Feasibility survey for a study on selective antibiotic management of acute otitis media

OBJECTIVE

To assess the views of community physicians on management of acute otitis media (AOM) without antibiotics and their willingness to support research on this issue.

METHODS

Community physicians who admit to a children's hospital were surveyed using a questionnaire containing questions on current issues in AOM management and their willingness to support research on management of AOM without antibiotics.

RESULTS

Fifty-two percent of the surveys were returned. All respondents report concern about antibiotic resistant bacteria. Sixty-three percent treat otitis media with effusion with antibiotics and 68% give prophylactic antibiotics for recurrent otitis media. Thirty-five percent consider management of AOM without antibiotics as a possible alternative management practice. Forty-five percent of the respondents are willing to support research in this practice and 46% need more information.

CONCLUSIONS

Surveyed physicians indicate concern about antibiotic resistance and a willingness to support further research on the initial management of acute otitis media without antibiotics.

Salbutamol intoxication: is salbutamol a drug-inducing fever? A case report and treatment strategy

A four-year-old female with salbutamol intoxication was referred to our paediatric emergency medicine unit, due to agitation, tremulousness, sinus tachycardia, mild hypokalaemia and hyperglycaemia. On admission the child was agitated and had a noticeable tremor, an axillary temperature of 38 degrees C and a pulse rate of 185 beats/min. She had no identifiable focus of infection on physical examination to explain her fever. Gastric lavage, activated charcoal, intravenous hydration and electrocardiogram (ECG) monitoring were performed. Her plasma potassium level, blood sugar and QT interval were closely monitored during her hospital stay. Her fever, tachycardia and serum potassium and glucose levels returned to normal and she was discharged in good condition 24 h after admission. The difference of this case from prior cases of salbutamol intoxication was the observation of fever in the absence of evidence of infection. Since the cause of fever was not a reaction to the medication used in the treatment or related to environmental factors, it is assumed that salbutamol is a fever-inducing drug.

Accuracy of clinical variables in the identification of radiographically proven constipation in children

STUDY OBJECTIVE

To determine whether clinical variables accurately identify children with radiographically proven constipation.

METHODS

Prospective, cross sectional case series of children 2-12 years of age with abdominal pain (AP) requiring radiographic evaluation. Constipation was defined radiographically as the presence of fecal material throughout the colon. The presence of other pathology was noted. The pediatric emergency department (ED) physicians recorded a comprehensive history and physical examination and a provisional diagnosis was made. Radiographs were initially interpreted by the pediatric ED attending physicians; the official interpretation was later provided by a single board certified pediatric radiologist who was blinded to the ED interpretation. A discriminant analysis was performed to identify variables that could best discriminate between patients with, and without, radiographically proven constipation.

RESULTS

In total 251 patients were enrolled over a 12 month period. Four variables were noted to be more common in constipated patients: a history of normal or hard stools, absence of rebound tenderness, presence of tenderness in the left lower quadrant and stool in the rectal vault on exam. Stool present on rectal exam was the best discriminator between patients with and without constipation. The discriminant analysis model had a sensitivity of 77%, specificity of 35% and a negative predictive value of 55%.

CONCLUSION

No clinical variable, either as a single variable or in a model, accurately identified patients with abdominal pain and radiographically proven constipation.

Accidental isopropanol ingestion in children

OBJECTIVE

To describe the clinical course and determine the minimal observation period required following isopropanol ingestion in children.

METHODS

The emergency department records of children less than 6 years of age with isopropanol ingestion who presented between June 1992 and December 1998 were identified. Demographics, type, and amount of ingested substance, and time of ingestion were recorded. Symptoms, time of onset, and the results of physical examination and laboratory tests were collected. Group 1 included patients who did not have isopropanol level assayed, and group 2 members had isopropanol level assayed.

RESULTS

Ninety-one cases of isopropanol ingestion were identified. Clinical evidence of toxicity was noted in 26 (29%) patients. Symptoms included spontaneous emesis in (24/26), ataxia (5/26), altered mental status (3/26), and apnea (1/26). Toxic isopropanol levels were noted in three patients; all had altered mental status. Clinical evidence of toxicity developed between 0.5 and 2 hours post-ingestion. Patients who ingested more than 1 ounce of isopropanol were more likely to become symptomatic (RR 4.26, 95% CI = 1.61-11.2).

CONCLUSIONS

An observation period of 2 hours post-ingestion can be used to rule out clinical toxicity in pediatric patients with suspected isopropanol ingestion. Patients with a history of ingesting more than 1 ounce are likely to develop adverse clinical effects. The development of altered mental status is the most useful clinical predictor of a toxic blood isopropanol level.

Serum neuron-specific enolase as a predictor of intracranial lesions in children with head trauma: a pilot study

OBJECTIVE

To determine the reliability of serum neuron-specific enolase (NSE) levels in predicting intracranial lesions (ICL) in children with blunt head trauma (HT).

METHODS

A prospective pilot study was conducted of patients 0 to 18 years of age presenting to a children's hospital emergency department (ED) between December 1997 and October 1998. Children presenting within 24 hours of injury who required head computed tomography (CT) were eligible. Blood samples were obtained to measure serum NSE level. Data collected included patient demographics, historical information, Glasgow Coma Scale score (GCS), physical examination, head CT results, and outcome. Patients were assigned to one of two groups based on the head CT results (PICL; presence of intracranial lesion, or NICL; no intracranial lesion). Data were analyzed using Student's t-test and chi-square. The 95% confidence interval (95% CI) was calculated when appropriate. A receiver operating characteristic curve was constructed to determine the NSE level that yielded the highest sensitivity and specificity for predicting ICL.

RESULTS

Fifty patients were enrolled; 22 (45%) had abnormal head CT. No difference in demographics or mechanism of injury was observed between those with abnormal or normal CT scans. The mean GCS level was 11.9 +/- 4.2 for PICL and 13.9 +/- 2.6 for NICL (p = 0.045; 95% CI = -0.05 to -3.9). The mean NSE level was 26.7 +/- 21.4 for PICL and 17.7 +/- 7.8 for NICL (p = 0.048; 95% CI = 0.1 to 17.9). An NSE level > or = 15.3 ng/mL yielded a sensitivity of 77%, a specificity of 52%, and a negative predictive value of 74%.

CONCLUSIONS

These results suggest that serum NSE may be a useful screening tool for predicting ICL in children with blunt head trauma. However, the NSE alone was neither sensitive nor specific in predicting all patients with ICL.

Adult-worn child carriers: a potential risk for injury

OBJECTIVES

To examine and describe types of injuries associated with adult-worn child carriers and illustrate the need for careful use of these products by parents.

METHODS

A literature search for the terms infant carriers, backpack carriers, infant slings, baby carriers, and baby slings was conducted. Information was also obtained and tabulated from the three Consumer Product Safety Commission databases: the National Electronic Injury Surveillance System (NEISS), the In-Depth Investigations File, and the Injury/Potential Injury Incident File.

RESULTS

No reports of injuries were found in the medical literature. In the NEISS database, 51 injuries were reported between January 1990 and September 1998. Of these injuries, 38 (74.5%) were head traumas and eight (15.7%) were facial trauma. Of the 51 injuries, 11 (22%) required hospitalization.

CONCLUSIONS

Based on the data presented in this paper, injuries associated with the use of adult-worn child carriers appear to come from three general sources: product appropriateness and design, product condition, and product use. It is important for health care providers to assist in the dissemination of information regarding the safe use of these products to parents in an effort to prevent injuries.

Current income profile for academic pediatric emergency medicine faculty

STUDY OBJECTIVES

To survey academic pediatric emergency medicine (PEM) programs for information on financial compensation and patient care activities of PEM faculty and compare the results to the financial data published by the AAEM, AAAP, and MGMA.

METHODS

A survey was mailed to program directors requesting information on medical school affiliation, ED census, recruitment, patient care activity and annual income for each academic rank. The survey also included questions on CME benefits, and income adjustment mechanisms/bonus plans for PEM faculty. The survey income data were stratified by program size and geographic region and then compared to income data from the AAMC, AAAP, and MGMA.

RESULTS

Of 47 eligible programs, 37 (78.7%) responded,and four were excluded. Mean number of clinical hours per week for academic faculty and clinical faculty were 27.9 +/- 3.5 and 32.4 +/- 3.9, respectively, (P = 0.000). Clinical appointments in academic departments were offered by 82% of the programs. Mean annual income for all academic ranks was $121,503 +/- $15,795, and is nearly $37,000 less than the annual income for academic adult emergency medicine (AEM) faculty. Compared to medium and large programs, small programs are offering higher salaries to recent fellowship graduates (P = 0.004). When income data were stratified by program size or geographic region, no significant difference in average annual income was observed. Bonus or incentive plans were available only in 45.5% of the programs.

CONCLUSION

Direct patient care responsibility of PEM academic faculty has not changed significantly in the past 13 years, despite the availability of clinical appointments within most of the surveyed programs. Our data indicate that the annual income for PEM faculty in academic institutions is significantly less than AEM faculty. No significant difference was observed between programs at the assistant, associate, or full professor level when stratified by size or geographic region. Bonus/incentive plans for exceptional patient care or scholarly activity were available in less than half of the surveyed programs.

A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department

OBJECTIVE

To compare the effectiveness, recovery time from sedation, and complication rate of propofol with those of midazolam when used for procedural sedation in the pediatric emergency department (PED).

METHODS

A prospective, blinded, randomized, clinical trial comparing propofol and midazolam was conducted in the PED of a tertiary pediatric center. Eligible patients were aged 2-18 years with isolated extremity injuries necessitating closed reduction. All patients received morphine for pain, then were randomized to receive propofol or midazolam for sedation. Vital signs, pulse oximetry, and sedation scores were recorded prior to sedation and every 5 minutes thereafter until recovery. Recovery time, time from cast completion to discharge, and other time intervals during the PED course and all sedation-related complications were also recorded.

RESULTS

Between August 1996 and October 1997, 91 patients were enrolled. Demographic data, morphine doses, and sedation scores were similar between the propofol and midazolam groups. Mean +/- SD recovery time for the propofol group was 14.9+/-11.1 minutes, compared with 76.4+/-47.5 minutes for the midazolam group, p<0.001. Mild transient hypoxemia was the most significant complication, occurring in 5 of 43 (11.6%) patients given propofol and 5 of 46 (10.9%) patients given midazolam (odds ratio 1.08, 95% CI = 0.24 to 4.76).

CONCLUSION

In this study, propofol induced sedation as effectively as midazolam but with a shorter recovery time. Complication rates for propofol and midazolam were comparable, though the small study population limits the power of this comparison. Propofol may be an appropriate agent for sedation in the PED; however, further study is necessary before routine use can be recommended.

A review of violence statistics among children and adolescents in the United States

This article defines the violence and data on juvenile homicide rates and arrest rates for violent crimes in the United States. Mortality data associated with juvenile violence from the United States and similar data from other industrial countries are also compared.

Visual hallucinations in a toddler: accidental ingestion of a sympathomimetic over-the-counter nasal decongestant

Hallucinations are uncommonly encountered in the young child. The differential diagnosis of such behavior includes a number of potentially serious syndromes such as central nervous system malignancy, encephalitis, temporal lobe epilepsy, closed head trauma with frontal lobe confusion, hypoglycemia, drug intoxications, and childhood psychiatric syndromes. Organic explanations are most often discovered and frequently involve toxicologic causes. A case is presented of a toddler with hallucinations caused by inappropriately high doses of pseudoephedrine.

Pattern of basic life support ambulance use in an urban pediatric population

To evaluate the pattern of use of basic life support (BLS) ambulances in a pediatric population, emergency medical service (EMS) and pediatric emergency department (PED) records from an urban hospital PED for all children transported to PED by ambulance during a 1-month study period were retrospectively reviewed. Excluded were: (1) advanced life support transport, (2) transport from other medical facility, (3) patients with chronic medical disability without acute decompensation, and (4) patients in police custody. BLS transport was considered inappropriate if: (1) no intervention by BLS technicians, (2) minimal to no intervention in the PED, and (3) discharge without prescription medication. Of 376 ambulance transports evaluated, 238 (63%) met entry criteria, and 105 (44%) transports met criteria for being inappropriate. The mean charge for appropriate transport was $240.68, and for inappropriate, $237.12 (P = .2). The total charge for inappropriate transports was $26,523.20. Patients on federal assistance had a significantly higher rate of inappropriate transport (51%) compared with patients who had commercial insurance (30%) and those who self paid (42%). Trauma was the most common cause for transport, 48% of which was inappropriate. It was concluded that inappropriate BLS transport of pediatric patients is common. This use is costly and may disrupt the delivery of EMS care to the remainder of the community. Efforts aimed at public education and providing alternative means of transport may significantly reduce charges and improve the delivery of EMS care.

Wheezing during induction of general anesthesia in patients with and without asthma. A randomized, blinded trial

BACKGROUND

Patients with asthma who require general anesthesia and tracheal intubation are at increased risk for the development of bronchospasm during induction. The incidence of wheezing during induction with different intravenously administered agents is unknown. A randomized, double-blinded prospective study was undertaken to evaluate the incidence of wheezing in asymptomatic asthmatic and nonasthmatic patients receiving three commonly used intravenous anesthetic agents for induction of anesthesia.

METHODS

Fifty-nine asymptomatic asthmatic and 96 nonasthmatic patients of ASA physical status 1 and 2 were studied. All patients received 1.5 micrograms/kg fentanyl, oxygen, followed by either 5 mg/kg thiopental or thiamylal, 1.75 mg/kg methohexital or 2.5 mg/kg propofol, 1.5 mg/kg succinylcholine, tracheal intubation, and inhalational anesthesia. Wheezing was assessed by an independent blinded observer, auscultating the lungs at 2 and 5 min postintubation. Data were analyzed by Pearson's chi-squared, Fisher's exact test, and multiple logistic regression with significance set at P < 0.05.

RESULTS

Both asthmatic and nonasthmatic patients who received a thiobarbiturate for induction had a greater incidence of wheezing than did patients receiving propofol. In asthmatic patients, 45% (23, 67) (mean and 95% confidence interval) who received a thiobarbiturate, 26% (8, 44) who received an oxybarbiturate, and none (0, 17) who received propofol wheezed after intubation. In nonasthmatic patients, 16% (3, 28) who received thiobarbiturate and 3% (0, 9) who received propofol wheezed.

CONCLUSIONS

This study suggests that propofol should be considered for induction of anesthesia in patients, particularly those with asthma, who require timely intubation.

Reliability of observation variables in distinguishing infectious outcome of febrile young infants

We prospectively evaluated 7 observation variables (level of activity, level of alertness, respiratory status/effort, peripheral perfusion, muscle tone, affect, feeding pattern) which qualify patient clinical appearance in order to determine reliability in distinguishing the infectious outcome of 233 febrile infants ages 0 to 8 weeks. Each variable was graded either 1, 3, or 5, with a higher score indicative of a greater degree of compromise. All infants received physical examination and sepsis evaluation (lumbar puncture, complete blood count/blood culture, urinalysis/urine culture). The 3 outcome groups compared were 29 cases of serious bacterial infections, (+SBI; 10 with bacterial meningitis, 12 with bacteremia, 7 with urinary tract infection), 45 cases of aseptic meningitis (AM) and 159 cases culture-negative with normal cerebrospinal fluid (CN-NCSF). The mean score for each of the 7 variables was significantly greater in the +SBI group compared with both the AM and CN-NCSF groups (P < 0.05), whereas there was no significant difference in mean score for each of the 7 variables between the AM and CN-NCSF groups. Stepwise discriminant analysis identified 3 variables that best distinguished outcome: affect; respiratory status/effort; and peripheral perfusion, which constituted the Young Infant Observation Scale. The mean total Young Infant Observation Scale score generated from assessing these 3 variables was significantly greater (P = 0.0001) in the +SBI, group (9) compared with both the AM (5) and CN-NCSF (5) groups. A total Young Infant Observation Scale score > or = 7 had a sensitivity of 76%, specificity of 75% and negative-predictive value of 96% for outcome of +SBI.

Relationship of temperature pattern and serious bacterial infections in infants 4 to 8 weeks old 24 to 48 hours after antibiotic treatment

STUDY OBJECTIVE

A new management approach to selected febrile infants 4 to 8 weeks old evaluated for possible sepsis is outpatient ceftriaxone therapy, with subsequent re-evaluation 24 to 48 hours after presentation. This study assessed whether the temperature profile of such infants during the 24- to 48-hour period after treatment distinguished those with from those without serious bacterial infections (SBIs).

DESIGN

Prospective, descriptive clinical study.

PARTICIPANTS

One hundred sixty-one febrile infants 4 to 8 weeks old.

SETTING

An urban pediatric emergency department and hospital.

MEASUREMENTS AND MAIN RESULTS

All infants underwent a sepsis evaluation (lumbar puncture, CBC/blood culture, and urinalysis/urine culture) and were hospitalized for at least 48 hours. Temperatures were measured on presentation and then every four hours during hospitalization. All infants received parenteral third-generation cephalosporin antibiotic therapy, and none received antipyretic medication unless fever was documented. Fever (rectal temperature of more than 38.0 C) was documented during the 24- to 48-hour period after presentation in 28 infants (17.6%)--one of a total of 18 infants (5.6%) with SBI and 27 of a total of 143 infants (19%) without SBI (alpha, more than .2: power .30). All bacterial isolates in cases of SBI were susceptible to third-generation cephalosporin antibiotics. All repeat blood and urine cultures that were performed in infants with bacteremia or urinary tract infections, respectively, were negative 24 hours after presentation.

CONCLUSION

Infants 4 to 8 weeks old who remain febrile during the 24 to 48-hour period after presentation and initiation of parenteral antibiotic therapy are less likely to have SBI. This study did not have sufficient power for this difference to be statistically significant.

Prehospital countershock treatment of pediatric asystole

Prehospital care was retrospectively reviewed in 117 pulseless nonbreathing (PNB) pediatric patients (0 to 18 years of age) to determine the effects of immediate countershock treatment of asystole. Of 90 (77%) children with an initial rhythm of asystole, 49 (54%) received countershock treatment. Rhythm change occurred in ten (20%) of the asystolic children who received countershock treatment. Three of the countershocked asystolic children were successfully resuscitated, but none survived. Rhythm change occurred in nine (22%) of the asystolic children not countershocked. Six were successfully resuscitated, and one survived. The two groups (countershocked asystole v noncountershocked asystole) did not differ significantly in age, sex, witnessed arrest, witnessed arrest with bystander basic life support (BLS), prehospital endotracheal intubation, both intubation and vascular access success, or diagnosis. However, prehospital vascular access was successfully established in a significantly greater number of countershocked patients (P less than .05). The mean times to the scene, at the scene, and to the hospital for the countershocked v noncountershocked asystolic patients were 6.2, 23.8, and 6.1 v 5.9, 14.7 and 7.0 minutes. The mean time at the scene was significantly greater in the countershock group (P less than .001). The successful performance of prehospital endotracheal intubation was significantly associated with rhythm change (P less than .05). Patients age, witnessed arrest, witnessed arrest with bystander BLS, successful establishment of prehospital vascular access, diagnosis, and countershock treatment were not significantly associated with rhythm change. In conclusion, prehospital countershock treatment prolonged prehospital care time and was not associated with rhythm change in asystolic children. Therefore, prehospital countershock treatment of asystolic children is not recommended.

Prehospital pediatric endotracheal intubation performance review

Pediatric prehospital care was reviewed over a one-year period to determine success rate, causes of unsuccessful attempts, and complications of performing endotracheal intubation. The Milwaukee County Emergency Medicine Technician-Paramedics (EMT-Ps) responded to 1467 pediatric (less than 19 years of age) patient calls. This accounted for 11% of the patients who received EMT-P care during the study period. Of the 63 patients requiring pediatric endotracheal intubation, 49 (78%) were successfully intubated. Of the 42 pulseless nonbreathing (PNB) patients, 39 (93%) were successfully Of the 21 patients judged to be in impending respiratory failure, 10 (48%) were successfully intubated. Common difficulties in intubating the PNB patient included inability to visualize the glottis and cords secondary to mucus and/or vomitus, use of inappropriately small endotracheal tubes, and accidental extubation during transport. Difficulties in intubating impending respiratory failure patients included patient resistance and seizure activity. We recommend that the EMT-P training curriculum include a review of these difficulties and that prehospital pediatric endotracheal intubation performance be monitored and reviewed with the EMT-Ps.

Clinical predictors of severe head trauma in children

We reviewed the medical records of 55 patients who underwent a cranial computed tomographic (CT) scan for acute head trauma. The severity of head trauma was classified according to objective clinical findings as severe in 44 patients, moderate in three, and mild in eight. Thirty-seven patients (84%) with severe head trauma had a brain injury identified on CT scan. Six patients with severe head trauma had a Glasgow Coma Scale score of 12 or greater and an abnormal CT scan. All patients with mild or moderate head trauma had normal CT scans. Severe head trauma, as defined in this study, accurately identified all patients with abnormal CT scan findings. We conclude that a classification based on objective clinical findings accurately identifies the severity of head trauma. This is particularly important in evaluating patients with a Glasgow Coma Scale score of 12 or greater. A prospective study including larger numbers of patients is needed to further evaluate such a classification.

Pediatric intraosseous infusions: impact on vascular access time

A 1-year retrospective chart review was performed to evaluate the effect of intraosseous infusions (IO) on the time required to establish vascular access in pediatric patients requiring immediate vascular access for resuscitation. Eighty-one patients were identified, including 29 pulseless and non-breathing and 52 noncardiopulmonary arrest children, who required intravenous fluids or medication for resuscitation. Comparing the results with a previous review, the IO method effectively reduced the time needed to establish vascular access in the arrested group when standard techniques failed, particularly in the child less than 2 years old. The IO method was not used effectively in the non-arrest group, as evidenced by a significantly greater mean time required to establish vascular access. There were no significant complications related to the IO procedure. Nine (50%) of the patients receiving IO fluids or medication had clinical and/or laboratory evidence that these substances reached the central circulation. Early use of IO infusion in the resuscitation is recommended for not only the arrested patient, but also the critical nonarrested patient requiring immediate vascular access.

Computerized tomography in hemophiliacs with head trauma

Intracranial hemorrhage secondary to head trauma is a major cause of morbidity and mortality in patients with bleeding disorders. Indications for head computerized tomographic scanning (CT scan) on patients with bleeding disorders who sustain head trauma are not well established. We retrospectively reviewed the medical records and head CT scan results of 21 patients with bleeding disorders. Five patients had more than one episode of head trauma. The severity of head trauma per episode was classified according to objective clinical findings as minor in 12 episodes, moderate in 12, and severe in four. In three of four patients with severe head trauma, the CT scan showed evidence of intracranial hemorrhage. In this series, all 17 patients with 24 episodes of moderate or minor head trauma had normal head CT scans. We conclude that a larger prospective study is needed to further evaluate the diagnostic value of head CT scan in hemophilia patients with minor or moderate head trauma, as defined in this study.

Prehospital care of the pulseless, nonbreathing pediatric patient

The performance of life-saving procedures by prehospital care personnel was reviewed in the cases of 114 pulseless, nonbreathing pediatric patients. Children 18 months to 18 years of age had a significantly greater chance of having prehospital endotracheal intubation and vascular access established compared to children younger than 18 months of age. For all patients, witnessed arrest and initial rhythm of ventricular fibrillation were significantly associated with survival. In the younger children, endotracheal intubation also was associated significantly with survival. Nine (8%) patients survived, and only three of the survivors were without neurologic sequelae. The number of neurologically intact survivors was too small to show a statistically significant association with these factors.