Delayed presentations of congenital diaphragmatic hernia

The delayed presentation of a congenital diaphragmatic hernia may include symptoms of acute respiratory distress or gastrointestinal obstruction. We review the presentation and management of the different types of diaphragmatic hernias. In addition, we present a case of twins with a left-sided congenital diaphragmatic hernia through the foramen of Morgagni and an associated malrotation of the gastrointestinal tract.

End-tidal carbon dioxide monitoring in pediatrics - clinical applications

End-tidal CO2 monitoring is an exciting non-invasive technology that is more commonly used in the emergency department, intensive care unit and in the prehospital setting. Its main use has been in verifying endotracheal tube position, during mechanical ventilation and cardiopulmonary resuscitation, but it is being studied and used for other purposes as well. The new American Heart Association guidelines require secondary confirmation of proper tube placement in all patients by exhaled CO2 immediately after intubation and during transport. This article covers the clinical applications of end-tidal CO2 monitoring with special reference to the paediatric patient.

NPB-75: A portable quantitative microstream capnometer

A portable quantitative microstream capnometer (NPB-75) was tested in intubated children. The end-tidal CO(2) values measured by this device showed good agreement with concomitantly measured values of a stationary mainstream capnometer (N-6000). This lightweight device, with a 4-hour battery life, graphic capnogram display, and audiovisual alarms is well suited for the prehospital setting.

End-tidal carbon dioxide monitoring in the prehospital setting

End-tidal carbon dioxide (ETCO2) monitoring is an exciting technology and has the potential to become a very useful tool in the prehospital setting. It can be useful in verifying endotracheal tube position and during cardiopulmonary resuscitation in the field. Recent reports of misplaced endotracheal tubes in the prehospital setting make it important to ensure that paramedics learn correct techniques of endotracheal intubation, and that they verify tube placement with an ETCO2 monitor. The new American Heart Association guidelines require secondary confirmation of proper tube placement in all patients by exhaled CO2 immediately after intubation and during transport. This article covers the terminology, the basic physiology, the technology (both colorimetric detectors and infrared capnometers), and the clinical applications of ETCO2 monitoring with special reference to the pediatric patient.

Idiopathic priapism

Idiopathic priapism is rarely seen in children. Two children with idiopathic priapism are presented, followed by a detailed discussion of priapism. Particular attention is paid to idiopathic priapism. Additionally, an algorithm for diagnosing and managing children presenting with priapism is presented.

End-tidal carbon dioxide changes during cardiopulmonary resuscitation after experimental asphyxial cardiac arrest

A study was undertaken to determine the pattern of end-tidal carbon dioxide (ETCO2) changes during asphyxia-induced cardiac arrest in a pediatric canine model. Eleven intubated, anesthetized, paralyzed dogs (mean age, 4.1 mo; mean weight, 5.5 kg) were used. Asphyxia was induced by clamping the endotracheal tube (ETT) and discontinuing ventilation. Cardiac arrest ensued a few minutes later, after which closed-chest cardiopulmonary resuscitation (CPR) and ventilation were initiated. The ETCO2 level was recorded at baseline and every minute during CPR. Mean baseline ETCO2 was 31.9 mm Hg. The initial ETCO2 immediately after unclamping the ETT (mean, 35 mm Hg) was higher than subsequent values (mean, 12.4 mm Hg; P < .001). There was a sudden increase in ETCO2 to a mean of 27.0 mm Hg at or just before return of spontaneous circulation (ROSC) in all 11 cases (P < .01). During CPR, ETCO2 levels were initially high, decreased to low levels, and increased again at ROSC. This pattern, not previously described, is different from that observed in animal and adult cardiac arrest caused by ventricular fibrillation, during which ETCO2 decreases to almost zero after the onset of arrest, begins to increase after the onset of effective CPR, and increases to normal levels at ROSC. In this model of asphyxial arrest, continued cardiac output prior to arrest allows continued delivery Of CO2 to the lungs, resulting in higher alveolar CO2; this, in turn, is reflected as increased ETCO2 once ventilation is resumed during CPR. Further study is needed to determine whether the pattern Of ETCO2 changes can be used prospectively to define the etiology of cardiac arrest.

Evaluation of an end-tidal CO2 detector during cardiopulmonary resuscitation in a canine model for pediatric cardiac arrest

Our objective was to evaluate a colorimetric end-tidal CO2 detector in a canine model for pediatric cardiac arrest. In a prospective unblinded study, cardiac arrest was induced in 11 anesthetized and paralyzed puppies, weighing 5.0 to 6.1 kg, by clamping the endotracheal tube (ETT) and discontinuing mechanical ventilation. During cardiopulmonary resuscitation (CPR), the detector and the capnometer were connected between the ETT and ventilator tubing. Color shades on the detector ranged from 1 (purple) to 6 (yellow) corresponding to increasing concentrations of CO2. End-tidal CO2 concentrations as indicated by detector color and capnometric reading were monitored and recorded throughout the study. The results showed that there was a significant correlation between the detector color score and capnometric readings (P < 0.001). A sudden rise in end-tidal CO2 indicated by both the capnometer and the detector occurred at return of spontaneous circulation (ROSC) in seven or < 1 minute before ROSC in four animals. This association was significant (P = 0.0009). We conclude that these results demonstrate that, in a canine model for pediatric cardiac arrest, the detector readings correlate with capnometry during CPR and indicate ROSC.

Evaluation of a portable infrared end-tidal carbon dioxide monitor during pediatric interhospital transport

PURPOSE

Critically ill children often require endotracheal intubation before transport to a tertiary care center. Correct endotracheal tube (ETT) placement (trachea versus esophagus) and maintenance during transport are of the utmost importance. We evaluated a portable, qualitative, infrared end-tidal carbon dioxide monitor during transport of critically ill children.

METHODS

Fifty patients, ages 1 day to 19 years (median, 1 year), weighing 1.6 to 70 kg (median, 10 kg) who were intubated and transported by ground ambulance (n = 25) or rotorcraft (n = 25) were enrolled. ETT position was confirmed by physical examination, arterial blood gas or pulse oximetry, and sometimes by a chest radiograph. The instrument was attached, and readings were obtained before and during transport by transport nurses or respiratory therapists who also completed a brief questionnaire about the monitor. A moving bar indicator with a light-emitting diode display on the instrument indicates the presence of expired carbon dioxide.

RESULTS

All three esophageal tube positions and 48 of 50 tracheal tube positions were correctly identified (sensitivity, 96%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 60%). There were two false-negative results: in one case, there was instrument malfunction because of blood backing up into the tubing because of traumatic intubation, and in the second case, the patient had a chest tube that was leaking air. The device was evaluated as "too large" (30 of 50), "hard to secure" (25 of 50), and "not convenient" (29 of 50). Tube kinking was a problem (n = 7) when used in small infants in isolettes. The instrument was considered helpful in assuring ETT position when clinical evaluation was not possible because of noisy conditions.

CONCLUSIONS

We conclude that this carbon dioxide monitor was useful during transport of critically ill children in confirming ETT position. Further improvements in this noninvasive technology might be helpful in making the device more practical for use during interhospital transport.

Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation

OBJECTIVE

To determine the utility of a disposable colorimetric end-tidal CO2 detector during pediatric cardiopulmonary resuscitation (CPR) for (1) confirming endotracheal tube (ETT) position, and (2) assessing the relationship between end-tidal CO2 recorded by this method and outcome of pediatric CPR.

DESIGN/SETTING

Prospective observations during CPR in a university children's hospital.

PARTICIPANTS

Forty children (28 male, 12 female) aged 1 week to 10 years (25 children aged < or = 1 year, mean age 27.2 months, median 7 months), weighing 2.5 to 40 kg (31 children weighing < or = 15 kg, mean 10.94 kg, median 7 kg) who underwent a total of 48 endotracheal intubations during CPR.

METHODS

After intubation, ETT position was verified by usual clinical methods including direct visualization. The device was attached between the ETT and ventilation bag, the patient was manually ventilated, and a first reading was obtained. Any color change from purple (Area A, end-tidal CO2 < 0.5%) to tan or yellow (Area B or C, end-tidal CO2 > or = 0.5%) was considered to be positive for airway intubation. CPR was conducted as per Pediatric Advanced Life Support guidelines. A second reading was obtained when the decision to discontinue CPR was made.

RESULTS

All nine esophageal tube positions were correctly identified by the detector. Thirty-three of 39 tracheal tube positions were correctly identified (P < .001). For verifying ETT position, the device had a sensitivity of 84.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 60%. Readings were obtained at the end of CPR in 25 patients. All 13 patients who regained spontaneous circulation and survived to ICU admission had a second reading in the C range, while none of the 12 patients with a second reading in the A or B range survived. Both the first and second end-tidal CO2 readings in the C range correlated significantly with short-term survival (P = .01 and P < .001, respectively). Two patients were eventually discharged from the hospital.

CONCLUSIONS

During CPR a positive test confirms placement of the ETT within the airway, whereas a negative test indicates either esophageal intubation or airway intubation with poor or absent pulmonary blood flow and requires an alternate means of confirmation of tube position. The detector may be of prognostic value for return of spontaneous circulation and short-term survival.

Hand injuries in children presenting to a pediatric emergency department

STUDY OBJECTIVE

To study the epidemiology of pediatric hand injuries.

DESIGN

Retrospective chart review.

SETTING

Emergency department of a children's hospital.

PARTICIPANTS

All patients with a final diagnosis of hand injury from July through December 1989.

INTERVENTIONS

None.

RESULTS

Four hundred sixty-four patients (287 boys and 177 girls; median age, 10 years) with a total of 477 hand injuries were enrolled in the study. The most common types of injuries were lacerations (38.1%), soft tissue injuries (28.7%), and fractures (19.3%) and sprains (8%); most (60.8%) were sustained at home. Children with lacerations and burns were significantly younger than those with other types of hand injuries (P < .0001). Children with fractures, sprains, and sports injuries were significantly older than those with other types of hand injuries (P < .001). The fifth finger was the most commonly fractured digit (37%), and the fifth metacarpal was the most commonly fractured bone (P < .01). Boys were more likely than girls to sustain sports-related injuries (P < .05) and hand injuries resulting from first fights (P < .01). More hand injuries were associated with football than with any other organized sport (P < .01). All but 16 children (3.4%) were managed as outpatients.

CONCLUSION

Hand trauma accounts for a significant number of pediatric ED visits. Physicians caring for children in the ED setting must be prepared to manage a wide spectrum of pediatric hand injuries.

Utility of an end-tidal carbon dioxide detector during stabilization and transport of critically ill children

Critically ill children often require endotracheal intubation prior to transport to a medical center. Correct endotracheal tube placement and maintenance during transport are essential. The utility of a portable colorimetric end-tidal CO2 detector during transport of critically ill children was evaluated. Fifty-eight children with spontaneous circulation (aged 1 day to 12 years, weight 0.9 to 26 kg) who underwent 59 intubations during transport by ground (n = 31) or air (n = 27) were studied. Tube position was confirmed by physical examination, arterial blood gas values, or arterial oxygen saturation, and sometimes by chest radiography. The detector was attached and readings were obtained after intubation; readings were repeated if endotracheal tube position was rechecked during transport. Fifty-seven of 58 tracheal positions and the 1 esophageal tube position were correctly identified. One false-negative result occurred in a severely hypocarbic 900-g premature newborn. On each occasion that the detector was used en route, the endotracheal tube position was correctly identified. It is concluded that the end-tidal CO2 detector is a useful tool for confirming endotracheal tube position during transport of critically ill children weighing more than 2 kg who are not in cardiopulmonary arrest.

Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children

STUDY OBJECTIVE

To examine the validity of a disposable, colorimetric end-tidal CO2 detector in verifying endotracheal tube (ETT) placement in infants and children.

DESIGN

The detector was studied prospectively in 151 intubations.

SETTING

Operating room, ICU, and emergency department of a children's hospital.

PARTICIPANTS

One hundred thirty-seven children undergoing endotracheal intubation for anesthesia (52), respiratory support (76), or CPR (23).

INTERVENTIONS

After endotracheal intubation, tube position was verified, the detector was attached, and readings were obtained.

MEASUREMENTS AND RESULTS

The detector correctly identified tube position (trachea, 124; esophagus, four) in all 120 patients who were not in cardiac arrest (P less than .01). In the cardiac arrest setting, all six esophageal intubations were correctly identified, but two of the 17 tracheal intubations were incorrectly interpreted as esophageal intubations (P less than .01).

CONCLUSION

The detector accurately identifies ETT position in children with spontaneous circulation who weigh more than 2 kg. During CPR, a positive test correctly indicates that the ETT is in the airway, but a negative result (suggesting esophageal placement) requires an alternate means of confirming ETT position.

Pediatric emergency department complaints: a three-year analysis of sources and trends

STUDY OBJECTIVE

To identify the incidence and major causes of patient and parental complaints in a pediatric emergency department.

DESIGN

Retrospective analysis of complaints received regarding patients seen between January 1987 and December 1989.

SETTING

ED of Children's Hospital of Pittsburgh.

PARTICIPANTS

All complaints received during the three-year period.

INTERVENTIONS

Complaints were reviewed for reason, validity, and location at which patient was seen.

MEASUREMENTS AND RESULTS

One hundred seventy-six complaints from a total of 154,648 ED visits yielded a frequency of 1.1 complaints per 1,000 patient visits. Main reasons for dissatisfaction were misdiagnosis, billing, and inadequate treatment; 49% of complaints were judged valid. There were 0.69 complaints per 1,000 patient visits in the nonurgent medical portion of the ED. Patients seen emergently (critical care and trauma) had a significantly lower complaint frequency of 0.08 per 1,000 patient visits (P less than .001 by chi 2 analysis).

CONCLUSION

Assessment of ED complaints is useful to highlight areas of patient dissatisfaction and develop plans for improving patient care.

Validity of a disposable end-tidal carbon dioxide detector in verifying endotracheal tube position in piglets

BACKGROUND AND METHODS

the most reliable methods for confirming endotracheal tube placement are direct visualization of passage through the vocal cords and documentation of CO2 in the expired gas. We evaluated the use of a disposable colorimetric CO2 detector for verifying endotracheal tube position in small animals. The end-tidal CO2 (Petco2) detector was tested in 11 piglets with the endotracheal tube sequentially in the trachea, the esophagus, the esophagus with a carbonated beverage in the stomach, the esophagus after bag-mask ventilation. Endotracheal tube position was confirmed in all cases by direct visualization and capnometry.

RESULTS

The Petco2 detector identified the tube placement accurately in all 54 (21 tracheal, 33 esophageal) intubations (p less than .001).

CONCLUSIONS

This disposable Petco2 detector is highly sensitive and specific for verifying endotracheal tube placement in this nonarrest piglet model.