Alfred Sacchetti

Pediatric analgesia and sedation.

Sedation and analgesia are essential components of the ED management of pediatric patients. Used appropriately, there are a number of medications and techniques that can be used safely in the emergency care of infants and children. Emergency physicians should be competent in the use of multiple sedatives and analgesics. Adequate equipment and monitoring, staff training, discharge instructions and continuous quality management should be an integral part of the ED use of these agents.

Family member presence during pediatric emergency department procedures

Objective Exclusion of family members (FM) during pediatric procedures in the emergency department (ED) is an accepted practice. This study questions the validity of such a practice. Subjects FM of ED pediatric patients undergoing procedures and ED staff performing procedures. Sites ED of a tertiary care university-affiliated community hospital and the pediatric ED of a university hospital. Methods Post-procedure surveys were obtained from FM remaining with their child during an ED procedure and from the ED personnel performing the procedures. FM activity during the procedure was also recorded. Results Ninety-six children (average age 20 months) underwent a total of 127 procedures. ED procedures included: vascular access 91, lumbar puncture 23, urethral catheterization 9, nasogastric tube placement 1, rapid sequence intubation 1, fluid resuscitation from shock 1, and removal of foreign body from eye 1. Three children were critically ill during performance of procedures. ED staff answered 98 surveys concerning the performance of the 127 procedures. FM activities included Stood at bedside 35 (31%), soothed child 21 (19%), and helped restrain child 55 (55%). In 55 (57%) cases the FM was the only adult present with the ED staff member performing the procedure(s). FM member opinions of presence during procedures were Good idea 101 (91%), bad idea 6 (5%), and did not care 4 (4%). ED staff opinions were: good idea 92 (93%), bad idea 2 (2%), and did not care 4 (5%). FM presence made four (5%) members of the ED staff nervous. Conclusion FM presence during ED procedures is a practice favored by both parents and ED staff at our institutions. This practice should not be limited to minimally invasive procedures in stable patients but should be considered for procedures such as lumbar punctures and intubations even in critically ill patients.

Rapid-Sequence Intubation of the Pediatric Patient

Airway compromise is the most common cause of death and severe morbidity in acutely ill and injured children. Rapid-sequence intubation (RSI) is a technique for emergency airway control designed to maximize successful endotracheal intubation while minimizing the adverse physiologic effects of this procedure. RSI requires familiarity with patient evaluation, airway-management techniques, sedation agents, neuromuscular blocking agents, additional adjunctive agents, and postintubation management techniques. Emergency physicians should use RSI techniques in the endotracheal intubation of critically ill children.

Propranolol-induced hypertension in treatment of cocaine intoxication

The case of a patient with apparent cocaine toxicity and drug-mediated hypertension and tachycardia is presented. IV propranolol was used as the initial treatment for his hyperadrenergic state, resulting in a decrease in heart rate but a paroxsymal increase in blood pressure. The patient required nitroprusside for control of elevated blood pressure. A mechanism of unopposed alpha stimulation as a result of beta-2 receptor blockade is proposed, and a cautious approach to the use of propranolol in these patients is suggested.

Acceptance of family member presence during pediatric resuscitations in the emergency department: Effects of personal experience

Objective Opinions remain polarized on allowing family member presence during pediatric resuscitations (FMP). Reluctance to adopt FMP may stem from preconceived notions on this practice. This study evaluates the effect of prior experience with FMP and on its acceptance by emergency department personnel (EDP). Methods EDP from three different EDs were surveyed concerning FMP. Study facilities included an urban teaching community ED with routine FMP (R-ED), a suburban community ED with occasional FMP (O-ED) and an urban university pediatric ED with virtually no FMP (N-ED) during pediatric resuscitations. Survey information included hospital of practice, position in ED, years in practice, opinions on FMP and personal experience with FMP for five clinical scenarios: laceration repair (LAC), intravenous access (IV), lumbar puncture (LP), endotracheal intubation (ETI), cardiopulmonary resuscitation (CPR), and critical resuscitation (CR). Statistical analysis was through chi square and regression analysis. Results Eighty-five emergency department personnel participated in the survey, 57 (67%) nurses, 22 (25%) physicians, 4 technicians (5%), and 2 nurses aids (2%). There was a significant correlation between a favorable opinion concerning family member presence during LP, ETI, CPR and CR and the type of Emergency Department in which the individual practiced (P< 0.002). Regression analysis demonstrated a similar relation between personal experience with LAC, IV, ETI, CR, and CPR and a favorable opinion on FMP during that activity (P< 0.03). Conclusion Opinions on FMP are strongly influenced by experience with this practice. Emergency department personnel with prior exposure to family member presence during resuscitations favor this activity. Biases by EDP lacking experience with FMP may limit its introduction into unfamiliar institutions.

Effect of ED management on ICU use in acute pulmonary edema

Acute pulmonary edema (APE) is a common Emergency Department (ED) presentation requiring admission to an intensive care unit (ICU). This study was undertaken to examine the effect of ED management on the need for ICU admission in patients with APE. ED records of APE patients were abstracted for patient age, prehospital and ED pharmacological treatment, diagnoses, airway interventions, and ICU length of stay (LOS). Statistical analysis was through multiple regression, logistic regression, chi-square, and ANOVA. One hundred eighty-one patients composed the study group. Pharmacological treatment included nitroglycerin (NTG), 147 patients (81%); morphine sulfate (MS), 88 (49%); loop diuretics (LD), 133 (73%); and captopril sublingual (CSL), 47 (26%). Use of CSL and MS were associated with opposing needs for ICU admission. MS use was associated with increased ICU admissions (odds ratio, 3.08; P = .002), whereas CSL use was associated with decreased ICU admissions (odds ratio, 0.29; P = .002). Morphine sulfate use also demonstrated an increased need for endotracheal intubation (ETI) (odds ratio, 5.04; P = .001), whereas CSL demonstrated a decreased need for ETI (odds ratio, 0.16; P = .008). Ninety-three patients required some form of respiratory support. Forty received noninvasive pressure support ventilation (NPSV) from a bilevel positive airway pressure system (BiPAP), and 60 received endotracheal intubation. Some patients received more than 1 form of respiratory support; all other patients received supplemental oxygen only. The ICU-LOS associated with different airway interventions were supplemental oxygen, 0.72 days; BiPAP, 1.48 days; and ETI, 3.70 days (P < .001). Specific ED pharmacological interventions are associated with a decreased need for ICU admission and endotracheal intubation in acute pulmonary edema patients, whereas use of noninvasive pressure support ventilation correlates with a reduction in the ICU length of stay for patients who do require critical care admission.

Reliability of patient history in determining the possibility of pregnancy

In an effort to assess the reliability of patient history in excluding pregnancy, we studied the correlation between specific historical factors and the presence of a positive qualitative serum beta-human chorionic gonadotropin assay. Two hundred eight patients were studied, and information was collected prospectively on a variety of historical criteria. Three historical variables were statistically less likely to be associated with pregnancy: last menstrual period that was on time, the patient thinking she was not pregnant, and the patient stating there was no chance she could be pregnant (P less than .001). There was, however, still at least a 10% chance of the patient being pregnant. Combinations of historical criteria were likewise unsuccessful at totally excluding pregnancy. These data support the contention that patient history is an unreliable method of excluding pregnancy in emergency department patients and supports the liberal use of pregnancy tests.

Pediatric Procedural Sedation in the Community Emergency Department: results from the ProSCED registry.

Objectives: Emergency department procedural sedation practices for children have been reported for pediatric tertiary care centers. This report describes these same practice patterns and outcomes for community hospital-based general emergency physicians (EPs) in their treatment of pediatric patients. Methods: The Procedural Sedation in the Community Emergency Department registry is a prospective observational database composed of consecutive EP-directed procedural sedation cases in community hospitals. Information on sedation cases is collected at the time of the patient encounter and entered into an Internet-accessed database. Results: A total of 1028 procedural sedations were performed on 977 patients at 14 study sites, with 341 procedures performed in 339 patients younger than 21 years. The most common specified pediatric procedures performed included laceration repairs (n = 86, 25%), shoulder relocations (n = 78, 23%), and fracture care of the upper extremity (n = 56, 16%). Medications used included ketamine (n = 141, 41%), midazolam (n = 10, 32%), etomidate (n = 54, 16%), fentanyl (n = 51, 15%), and propofol (n = 47, 14%). Complications were reported in 2 cases (0.6%), 1 episode of apnea requiring a reversal agent and 1 episode of hypoxia responsive to supplemental oxygen. Of procedures attempted, 339 (99.4%) were successfully completed. Emergency physicians both directed the sedation and performed the procedure in 252 cases (74%), whereas in another 69 cases (20%), they directed the sedation for another physician performing the procedure. In 20 cases (5.8%), the EP directed sedation for a painless diagnostic study. Conclusions: Community EPs in the Procedural Sedation in the Community Emergency Department registry deliver safe and effective pediatric sedation using a broad selection of agents.

Clinical Policy: Critical Issues in the Sedation of Pediatric Patients in the Emergency Department

From the EMSC Panel (Writing Committee) on Critical Issues in the Sedation of Pediatric Patients in the Emergency Department: Sharon E. Mace, MD, Chair, American College of Emergency Physicians (ACEP) Lance A. Brown, MD, MPH (ACEP) Lisa Francis, BSN, RN (Society of Pediatric Nurses) Steven A. Godwin, MD (ACEP) Sigrid A. Hahn, MD (ACEP) Patricia Kunz Howard, PhD, RN, CEN (Emergency Nurses Association) Robert M. Kennedy, MD (American Academy of Pediatrics) David P. Mooney, MD (American Pediatric Surgical Association) Alfred D. Sacchetti, MD (ACEP) Robert L. Wears, MD, MS, Methodologist (ACEP) Randall M. Clark, MD (American Society of Anesthesiologists)

Primary cardiac arrhythmias in children

OBJECTIVES Primary cardiac arrhythmias are much less common in children than adults. This study was performed to identify the characteristics of primary arrhythmias in pediatric patients in the Emergency Department (ED). METHODS Retrospective review of ED visits of patients <18 years of age presenting between January 1991 and November 1996 with an Emergency Department diagnosis of primary cardiac arrhythmia. Secondary cardiac arrhythmias, ie, sinus tachycardia resulting from a fever, were excluded. Clinically significant arrhythmias were defined as those capable of altering cardiovascular stability. SITE: 26 Community Hospital EDs. RESULTS A total of 2.3 million ED visits were reviewed and 320 arrhythmias in children were identified in 0.58 million patients under 18 years of age. The overall incidence of arrhythmias was 13.9 per 100,000 ED visits and 55.1 per 100,000 pediatric ED visits. The incidence of clinically significant arrhythmias was 5.7 per 100,000 ED visits and 22.5 per 100,000 patients <18 years of age. The mean patient age was 113 (+/-0.31) years with a peak in infancy and a second peak in late childhood and adolescence. The most common arrhythmias were: Sinus tachycardia: 160 (50%); Supraventricular tachycardia (SVT): 42 (13%); Nonspecific arrhythmia (NSA): 34 (10.6%); Bradycardia: 19 (6%); and Atrial fibrillation (a-fib): 15 (4.6%). The most common clinically significant arrhythmias by age group were: [table in text]. Nine patients had an additional diagnosis of Wolf-Parkinson-White syndrome, eight with Sinus tachycardia and one with SVT. There were four cardiac arrests noted all with ventricular fibrillation as the recorded arrhythmia. CONCLUSION Primary arrhythmias are unusual ED presentations in children and atrial tachyarrhythmias are the most common rate and rhythm disturbance in this population.