Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits

OBJECTIVE

To compare the total costs and the physician time requirements for suture and staple repair of pediatric scalp lacerations.

STUDY DESIGN

Eighty-eight children, 13 months to 16 years of age, coming to a children's hospital emergency department with simple scalp lacerations were prospectively randomly selected to receive staple or suture repair. Wound lengths, times required for initial wound care and closure, and equipment use were recorded. Patients returned in 1 week for suture or staple removal and wound reevaluation. The two methods were compared in terms of both time expended and costs of equipment and physician compensation.

RESULTS

Forty-five children underwent staple repair and 43 underwent suture repair. There were no differences in age, sex, wound length, number of sutures or staples per centimeter, or physician experience. Stapling resulted in shorter wound closure times (65 vs 397 seconds; p < 0.0001) and shorter overall times for wound care and closure (395 vs 752 seconds; p < 0.0001). Staple repair was less expensive in terms of equipment ($12.55 vs $17.59; p < 0.0001) and total cost based on equipment and physician time ($23.55 vs $38.51; p < 0.0001). The follow-up rate was 91%, with no cosmetic or infectious complications in either group.

CONCLUSIONS

Stapling is faster and less expensive than suturing in the repair of uncomplicated pediatric scalp lacerations, with no additional complications. Physicians who treat children with scalp lacerations should consider the use of stapling devices.

Failure of technetium-99m hexamethylpropylene amine oxime leukocyte scintigraphy in the evaluation of children with suspected appendicitis

To determine the accuracy and reliability of a labeled leukocyte imaging technique in the early diagnosis of pediatric appendicitis, we prospectively studied patients presenting to the pediatric emergency department with abdominal pain suggestive of appendicitis. Patients scheduled for urgent laparotomy were excluded, as were postmenarchal females. Blinded interpretations by two independent radiologists were compared with surgical findings, if managed operatively, or with discharge diagnoses and three week follow-up, if managed medically. Twenty-three children underwent technetium-99m hexamethylpropylene amine oxime (HMPAO) leukocyte scintigraphy. Seven had pathologically proven appendicitis, with false negative interpretations made in three and five cases by the two radiologists. Sixteen patients had prompt resolution of symptoms; however, scintigraphic abnormalities were identified in 10 and seven cases by the two radiologists. Resulting sensitivity, depending on the individual reader, ranged from 29 to 57%, with specificity 38 to 56%, positive predictive value 22 to 29%, negative predictive value 64 to 67%, and accuracy 43 to 48%. Interrater reliability for agreement on the scintigraphic diagnosis of appendicitis was poor (kappa = 0.38). Technetium-99m HMPAO leukocyte scintigraphy was neither accurate nor reliable as a diagnostic tool in a subgroup of pediatric patients with an initial clinical presentation equivocal for appendicitis. This finding contradicts previously published experience using similar scintigraphic techniques.

How much information is lost during processing? A case study of pediatric emergency department records

This is a retrospective study determining the completeness and accuracy of processed information of emergency department (ED) records of a busy urban children's hospital. The method of study was based on comparing computer processed information with that in the patient's medical chart. A total of 457 ED visits from April 5 to April 25 of 1992 were audited. Accuracy was found to differ with the type of data element and the setting. Among admissions, admitting diagnoses coding had the highest error rate (53.1%), followed by age (33.2%), admitting time (31.0%), and admitting ward (12.5%). Among discharges, time in had the highest error rate (76.0%), followed by area where seen (56.9%), physician name (48.4%), time out (37.8%), age (33.3%), mode of arrival (26.2%), diagnosis (20.1%), patient's condition (17.3%), and triage level (10.7%). Despite advances in computerized information systems, error rates of processed information remain unacceptably high. Future information systems should be interactive, recording rather than processing information flows between the provider and the patient.

Falls from heights: a problem not just in the northeast

BACKGROUND

Falls from windows and balconies have long been recognized as a health hazard facing children in large, eastern cities. No study has explored this problem in western and sunbelt states.

METHODS

A retrospective chart review of children admitted to a large, west coast hospital for injuries sustained secondary to a fall from a building was conducted. The health care costs for injuries secondary to falls were estimated by reviewing Los Angeles County hospital discharge data over a 3-year period. Representative cities in western and sunbelt states were surveyed about their building code regulations for windows and balconies.

RESULTS

Ninety-three children fell from windows and 58 from other structures (balconies, fire escapes, and roofs). The fall victims were more likely to be male (male-female ratio, 1.6:1), younger than 3 years old, and playing at the time of the fall. In more than 70% of the cases reviewed, the child fell from a second-story window. Morbidity was significant, with two thirds of children experiencing at least one fracture and more than 30% of the children requiring the intensive care unit. The mortality rate was low (0.7%); however, 10% were left neurologically impaired. The cost for hospitalization was approximately $5000 to $8000 per child. The survey revealed a lack of building code regulations for windows or window guards in western and sunbelt states.

CONCLUSIONS

Falls from windows are a significant problem for children, not only in eastern cities, but throughout the nation. Morbidity is significant, even from less than three stories, and the health care cost is high. Preventive strategies are suboptimal.

Penile zipper entrapment: a simple and less threatening approach using mineral oil

Penile zipper entrapment, when it presents to the office or emergency department, can prove to be a challenging management problem. An easily implemented alternative approach is presented, along with a review of previously reported experience with this problem.

Outpatient management of burns in children

The majority of burn wound management can be performed on an outpatient basis by the primary care physician or emergency physician. The physician, however, needs to know when to refer the patient for surgical evaluation and must be reasonably certain that the family will be compliant with wound care and follow-up. Fire prevention counselling still remains one of the most important aspects of burn management.

Hanging leg weight--a rapid technique for estimating total body weight in pediatric resuscitation

The accuracy of two methods of rapidly estimating total body weight in children was assessed. The first method correlated patient length to known total body weight, and the second correlated the weight of both legs weighted together to known total body weight. One hundred children undergoing general anesthesia in the operating rooms of Childrens Hospital of Los Angeles were entered into the study. Each child had a known preoperative body weight. After induction of anesthesia, each child's supine length was measured and hanging (inert) legs were weighted. There was excellent linear correlation between hanging leg weight and total body weight (correlation coefficient [r2], 0.95) for all patients, and good linear correlation between supine length and total body weight, r2, 0.86). Range restriction analysis for both techniques showed poor correlation for total body weights of less than 10 kg and poor correlation for the supine length technique when total body weight was more than 25 kg. The hanging leg weight of an inert child has excellent correlation to total body weight for children weighing more than 10 kg.

Treatment of hemorrhagic shock with intraosseous administration of crystalloid fluid in the rabbit model

Intravenous access can be very difficult to obtain in small hypotensive infants. We studied the ability of the intraosseous route to accept a large volume of resuscitation fluid administered to hypovolemic rabbits. Hypotension induced by withdrawing one-third of the blood volume of rabbits was treated by infusion of saline, IV or intraosseously. A control group was bled, but received no saline. All three groups experienced a drop in mean arterial blood pressure (MAP) to at least 50% of the prebleed baseline value. Also, all groups' heart rates dropped to between 90 and 95% of prebleed baseline values. A ten-minute infusion of a saline volume equal to three times the volume of blood removed reversed hypotension equally by the intraosseous and IV routes. After one-half of the fluid was administered, the MAP was 107 +/- 4% and 104 +/- 11% of baseline in the intraosseous and IV groups, respectively. In contrast, the control group had a MAP of 70 +/- 8% of baseline at the same time. At the end of the fluid bolus the intraosseous group had a MAP of 97 +/- 3% of baseline and the IV group a MAP of 99 +/- 8%. The control group continued to have a low MAP of 72 +/- 6% of baseline. Heart rates rose during fluid administration in both the intraosseous and IV groups, reaching 103 +/- 2% and 99 +/- 3%, respectively, at the end of fluid administration. The control group was 88 +/- 2% of baseline at the same time. The differences between the treatment groups and the control group were significant at the .05 level. The intraosseous route will allow sufficient flow of fluid to rapidly reverse hypotension secondary to hemorrhage in a small mammal (ie, the rabbit).