Clinical and Laboratory Predictors of Dehydration Severity in Children With Diabetic Ketoacidosis

STUDY OBJECTIVE

Our primary objective was to characterize the degree of dehydration in children with diabetic ketoacidosis (DKA) and identify physical examination and biochemical factors associated with dehydration severity. Secondary objectives included describing relationships between dehydration severity and other clinical outcomes.

METHODS

In this cohort study, we analyzed data from 753 children with 811 episodes of DKA in the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation Study, a randomized clinical trial of fluid resuscitation protocols for children with DKA. We used multivariable regression analyses to identify physical examination and biochemical factors associated with dehydration severity, and we described associations between dehydration severity and DKA outcomes.

RESULTS

Mean dehydration was 5.7% (SD 3.6%). Mild (0 to <5%), moderate (5 to <10%), and severe (≥10%) dehydration were observed in 47% (N=379), 42% (N=343), and 11% (N=89) of episodes, respectively. In multivariable analyses, more severe dehydration was associated with new onset of diabetes, higher blood urea nitrogen, lower pH, higher anion gap, and diastolic hypertension. However, there was substantial overlap in these variables between dehydration groups. The mean length of hospital stay was longer for patients with moderate and severe dehydration, both in new onset and established diabetes.

CONCLUSION

Most children with DKA have mild-to-moderate dehydration. Although biochemical measures were more closely associated with the severity of dehydration than clinical assessments, neither were sufficiently predictive to inform rehydration practice.

Effects of Fluid Rehydration Strategy on Correction of Acidosis and Electrolyte Abnormalities in Children With Diabetic Ketoacidosis

OBJECTIVE

Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known about optimal fluid infusion rates and electrolyte content. The objective of this study was to evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment.

RESEARCH DESIGN AND METHODS

The current analysis involved moderate or severe DKA episodes (n = 714) in children age <18 years enrolled in the Fluid Therapies Under Investigation in DKA (FLUID) Trial. Children were assigned to one of four treatment groups using a 2 × 2 factorial design (0.90% or 0.45% saline and fast or slow rate of administration).

RESULTS

The rate of change of pH did not differ by treatment arm, but Pco₂ increased more rapidly in the fast versus slow fluid infusion arms during the initial 4 h of treatment. The anion gap also decreased more rapidly in the fast versus slow infusion arms during the initial 4 and 8 h. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 h. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% versus 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) versus the slow arms (35.2%).

CONCLUSIONS

In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and Pco₂ than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.

Circulating matrix metalloproteinases in children with diabetic ketoacidosis

BACKGROUND AND OBJECTIVE

Matrix metalloproteinases (MMPs) mediate blood-brain barrier dysfunction in inflammatory disease states. Our objective was to compare circulating MMPs in children with diabetic ketoacidosis (DKA) to children with type 1 diabetes mellitus without DKA.

RESEARCH DESIGN AND METHODS

This was a prospective study performed at five tertiary-care pediatric hospitals. We measured plasma MMP-2, MMP-3, and MMP-9 early during DKA (time 1; within 2 h of beginning intravenous fluids) and during therapy (time 2; median 8 h; range: 4-16 h). The primary outcome was MMP levels in 34 children with DKA vs. 23 children with type 1 diabetes without DKA. Secondary outcomes included correlations between MMPs and measures of DKA severity.

RESULTS

In children with DKA compared with diabetes controls, circulating MMP-2 levels were lower (mean 77 vs. 244 ng/mL, p < 0.001), MMP-3 levels were similar (mean 5 vs. 4 ng/mL, p = 0.57), and MMP-9 levels were higher (mean 67 vs. 25 ng/mL, p = 0.002) early in DKA treatment. MMP-2 levels were correlated with pH at time 1 (r = 0.45, p = 0.018) and time 2 (r = 0.47, p = 0.015) and with initial serum bicarbonate at time 2 (r = 0.5, p = 0.008). MMP-9 levels correlated with hemoglobin A1c in DKA and diabetes controls, but remained significantly elevated in DKA after controlling for hemoglobin A1c (β = -31.3, p = 0.04).

CONCLUSIONS

Circulating MMP-2 levels are lower and MMP-9 levels are higher in children during DKA compared with levels in children with diabetes without DKA. Alterations in MMP expression could mediate BBB dysfunction occurring during DKA.

Taste test: children rate flavoring agents used with activated charcoal

OBJECTIVE

To compare flavoring agents added to activated charcoal (AC) to determine which mixture is most palatable to children.

DESIGN

Healthy volunteers between the ages of 3 and 17 years participated in a prospective masked trial. Five identical pitchers were prepared containing AC alone, AC with chocolate milk, AC with Coca-Cola (Coca-Cola Corp, Atlanta, Ga), AC with cherry-flavored syrup, and AC with sorbitol. Subjects tasted all 5 substances in random order. Children younger than 8 years rated taste on a 10-point Faces Scale. Children 8 years and older used a 100-point visual analog scale to rate taste and, separately, ease of swallowing. All children were asked which mixture was best. Ratings were compared using 1-way analysis of variance, and comparisons for all pairs were made using the Tukey test. P<.05 was considered significant.

RESULTS

Mean age among the 53 children enrolled was 8.3 years; 23 children were younger than 8 years. Girls made up 52% of the group. Taste scores for chocolate milk, Coca-Cola, and cherry-flavored syrup were significantly better than those for no flavoring agent. The scores for ease of swallowing for Coca-Cola, chocolate milk, and cherry-flavored syrup were significantly better than those for either no flavoring agent or sorbitol. When asked to choose a single best flavoring agent, 39% chose chocolate milk, 23% picked Coca-Cola, and 23% chose cherry-flavored syrup.

CONCLUSION

The addition of chocolate milk, Coca-Cola, or cherry-flavored syrup to AC improves palatability for children and is favored over no flavoring agent or sorbitol.

The addition of ceftriaxone to oral therapy does not improve outcome in febrile children with urinary tract infections

OBJECTIVE

To determine whether the addition of a single dose of ceftriaxone sodium to a 10-day course of trimethoprim and sulfamethoxazole hastens urine sterilization or resolution of clinical symptoms in febrile children with urinary tract infections.

DESIGN

Prospective, single-blind, randomized study.

SETTING

Tertiary care children's hospital emergency department.

PATIENTS

Febrile children aged 6 months to 12 years with a presumptive urinary tract infection based on history, physical examination, and urinalysis findings.

INTERVENTIONS

A history was taken, a physical examination and urinalysis and culture were performed, and a white blood cell count and erythrocyte sedimentation rate were obtained. Children were randomized to receive an intramuscular dose of ceftriaxone then 10 days of trimethoprim-sulfamethoxazole (IM + PO group) or oral trimethoprim-sulfamethoxazole alone (PO group). After receiving study medication, patients were discharged from the hospital to return in 48 hours for a follow-up evaluation and urine culture. Treatment failure was defined as the persistence of a positive culture at 48 hours or the need for hospital admission for intravenous rehydration or antibiotic therapy.

RESULTS

Sixty-nine children were enrolled, 34 in the IM + PO group and 35 in the PO group. The 2 groups were similar at the initial visit with respect to age, sex, clinical degrees of illness, white blood cell count, and erythrocyte sedimentation rate (P>.05). At the 48-hour follow-up visit, there were no differences between the 2 treatment groups in resolution of vomiting, fever, general appearance, abdominal tenderness, and hydration state (P>.05). There were 9 treatment failures, 4 in the IM + PO group and 5 in the PO group (P =.93).

CONCLUSION

The addition of a single dose of intramuscular ceftriaxone to a 10-day course of oral trimethoprim-sulfamethoxazole for urinary tract infection with fever resulted in no difference at 48 hours in the urine sterilization rate, degree of clinical improvement, or subsequent hospital admission rate.

Do parents choose appropriate automotive restraint devices for their children?

This study aims to describe parental choices of childhood automotive restraints and compare them with guidelines based on weight and height. Parents were surveyed and their children's heights and weight were measured. Results indicated that many parents believed their child fit a lap or shoulder belt when their children were too short to fit these devices. For children weighing < 40 pounds, 45% of parents believed the lap belt fit. Thirteen percent of 4-7-year-olds used booster seats, appropriate for 72% by sitting height criteria; and 33% of children < or = 7 years used the lap/shoullder belt, appropriate for 8% by sitting height criteria. Implications are that parental perceptions of fit may lead to inappropriate restraint choices for children. Practitioners should discuss child restraint use with parents in the context of their child's weight and height.

Localizing ingested coins with a metal detector

This study was conducted to determine the utility of metal detection in coin localization by inexperienced operators, and determine the rate of spontaneous passage of asymptomatic esophageal coins. All children who presented to the emergency department of an urban children's hospital with a suspected coin ingestion were eligible. Coin location was predicted from metal detector results, while radiographs confirmed location. Asymptomatic patients with esophageal coins were observed for spontaneous passage. Ninety-one children (ages 9 months to 17 years) were prospectively enrolled. The metal detector had a sensitivity of 98% (53/54) in coin detection and 98% (81/83) in determining coin location as esophageal. Symptoms were poor predictors of coin location. Six of eight asymptomatic patients with esophageal coins spontaneously passed their coins. These results show that metal detection is a good screening test for coin presence and to determine coin location as esophageal. Spontaneous passage of asymptomatic esophageal coins warrants further study.

ABCs of scoring systems for pediatric trauma

This review presents an overview of scoring systems used in pediatric and adult trauma. Triage scoring systems, using readily available physical examination, physiologic, and/or mechanism of injury parameters, are used to determine appropriate prehospital referral patterns. The Trauma Score, Revised Trauma Score, Circulation/Respiration/Abdomen/Motor/Speech Scale, Prehospital Index, and Trauma Triage Rule were reviewed. Injury scoring systems based upon anatomic descriptions of all identified injuries, are retrospectively used to analyze trauma populations. The Abbreviated Injury Scale, Injury Severity Score, Modified Injury Severity Score, Organ Injury Scaling, and Anatomic Profile were discussed. The two trauma outcome analysis systems presented, TRISS and ASCOT, allow for reproducible quantification of trauma severity, and survival comparison between trauma populations. Many of these triage, injury severity, and outcome analysis systems were developed with patient survival as the major outcome variable. Although subsequent studies may have found them to have some predictive value for measures of trauma morbidity, these scoring systems do not specifically address long-term risk of impairment, and therefore overlook one of the most crucial elements of pediatric trauma care. The last 2 decades have seen considerable development of scoring systems and analysis methods applicable to the trauma patient. As presented, this trend includes both the elaboration of increasingly simple, field-oriented triage tools, and more complex mathematical techniques for trauma outcome analysis. Although not all systems were designed specifically with the pediatric patient in mind, validation or modification of these systems for the pediatric patient will likely occur in the future. It is anticipated that this field will continue to evolve with greater mathematical sophistication; a baseline familiarity of the early stages of this evolution may be of benefit to those caring for the pediatric trauma patient.

Too many pediatric trampoline injuries

BACKGROUND

Recent reports note a dramatic increase in the number of pediatric trampoline injuries (PTI) during the past several years. In 1996, the US Consumer Product Safety Commission estimates that 83 000 patients received treatment for trampoline injuries in US hospital emergency departments (EDs), and that approximately 75% of these patients were <15 years of age. We sought to review our experience with PTI since our previous report (Pediatrics 1992;89:849), and to determine if the American Academy of Pediatrics' current (Pediatrics 1981;67:438) safety recommendations are adequate.

METHODS

Retrospective medical record review of all PTI patients presenting to the pediatric ED from November 1990 through November 1997.

RESULTS

A total of 727 PTI patients were included; medical records were unavailable for 3 patients. The annual number of PTI nearly tripled during the study period, from 51 in 1991 to a peak of 148 in 1996. PTI patients were 53% female, with a median age of 7 years; 37% were <6 years of age. Privately owned trampolines accounted for 99% of PTI. Most injuries (66%) occurred on the trampoline, 28% resulted from falls off, and 4% from imaginative mechanisms. One hundred eleven patients (15%) suffered severe injury (1990 Abbreviated Injury Scale value >/=3), usually of an extremity (89 out of 111). Fractures occurred in 324 patients (45%). Spinal injuries were common (12%), including 7 patients with cervical or thoracic fractures, and 1 with C7 paraplegia. Fractures were more frequently associated with falls off the trampoline, whereas spinal injuries more frequently occurred on the trampoline. Eighty patients (11%) required prehospital medical transport to our ED, 584 (80%) had ED radiographs, and 382 (53%) required pediatric surgical subspecialty involvement. Seventeen percent of PTI patients (125 out of 727) were admitted to the hospital, including 9 to the pediatric intensive care unit; 99 (14%) required one or more operations. Mean hospital stay was 2 days (range, 1-63 days); 24 stays (19%) were for >/=3 days. We estimate that the hospital charges for the acute medical care of PTI study patients at our institution totaled approximately $700 000.

CONCLUSIONS

PTI are dramatically increasing in number, and result in considerable childhood morbidity. Most PTI occur on privately owned trampolines. Few, if any, safety recommendations for the trampoline are followed. We support recommendations for a ban on the recreational, school, and competitive pediatric use of trampolines.

Evaluation of pediatric cervical spine injuries

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.

Management of febrile children with urinary tract infections

This study of the management of children with fever and urinary tract infection (UTI) was conducted to identify factors associated with initial admission, outpatient treatment, and outpatient treatment failure. A retrospective chart review identified children 3 months to 16 years of age with an emergency department (ED) diagnosis of cystitis, pyelonephritis, or UTI, a positive urine culture, and an ED temperature of >38 degrees C. Sixty-nine patients (90% female) were studied; 19% were admitted initially. Age younger than 2 years was associated with admission (P < .001). Of those initially discharged, 63% received parenteral antibiotics (usually intramuscular ceftriaxone), followed by oral antibiotics; 9% failed outpatient treatment. Outpatient failure was associated with higher initial temperatures (median 40.1 degrees C v 39.2 degrees C, P=.03, Mann-Whitney U) but was unrelated to age, initial white blood cell count, or use of parenteral antibiotics. These results indicate that most children with fever and UTI do not require hospital admission; those with temperatures of > or = 40 degrees C are at increased risk for outpatient failure.

Pediatric male rectal and genital trauma: accidental and nonaccidental injuries

OBJECTIVE

To characterize accidental pediatric rectal/genital trauma in males and compare these physical findings to a cohort of boys evaluated for sexual abuse.

DESIGN

Retrospective chart review.

SETTING

Tertiary pediatric trauma center/sexual abuse clinic.

PARTICIPANTS

Male patients evaluated in the emergency department for rectal/genital trauma from 9/1/89 through 10/31/93 ("accidental group"). Male patients referred to Child Protection Services for suspected sexual abuse from 1/1/93 through 12/31/95 who had abnormal genital physical findings ("sexual abuse group").

MAIN OUTCOME MEASURES

Outcomes measured included age, mechanism of injury, category of diagnosis, location of injury, and type of injury.

RESULTS

Forty-four male patients comprised the accidental group, aged six months to 17 years. The most common mechanism was a fall onto an object (34%). The most common injuries were lacerations/perforations of the scrotum (36%) followed by penile lacerations/perforations (25%). No patient had an isolated rectal laceration. Forty-four male patients with positive physical findings comprised the sexual abuse group. Ages ranged from seven months to 18 years. All patients had rectal lesions. Penile lacerations/perforations were the only other injuries documented, occurring in two patients.

CONCLUSIONS

Accidental rectal/genital trauma in the pediatric population is uncommon; scrotal trauma occurs much more frequently than rectal trauma. Rectal/genital injury in the sexual abuse group typically involves only the rectal area. Sexual assault should be considered in patients with isolated rectal injury or whenever the alleged history does not correlate with physical findings.

Treatment of convulsive status epilepticus with propofol: case report

INTRODUCTION

Convulsive status epilepticus (CSE) refractory to treatment with benzodiazepines, phenobarbital, and phenytoin presents a challenge to pediatric emergency and critical care specialists. Prompt seizure control may prevent mortality and morbidity.

CASE

A nine-month-old girl with hereditary fructose intolerance had prolonged, refractory CSE. Her seizures promptly stopped after administration of propofol (3 mg/kg bolus followed by infusion of 100 micrograms/kg/min). This dose resulted in electroencephalographic burst suppression. She required endotracheal intubation, invasive hemodynamic monitoring, and pressor support.

DISCUSSION

This is the first pediatric case of prolonged, refractory CSE treated with propofol. The adult experience is reviewed. Propofol should be used only in a setting where definitive airway control and hemodynamic support is possible.

Using the hand to estimate the surface area of a burn in children

OBJECTIVE

Estimation of the surface area involved is vital to evaluation and treatment of burns. Common teaching suggests the palm approximates 1% of the total body surface area (TBSA). However, early century literature suggests the palmar surface of the entire hand approximates 1% of the TBSA. We sought to determine whether the palm or the entire palmar surface of the hand approximates 1% TBSA in children.

DESIGN

A prospective, convenience sample.

MATERIALS AND METHODS

Using height, weight, and standard nomograms, body surface area was determined. A photocopy of the hand was used to determine the surface area of the palm and the entire palmar surface of the hand.

RESULTS

In 91 children, the mean percent of the TBSA represented by the entire palmar surface was 0.94% (95% confidence interval (C.I.) 0.93-0.97), and the mean percent of the TBSA represented by the palm was 0.52% (95% C.I. 0.51-0.53).

CONCLUSION

The entire palmar surface of a child's hand more closely approximates 1% TBSA, while the palm approximate 0.5% TBSA.

Laboratory presentation in diabetic ketoacidosis and duration of therapy

OBJECTIVE

To determine if initial emergency department (ED) laboratory parameters in children with diabetic ketoacidosis (DKA) can predict the minimum duration of continuous insulin therapy and aid in ED triage.

DESIGN

Retrospective chart review, over a four-year period.

SETTING

Tertiary care pediatric center ED.

PATIENTS

All patients in DKA, managed with a standard hospital protocol were included. Standard therapy consisted of an intravenous infusion over an hour of normal saline or Ringer's lactate, followed by 0.45% saline (potassium acetate/ phosphate added) at 1.5 times maintenance and insulin infusion (0.1 units/kg/h). New-onset diabetic patients were excluded.

MAIN RESULTS

One hundred thirty-two visits (45 patients, 55.5% female) were reviewed. Three of 60 (5%) patient-visits with moderate to severe DKA (serum pH < 7.20 and serum bicarbonate concentration < 10 mmol/L) had their acidosis corrected (serum pH > or = 7.30 or serum bicarbonate concentration > or = 15 mmol/L) within four hours compared to 33 of 72 (46%) patient-visits with mild DKA (serum pH > or = 7.20 or serum bicarbonate concentration > or = 10 mmol/L) (P < 0.0001). The acidosis was corrected within six hours in 69 and 11% of the mild and moderate-severe DKA group, respectively (P < 0.0001).

CONCLUSIONS

Initial laboratory presentation can help predict the minimum necessary duration of therapy in pediatric patient with DKA, aid early triage decision in the ED, and select a subgroup of patients who may be considered for outpatient management.

Cyclizine abuse by teenagers in Utah

Substance abuse by teenagers is common, often involving use of alcohol and illicit drugs. Ingestion of cyclizine hydrochloride, a nonprescription medication, was noted to occur frequently in Utah for abuse reasons. A retrospective review was conducted of patients younger than 18 years of age over a 3-year period who intentionally ingested cyclizine identified from Utah Poison Control Center records. Eighty patients were included; 42 patients underwent hospital record review. Abuse accounted for 89% of cyclizine ingestions; hallucinations (70%) and confusion/disorientation (40%) were the most notable symptoms. Tachycardia (52%) and systolic hypertension (69%) were frequently present in patients who presented to a hospital. No serious complications occurred. This study illustrates teenage abuse of one nonprescription antihistamine presumably to induce hallucinations. Abuse of over-the-counter medications by adolescents may be more appealing than illicit drug use for numerous reasons, and may be more common than appreciated.

Delayed diagnosis of injury in pediatric trauma

OBJECTIVE

To define the frequency and nature of delayed diagnosis of injury (DDI) in pediatric trauma.

DESIGN

Retrospective review.

SETTING

Tertiary pediatric trauma center.

METHODS

Medical records of 1175 pediatric trauma admissions from July 1, 1989, through June 30, 1992, were reviewed.

RESULTS

Fifty (4.3%) patients had 53 DDI. Fractures accounted for 38 DDI, most commonly of the extremities (total, 16). The delay until injury diagnosis ranged from 1 to 55 (median, 3) days. Patients with DDI had lower scores on the Glasgow Coma Scale, higher injury severity scores, and longer pediatric intensive care unit and hospital stays than patients without DDI. Patients with DDI more frequently required medical transport, emergent intubation, admission to the pediatric intensive care unit, and surgery. The DDI altered treatment for 68% of patients; 10 required surgery, including second operations for 6 children.

CONCLUSIONS

DDI represents a failure of pediatric trauma care at all levels. The severely injured child is at the greatest risk of DDI. All pediatric patients with trauma warrant ongoing evaluation to identify initially unrecognized injuries.

The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department

Head injury is a frequent cause of morbidity and mortality in pediatric trauma. Guidelines for obtaining computed tomographic (CT) scans in the child with mild head injury are poorly defined. This study investigated the utility of head CT scanning in the pediatric patient presenting with normal neurologic examination. All patients undergoing head CT scanning for trauma in the emergency department (ED) at a tertiary care pediatric trauma center during 1992 were identified (508). Charts were reviewed for historical and physical examination findings, CT results, and need for neurosurgical intervention. Patients were excluded if they had an abnormal neurologic examination (179), known depressed skull fracture (11), bleeding diathesis (3), age older than 18 years (1), or developmental delay (1). Included were 313 patients (median 5.5 years) who presented with clinical variables including sleepiness (38%), vomiting (34%), headache (30%), loss of consciousness (LOC) (25%), irritability (22%), amnesia (20%), and seizures (8%). An abnormal head CT was noted in 88 cases (28%); 79 (25%) were traumatic abnormalities involving the skull and/or contents. Thirteen patients (4%) had intracranial injuries (ICI); all had either a linear (10), basilar (2), or depressed (1) skull fracture noted on CT. Four patients required neurosurgery, three for epidural hematoma, and one for a complicated orbital fracture (without ICI). No clinical variables (seizure, LOC, vomiting, headache, confusion, irritability, sleepiness, amnesia) were associated with ICI (P > 0.05). In pediatric head trauma patients, with normal neurologic examinations in the ED, ICI occurs < 5% of the time and neurosurgery is needed in 1% of the cases. Commonly used clinical variables are not associated with ICI in these children.

Felbamate overdose: a case report and discussion of a new antiepileptic drug

Felbamate was approved in July 1993 for use alone or in combination with other antiepileptic drugs for partial seizures and Lennox-Gastaut syndrome. We report an overdose of felbamate in a teenage female patient who, in a suicide gesture, ingested eight times her maximum dose and suffered only mild side effects. This first report of a felbamate overdose is presented and followed by a discussion of felbamate's effectiveness, pharmacology, adverse effects, and drug interactions.

Pediatric basilar skull fracture: do children with normal neurologic findings and no intracranial injury require hospitalization?

STUDY OBJECTIVE

To delineate complications in patients with basilar skull fractures (BSFs) and normal neurologic findings, including computed tomography (CT) scans without intracranial injury, and to assess the need for hospitalization.

DESIGN

Retrospective chart review.

PARTICIPANTS

All emergency department patients with the ED diagnosis or hospital discharge diagnosis of BSF. Patients were included if they had a clinical or radiographic diagnosis of BSF. A subgroup of patients ("simple BSF") with normal neurologic examination findings in the ED, Glasgow Coma Scale scores of 15, and cranial CT scans without intracranial pathology was specifically analyzed.

RESULTS

We included 239 patients in the study. One hundred fourteen patients (48%) were included in the "simple BSF" subgroup. In this subgroup, vomiting (6%) was the most common complication, meningitis (1%) the most serious. There were no cases of delayed intracranial hemorrhage, and no patient with "simple BSF" required surgery.

CONCLUSION

Given the relatively low frequency of serious complications, our study suggests that some patients with BSFs may not require hospital admission.

Fluoroscopic foley catheter removal of esophageal foreign bodies in children: experience with 415 episodes

OBJECTIVE

This study sought to investigate the safety and efficacy of the fluoroscopic Foley catheter technique (FFCT) for removal of esophageal foreign bodies (EEBs) in children, and to identify factors associated with decreased success.

DESIGN/SETTING/PATIENTS

An 11-year retrospective review of all pediatric patients undergoing the FFCT for removal of EFBs at a tertiary-care children's hospital was performed.

RESULTS

Four-hundred and fifteen cases are reported. The median age was 29 months (range, 4 to 193); children < or = 24 months accounted for 45% (185) of the cases. Of all episodes 86% (355) involved children without known esophageal pathology. Coins comprised 76% (316) of the EFBs. The FFCT was successful in 91% (378) of the cases. In the 60 episodes involving children with underlying esophageal pathology, the technique had an 83% success rate compared to 92% in children without known pathology (P < .05). There were 290 patients where the duration of impaction was known. The success rate was 96% if the duration was 3 days or less compared to 50% if the duration was longer (P < .0001). Though the overall success in children < or = 24 months was less than older children (88% vs 94%, P < .05), this effect disappeared when corrected for duration of impaction. Minor complications occurred in 2% of the episodes, and major complications were noted in 1%.

CONCLUSIONS

The FFCT appears to be a safe and effective method for removal of EFBs especially in children without underlying esophageal lesions and a duration of impaction < or = 3 days. Major complications are rare.

Mini-dose Bier block intravenous regional anesthesia in the emergency department treatment of pediatric upper-extremity injuries

The safety and effectiveness of the "mini-dose" Bier block, a technique of i.v. regional anesthesia using low-dose lidocaine (1.5 mg/kg) without routine premedication, was evaluated in the emergency department treatment of pediatric upper-extremity fractures and dislocations. We prospectively studied 69 patients, aged from 2 to 16 years, treated at a pediatric primary care/referral-based emergency department. Good to excellent anesthesia was achieved during closed reduction in 90% of the cases. All patients achieved an acceptable reduction, as demonstrated by follow-up radiographs. None required further treatment of the injury under general anesthesia. No significant complications were noted. We conclude that the mini-dose Bier block provides safe, reliable, and cost-effective anesthesia for the outpatient reduction of pediatric upper-extremity injuries.

What dose of epinephrine is being used in pediatric resuscitation? Results of a survey

Standard-dose epinephrine (SDE) currently recommended by the American Heart Association for pediatric resuscitation is 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution). SDE has come under increasing scrutiny; many authors suggest that this dose is too small. We sought to determine current epinephrine dosing practices among physicians practicing pediatric emergency medicine. Half of the members of the American Academy of Pediatrics Emergency Medicine section, selected randomly, were surveyed by a mailed questionnaire. After two mailings, 105 of 162 surveys (65%) were completed by members in practice. Of the 105 responders, 59% described their practice as "pediatric emergency medicine"; 17% as "emergency medicine (children and adults)"; 10% as "general pediatric practice or clinic"; 10% as "critical care"; and 5% as "other." Fifty-one (49%) had completed fellowship training, and 81 (77%) were either PALS or APLS instructors (referred to as "instructors" below). Overall, 72% (76/105) indicated that they use doses larger than SDE. Sixty-five of these (86%) described their dosing practice as "recommended dose initially, then larger dose." Twenty-one percent use SDE less than half of the time, and 16% use a dose 10 to 20 times larger at least half of the time. No responder used doses smaller than SDE. Instructors were more likely to use larger doses than were noninstructors (83% compared with 38%; P < 0.001). In the instructor group, a significantly larger dose was being taught "informally" than "formally" (P < 0.001). This survey was undertaken to determine current dosing practices by a group of physicians who are knowledgeable and experienced in pediatric resuscitation, not to resolve the question of the optimal dose of epinephrine.(ABSTRACT TRUNCATED AT 250 WORDS)

Trampolines revisited: a review of 114 pediatric recreational trampoline injuries

A search of the medical literature failed to reveal any articles that discuss pediatric injuries acquired on privately owned recreational trampolines. This study was undertaken to quantify and qualify pediatric injuries from recreational trampoline use. A group of 114 patients who presented to the Emergency Department at Primary Children's Medical Center in Salt Lake City, Utah, with injuries directly related to use of a trampoline are discussed. There was a 1.2:1 male-female ratio. The average age was 8.0 years. Forty-eight percent of the patients were injured on their family's trampoline, with the remainder injured on a friend's, neighbor's, relative's, or gymnasium's equipment. The majority of injuries involved group use of the trampoline and the youngest person in a group was most often the injured participant. Extremity injuries were seen in 55% of the patient and head or neck injuries in 37%. Seventy-five percent of the patients required radiographs, 23% hospitalization, and 17% operative intervention. The history of the trampoline and medical literature discussions concerning injuries and safety are reviewed.

Radial head subluxation: epidemiology and treatment of 87 episodes

Radial head subluxation is a frequent upper-extremity injury in children. Through a prospective study of patients seen in the emergency department, the epidemiology and treatment were reviewed, and two methods of reduction were compared. During a nine-month period, there were 87 episodes of radial head subluxation in 83 children with six cases in infants 6 months old or younger. A pull mechanism of injury was not identified in 49% of the cases. Girls were seen more often than boys, the left arm was more frequently involved, and the incidence of recurrence was 26.7%. The two reduction methods did not differ significantly in their initial success rate. The presence of a click during a reduction attempt had a positive predictive value of 92% and a negative predictive value of 76%. Most children (76.8%) had return of arm use in less than ten minutes. Slow return of arm use (more than ten minutes) was not associated with delay in reduction but was associated with age of less than 2 years (P less than .001).