lippincott Williams & Wilkins, Inc.

The state of pediatric interfacility transport: Consensus of the Second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference

Interfacility transport of pediatric and neonatal patients for advanced or specialty medical care is an integral part of our medical delivery system. Assessment of current services and planning for the future are imperative. As part of this process, the American Academy of Pediatrics and the Section on Transport Medicine held the second National Pediatric and Neonatal Transport Leadership Conference in Chicago in June 2000. Ninety-nine total participants, representing 25 states and 5 international locations, debated and discussed issues relevant to the developing specialty of pediatric transport medicine. These topics included: 1) the role of the medical director, 2) benchmarking of neonatal and pediatric transport programs, 3) clinical research, 4) accreditation, 5) team configuration, 6) economics of transport medicine in health care delivery, 7) justification of transport teams in institutions, and 8) international transport/extracurricular transport opportunities. Insights and conclusions from this meeting of transport leaders are presented in the consensus statement. (C) 2002 Lippincott Williams & Wilkins, Inc.

Pediatric Emergency Medicine Fellowship Research Curriculum: A Survey of Fellowship Directors

Objective: To determine how pediatric emergency medicine (PEM) fellowship directors organize research training and to identify factors believed to be associated with successful research training. Methods: A 16-question survey study of PEM fellowship directors. Results: Of the 58 fellowship directors surveyed, 39 (67%) responded. Of 38 programs, PEM faculty from 20 (53%) served as research mentors for PEM fellows. The mean percentage of PEM faculty who had performed peer-review funded research was 26%. The mean number of trainee research months was 10.9 for 3 years. Of these research months, 93% were not protected (included clinical work hours). Only 5 programs provided some completely protected research months (months without any clinical work hours), and none of these were scheduled in blocks of greater than 3 consecutive months. Most (56%) of these research months were scheduled during the third year of training. The most likely explanations of the fellow successfully becoming research competent were eagerness to apply self and number of research months during training. Least likely explanations were faculty with peer-reviewed funded grants and blocks of research time. Thirty-five fellowship directors (90%) believed that upon completion of the training, their fellows would be research competent. Conclusions: Besides the fellow's eagerness to apply self, scheduling adequate time for research was reported as a highly important factor in achieving research competency among PEM fellows. Providing protected (no clinical responsibilities) research months to fellows and arranging more opportunities for PEM faculty to serve as research mentors may maintain or possibly improve the likelihood of PEM fellows to becoming research competent. (C) 2009 Lippincott Williams & Wilkins, Inc.

Recognition of "Plastic Bronchitis" in the Emergency Department

No abstract available

Traumatic Epidural Hematomas in Children and Adolescents: Outcome Analysis in 39 Consecutive Unselected Cases

Objective: Despite early diagnosis of traumatic epidural hematomas (EDHs) in children, mortality remained quite high in recent series. The aims of this analysis were to review the cause and outcome of pediatric EDH nowadays and to discuss outcome-related variables in a large consecutive series of surgically treated EDH in children. Methods: This is a retrospective case series of 39 patients (27 males, 69%) with surgically treated EDH between June 1997 and February 2007. Patients' medical records, computed tomographic scans, and, if performed, magnetic resonance imagings were reviewed to define variables associated with outcome. Variables included in the analysis were age, associated severe extracranial injury, abnormal pupillary response, hematoma thickness, severity of head injury (Glasgow Coma Scale score <= 8), parenchymal brain injury, and diffuse axonal injury. Long-term follow-up (mean [SD], 51.3 [27] months) was available in 38 patients, and outcomes were classified as excellent (modified Rankin Scale score [mRS], 0; Glasgow Outcome Scale score, 5) and good (mRS scores, 1 and 2; Glasgow Outcome Scale score, 4). Results: The mean (SD) age of the patients was 83.1 (59.9) months (range, 1-191 months). The mortality was zero, and the outcomes were excellent in 34 and good in 4 patients (one was lost to follow-up). Most of the injuries with EDH occurred in familial settings (23 cases), with falls being the most common mechanism of injury in 20 patients. Trauma was caused by traffic accidents in 14 cases (pedestrians hit by a motor vehicle, 7 cases; bicycle accidents, 5 cases; and motorbike and car accidents, 1 case each). One EDH occurred during delivery. The mean size of the EDH was 18.5 (12) mm (range, 5-40 mm). Three patients were referred with unilateral or bilateral dilated pupil(s). Except in 4 patients, all EDHs were associated with skull fracture(s) (90%). Computed tomography or magnetic resonance imaging revealed brain contusion in 13 patients, and 1 had diffuse axonal injury. None of the tested variables were found to have a prognostic relevance as tested by multivariate analysis (backward exclusion, Wald method). Conclusions: Regardless of the EDH size, the clinical status of the patients, the abnormal pupillary findings, or the cause of injury, the outcome and prognosis of the patients with EDH are excellent. (C) 2009 Lippincott Williams & Wilkins, Inc.

Severe hypernatremic dehydration and death in a breast-fed infant

Breast milk is acknowledged as the best source of nutrition for neonates. We present the case of a full-term newborn who was fed solely breast milk and developed severe dehydration and hypernatremia. The patient developed cerebral edema, transverse sinus thrombosis, and died. The literature on the uncommon entity of breast-feeding hypernatremia and dehydration is reviewed, and management strategies are presented. (C) 2001 Lippincott Williams & Wilkins, Inc.

Intraosseous Infusion: A Review of Methods and Novel Devices

Glass Thermometer Injuries: It Is Not Just About the Mercury

Background: Glass mercury thermometers were once used as the criterion standard for measuring core body temperature. Once broken, however, there is the dual hazard of broken glass and exposure to mercury. Previous studies have focused only on the mercury hazard rather than injuries related to thermometer glass. Objective: To identify injury patterns from glass thermometers, including glass-related injury and mercury exposure. Methods: We performed a retrospective cohort study of glass thermometer-related injuries in children evaluated in a pediatric emergency department between October 1995 and October 2007. Case identification was performed using a computer-assisted screening tool followed by a manual chart review. Collected data included age, sex, injury characteristics, physical examination findings, radiologic imaging, interventions, and disposition. To analyze injury rates during these years, we used a multiplicative Poisson model allowing for varying exposures. Results: Thirty-three patients were identified among 627,592 who presented to the emergency department during the study period. Approximately 1 to 6 patients presented every year, including 3 patients in 2007. Decline in injury incidence is less than 9% per year (P = 0.041). Median patient age was 2.4 years (interquartile range, 0.4-3.8 years); 12 patients (36%) were female. Twenty-two patients (66%) underwent radiologic imaging to identify potential foreign body (21 underwent radiography and 1 underwent computed tomographic scanning). There were 15 mouth injuries (45%), 13 anal injuries (39%), and 1 ear injury. Glass was identified by imaging in 5 patients (15%) and by sigmoidoscopic evaluation in 1 patient (3%). Mercury exposure was identified in 14 patients (42%). Conclusions: Persistent use of glass mercury thermometers has resulted in pediatric injury especially in children younger than 4 years. We reported the different mechanisms of injury with the hope of eliminating its use and reinforcing the use of alternative thermometers. (C) 2009 Lippincott Williams & Wilkins, Inc.

Embedded Earrings in Children

Objectives: The objectives of this study were: (1) to determine the incidence of embedded earrings as a chief complaint among children presenting to a pediatric emergency department (ED), (2) to describe the age distribution of children presenting to the ED with embedded earrings, and (3) to describe local experience with the evaluation and treatment of these children. Methods: We performed a retrospective chart review at Cincinnati Children's Hospital Medical Center ED for children presenting with a chief complaint of an embedded earring from 2000 to 2005. Demographic data, removal technique, presence of infection, and antibiotic administration were recorded. Results: A total of 100 patients met criteria for inclusion in the study. The overall incidence was 25 per 100,000 patient visits. Most of the patients were girls (n = 81) with a median age of 8 years. Sixty percent of the cohort were younger than 10 years. Locations for embedded earrings included: lobule (n = 87), tragus (n = 2), and pinna (n = 11), with the majority having the posterior portion of the earring embedded (n = 68). Thirty-five percent of the patients had an infection at the embedded earring site. Local anesthesia was used in the most of the patients (n = 72); none required procedural sedation. Conclusions: Embedded earring is an uncommon complaint among children presenting to a pediatric ED. Young children are likely overrepresented in the occurrence of this problem, which supports the American Academy of Pediatrics recommendation to postpone ear piercing until self-care is achievable. (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.

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.

Initial Base Deficit as Predictors for Mortality and Transfusion Requirement in the Severe Pediatric Trauma Except Brain Injury

Objective: The initial base deficit (BD) is an important indicator of shock in adult trauma patients, but its value is unclear in pediatric trauma patients. This study assessed the ability of the initial BD to predict mortality and blood transfusion requirements in children except severe brain injury patients. Methods: This study was a retrospective review of pediatric patients with severe trauma arriving at the emergency department of a university hospital from January 1998 to June 2005. Blood pressure, the initial BD, and the Injury Severity Score were assessed as independent predictors of mortality and the blood transfusion requirement using multiple regression analysis. Results: The study group constituted 102 patients. According to the multiple regression analysis results, the initial systolic blood pressure, Injury Severity Score, and blood transfusion requirement were not independent predictors of mortality (P = 0.104, 0.959, 0.386, respectively). By contrast, the initial BD was an independent predictor, with an odds ratio of 13.6 for BD of -8 mEq/L or less (confidence interval [CI], 3.51-35.23, P = 0.037), and systolic blood pressure and BD were independent predictors of blood transfusion requirement; the odds ratio for hypotension was 3.2 (CI, 0.51-8.32, P = 0.044), and the odds ratio was 15.3 for BD values of -8 or less (CI, 2.24-51.43, P = 0.003). Conclusion: The initial BD in pediatric trauma patients except severe brain injury was an independent predictor of mortality and blood transfusion requirement within 24 hours. Mortality and blood transfusion requirement were significantly high when initial BD was less than -8 mEq/L. (C) 2009 Lippincott Williams & Wilkins, Inc.

An Uncommon Cause of Throat Pain

Throat pain is a common presenting complaint in the pediatric emergency department and often occurs secondary to non-life-threatening conditions. Certain etiologies may initially appear benign, but if not recognized and treated, may result in airway compromise. Patients with blunt trauma to the neck may present with throat pain. This is an uncommon pediatric injury usually due to a sharp blow to the anterior neck. This injury is rarely seen in isolation. We present a case of laryngeal injury due to blunt trauma to the neck. This case illustrates the potentially serious consequence after an apparently minor traumatic injury. (C) 2009 Lippincott Williams & Wilkins, Inc.

Signs and Symptoms of Cerebrospinal Fluid Shunt Malfunction in the Pediatric Emergency Department

Objectives: Pediatric patients with cerebrospinal fluid shunts frequently present to the emergency department for evaluation of possible shunt malfunction. Most shunt studies appear in the neurosurgical literature. To our knowledge, none have reviewed presenting signs and symptoms of shunt malfunction in patients who present to the pediatric emergency department. The study objective was to evaluate the medical record of children with cerebrospinal fluid shunts who presented to a pediatric emergency department to determine if any signs and/or symptoms were predictive of shunt malfunction. Methods: A retrospective chart review was conducted on 352 pediatric patients aged 0 to 18 years, who presented to the pediatric emergency department between January 1, 1998, and December 31, 2002, with signs and/or symptoms that prompted an evaluation for possible shunt malfunction. Results: Univariate analysis of all signs and symptoms revealed lethargy (odds ratio, 1.99; 95% confidence interval, 1.15-3.42; P = 0.02) and shunt site swelling (odds ratio, 2.56, 95% confidence interval, 1.08-6.07, P = 0.03) to be significantly predictive of shunt malfunction. Logistic regression analysis continued to show significance for lethargy (odds ratio, 2.20; bias-corrected 95% confidence interval, 1.11-3.63) and shunt site swelling (odds ratio, 3.10; bias-corrected 95% confidence interval, 1.38-9.05), but found no other study variable to be significant. Bootstrap resampling validated the importance of the significant variables identified in the regression analysis. Conclusions: In this study, lethargy and shunt site swelling were predictive of shunt malfunction. Other signs and symptoms studied did not reach statistical significance; however, one must maintain a high index of suspicion when evaluating children with an intracranial shunt because the presentation of malfunction is widely varied. A missed diagnosis can result in permanent neurological sequelae or even death. (C) 2006 Lippincott Williams & Wilkins, Inc.

Tarsometatarsal Injury in a Child

Tarsometatarsal joint injuries are well described in adults. In children, these injuries have been less described and have been reported only as small case series. They frequently go unrecognized in children because of skeletal immaturity and lack of awareness among health care providers. However, these injuries if untreated can result in significant pain and deformity in children. It is important that treating physicians recognize the symptoms and signs of these injuries and initiate further diagnostic workup, especially when there is persistent foot pain in the absence of radiographic signs of a fracture. We present a case of an 11-month-old female infant who presented with foot pain after a fall. (C) 2009 Lippincott Williams & Wilkins, Inc.

Comparison of Methohexital and Pentobarbital as Sedative Agents for Pediatric Emergency Department Patients for Computed Tomography

Objectives: To determine if there are differences in the duration of sedation between pediatric emergency department (PED) patients receiving methohexital and PED patients receiving pentobarbital for the purpose of obtaining a head computed tomographic (CT) scan. Methods: Retrospective cohort study of PED patients receiving either methohexital or pentobarbital for a sedated head CT. Data were collected on patient demographics and medical condition, indications for head CT, duration of sedation, medication dosage, and medication adverse events. Primary analyses investigated whether there were differences between the 2 groups. Secondary analysis determined whether the need for additional sedative doses contributed to observed differences between groups. Results: The patients receiving methohexital completed their head CT more quickly and needed less total sedation monitoring than those receiving pentobarbital. The need for additional doses of medication does not appear to be responsible for the observed difference. Adverse medication events were minor and comparable between groups. Conclusions: Methohexital may be superior to pentobarbital for the purpose of sedating PED patients for head CT. (C) 2009 Lippincott Williams & Wilkins, Inc.

A Genital Hair Tourniquet in a 9-Year-Old Girl

The hair tourniquet is a well-described phenomenon. Typically, a hair or filament becomes tightly wrapped around an appendage, thereby causing swelling, pain, and, in extreme cases, necrosis. Affected areas include fingers, toes, and the genitalia. A case of a 9-year-old girl with a clitoral hair tourniquet is described, and a review of the literature of genital tourniquets in females is presented, with a discussion about potential etiology. The hair-thread tourniquet syndrome is a disease in which a hair or filament becomes wrapped around an end-perfusion appendage, thereby limiting adequate venous and lymphatic drainage of that tissue. This results in hyperemia, swelling and pain. If uncorrected, edema and interstitial pressures may increase to prevent adequate vascular supply, and the affected area can progress to necrosis. We are classically taught that this syndrome primarily affects the fingers, toes, and infantile penis and is an important consideration in the differential diagnosis of the colicky infant. The author presents a case of a prepubescent girl with a genital hair tourniquet. (C) 2007 Lippincott Williams & Wilkins, Inc.

Chlamydia Pneumonia Mimicking Miliary Tuberculosis

Chlamydia trachomatis is a common cause of subacute, afebrile pneumonia with onset from 1 to 3 months of age. On physical examination, crepitant inspiratory rales are commonly heard. Infiltration is usually bilateral and interstitial; reticulonodular pattern and atelectasis have also been described, which distinct the disease from miliary tuberculosis. We report an infant who had a disseminated miliary pattern in the chest radiograph and computed tomographic scan of the thorax that was diagnosed as Chlamydia pneumonia with serologic investigations. We emphasized that Chlamydia trachomatis can cause a miliary reticulonodular pattern in radiological examinations of infants who were admitted with respiratory symptoms. We suggest that pneumonia due to C. trachomatis should be kept in mind in the differential diagnosis of infants examined because of a diffuse miliary pattern. (C) 2009 Lippincott Williams & Wilkins, Inc.

Endotracheal Tube Size Estimation for Children With Pathological Short Stature

Objective: To compare length-based estimates of endotracheal tube (ETT) size and age-based estimates with anesthesiologist-selected ideal ETT size in children with medical conditions affecting normal growth, known as pathological short stature (PSS). Methods: We conducted a retrospective review of the anesthesia database of all children undergoing tracheal intubation for any surgical procedure during a 3-year period. The anesthesiologist-selected ideal ETT size was defined as that selected and successfully used throughout the case under the supervision of a board-certified pediatric anesthesiologist. Objective criteria, such as leak test and adequate oxygenation/ventilation, were used to validate the appropriateness of the ETT chosen. For analysis, the children were classified as normal length for age versus PSS, defined as less than 5% length for age on the Centers for Disease Control and Prevention growth chart. The proportions of clinically relevant predicted ETTs, within +/-0.5 mm of the anesthesiologist-selected ideal ETT size, based on both age- and length-based formulas for each group were then compared. Results: Five thousand one hundred seventy-five patient records were analyzed. In children with normal stature, age-predicted ETT size was within the clinically relevant range in 89.8% (95% confidence interval [CI], 88.9%-90.7%), and length-predicted ETT size was within the clinically relevant range in 92.8% (95% CI, 92.0%-93.6%). In children with PSS, age-predicted ETT size was within the clinically relevant range in 86.6% (95% CI, 84.3%-89.0%), and length-predicted ETT size was within the clinically relevant range in 92.2% (95% CI, 90.3%-94.0%). The correlation coefficient for age to anesthesiologist-selected ideal ETT size was strong for both normal and PSS patients (r = 0.91 and r = 0.93, respectively). Length was also highly correlated to actual ETT size used for both groups (r = .91). Conclusions: Length-based prediction of ETT size is at least as accurate as age-based estimation in both normal and pathologically short children. (C) 2006 Lippincott Williams & Wilkins, Inc.

A 9-month-old baby with subdural hematomas, retinal hemorrhages, and developmental delay

No abstract available