Andrew Capraro

Utility of Lumbar Puncture for First Simple Febrile Seizure Among Children 6 to 18 Months of Age

OBJECTIVES. American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis. Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children. METHODS. A retrospective cohort review was performed for patients 6 to 18 months of age who were evaluated for first simple febrile seizure in a pediatric emergency department between October 1995 and October 2006. RESULTS. First simple febrile seizure accounted for 1% of all emergency department visits for children of this age, with 704 cases among 71 234 eligible visits during the study period. Twenty-seven percent (n = 188) of first simple febrile seizure visits were for infants 6 to 12 months of age, and 73% (n = 516) were for infants 12 to 18 months of age. Lumbar puncture was performed for 38% of the children (n = 271). Samples were available for 70% of children 6 to 12 months of age (131 of 188 children) and 25% of children 12 to 18 months of age (129 of 516 children). Rates of lumbar puncture decreased significantly over time in both age groups. The cerebrospinal fluid white blood cell count was elevated in 10 cases (3.8%). No pathogen was identified in cerebrospinal fluid cultures. Ten cultures (3.8%) yielded a contaminant. No patient was diagnosed as having bacterial meningitis. CONCLUSIONS. The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low. Current American Academy of Pediatrics recommendations should be reconsidered.

Improving Adherence to PALS Septic Shock Guidelines

BACKGROUND AND OBJECTIVES: Few studies have demonstrated improvement in adherence to Pediatric Advanced Life Support guidelines for severe sepsis and septic shock. We sought to improve adherence to national guidelines for children with septic shock in a pediatric emergency department with poor guideline adherence. METHODS: Prospective cohort study of children presenting to a tertiary care pediatric emergency department with septic shock. Quality improvement (QI) interventions, including repeated plan-do-study-act cycles, were used to improve adherence to a 5-component sepsis bundle, including timely (1) recognition of septic shock, (2) vascular access, (3) administration of intravenous (IV) fluid, (4) antibiotics, and (5) vasoactive agents. The intervention focused on IV fluid delivery as a key driver impacting bundle adherence, and adherence was measured using statistical process control methodology. RESULTS: Two-hundred forty-two patients were included: 126 subjects before the intervention (November 2009 to March 2011), and 116 patients during the QI intervention (October 2011 to May 2013). We achieved 100% adherence for all metrics, including (1) administration of 60 mL/kg IV fluid within 60 minutes (increased from baseline adherence rate of 37%), (2) administration of vasoactive agents within 60 minutes (baseline rate of 35%), and (3) 5-component bundle adherence (baseline rate of 19%). Improvement was sustained over 9 months. The number of septic shock cases between each death from this condition increased after implementation of the QI intervention. CONCLUSIONS: Using QI methodology, we have demonstrated improved adherence to national guidelines for severe sepsis and septic shock.

Reforming Procedural Skills Training for Pediatric Residents: A Randomized, Interventional Trial

BACKGROUND: Pediatric housestaff are required to learn basic procedural skills and demonstrate competence during training. To our knowledge, an evidenced-based procedural skills curriculum does not exist. OBJECTIVE: To create, implement, and evaluate a modular procedural skills curriculum for pediatric residents. METHODS: A randomized, controlled trial was performed. Thirty-eight interns in the Boston Combined Residency Program who began their training in 2005 were enrolled and randomly assigned. Modules were created to teach residents bag-mask ventilation, venipuncture, peripheral intravenous catheter (PIV) insertion, and lumbar puncture skills. The curriculum was administered to participants in the intervention group during intern orientation. Interns in the control group learned procedural skills by usual methods. Subjects were evaluated by using a structured objective assessment on simulators immediately after the intervention and 7 months later. Success in performing live-patient procedures was self-reported by subjects. The primary outcome was successful performance of the procedure on the initial assessment. Secondary outcomes included checklist and knowledge examination scores, live-patient success, and qualitative assessment of the curriculum. RESULTS: Participants in the intervention group performed PIV placement more successfully than controls (79% vs 35%) and scored significantly higher on the checklist for PIV placement (81% vs 61%) and lumbar puncture (77% vs 68%) at the initial assessment. There were no differences between groups at month 7, and both groups demonstrated declining skills. There were no statistically significant differences in success on live-patient procedures. Those in the intervention group scored significantly higher on knowledge examinations. CONCLUSIONS: Participants in the intervention group were more successful performing certain simulated procedures than controls when tested immediately after receiving the curriculum but demonstrated declining skills thereafter. Future efforts must emphasize retraining, and residents must have sufficient opportunities to practice skills learned in a formal curriculum.

Severe intoxication from xylazine inhalation

We present the first documented case of overdose from xylazine inhalation. The patient developed findings consistent with alpha 2 adrenergic agonist toxicity, eg coma, miosis, apnea, bradycardia, hypothermia, and dry mouth 2 hours after exposure. Standard dose naloxone did not reverse these effects. The patient fully recovered after appropriate supportive measures. A review of prior reports of xylazine exposure is provided.

Yield of Emergent Neuroimaging Among Children Presenting With a First Complex Febrile Seizure

Objectives The objective of this study was to assess the risk of intracranial pathology requiring immediate intervention among children presenting with their first complex febrile seizure (CFS). Design/Methods This is a retrospective cohort review of patients 6 to 60 months of age evaluated in a pediatric emergency department between 1995 and 2008 for their first CFS. Cases were identified using computerized text search followed by manual chart review. We excluded patients with a prior history of a nonfebrile seizure disorder or a prior CFS, an immune-compromised state, an underlying illness associated with seizures or altered mental status, or trauma. Data extraction included age, sex, seizure features, prior simple febrile seizures, temperature, family history of seizures, vaccination status, findings on physical examination, laboratory and imaging studies, diagnosis, and disposition. Results We identified a first CFS in 526 patients. Two hundred sixty-eight patients (50.4%) had emergent head imaging: 4 patients had a clinically significant finding: 2 had intracranial hemorrhage, 1 had acute disseminated encephalomyelitis, and 1 patient had focal cerebral edema (1.5%; 95% confidence interval, 0.5%–4.0%). Assigning low risk to patients not imaged and not returning to the emergency department within a week of the original visit, the risk of intracranial pathology in our sample was 4 (0.8%; 95% confidence interval, 0.2%–2.1%) of 526. Three of these 4 patients had other obvious findings (nystagmus, emesis, and altered mental status; persistent hemiparesis; bruises suggestive of inflicted injury). Conclusions Very few patients with CFSs have intracranial pathology in the absence of other signs or symptoms. Patients presenting with more than one seizure in 24 hours in particular are at very low risk.

Holiday ornament-related injuries in children.

Objectives: Holiday ornament injuries in children have not been well documented in the medical literature. Our aim was to investigate the patterns of injuries sustained from these ornaments as a first measure toward prevention. Methods: This was a retrospective cohort analysis of all patients examined in an urban pediatric emergency department over a 13-year period ending in March 2008 for holiday ornament-related injuries. Cases were identified using a computer-assisted text query followed by a manual chart review. Data collected from each chart included the childs age, sex, injury characteristics, physical examination findings, radiographic imaging, interventions, and disposition. To analyze injury rates over the years, we used a multiplicative Poisson model allowing varying exposures. Results: Over the study period, we identified 76 eligible patients. The median age was 2 years (interquartile range, 1.17-3.3 years); 44.7% were female. Forty-three of the 76 cases (53.9%) involved ingestions: 35 were of holiday ornaments, and 8 were of light bulbs. All but one of these ornaments were made of glass. In 28%, there was an associated bleed either from the mouth or as a delayed gastrointestinal bleed. Other patients experienced lacerations (27.6%), eye injuries (5.1%), and minor electrocution injury (2.5%). Imaging was performed in 85%. A subspecialty consult was obtained in 23%, primarily addressing a foreign body ingestion or removal after skin exploration. The incidence rate has not changed over the years. Conclusions: Holiday ornament-related injuries primarily involve foreign body ingestions and glass-related injuries. Over half of the injuries involved small light bulbs and ornaments made of glass placed at the level a toddler can reach. Pediatricians are advised to discuss these points with families during holiday season.

Focal motor seizure in a wrestler with a sport-related concussion.

Abstract Although sport-related concussion is a common injury, it is infrequently associated with seizure. While concussive convulsions, consisting of brief, generalized myoclonic activity while an athlete is unconscious have been described, the authors are aware of no published cases of concussion complicated by focal motor seizures. The authors describe the case of a 16-year-old male wrestler who sustained a sport-related concussion complicated by a focal motor seizure. The acute assessment and management of his injury, as well as follow-up until resolution of his symptoms, is presented. A brief review of the association between convulsive activity and mild traumatic brain injury follows.

Etiologies and Yield of Diagnostic Testing in Children Presenting to the Emergency Department with Altered Mental Status

Objectives To identify etiologies of altered mental status in pediatric patients presenting to the emergency department (ED) and to characterize the yield of diagnostic testing in these patients. Study design Retrospective chart review of children aged 1‐17 years presenting to a pediatric tertiary care ED between December 31, 2013 and December 31, 2014 with a chief complaint or International Classification of Disease, Ninth Edition code of altered mental status. The primary outcome was the etiology, defined as “immediate diagnosis” if the etiology was known in triage, “definitely established” if established by physical examination and abnormal laboratory results, imaging, or electrocardiogram findings, “probable” if the etiology was highly suspected in the ED but not confirmed with positive test results, or “unknown.” The secondary outcome was testing utilization and contribution to the diagnosis. Results Three hundred thirty‐six eligible subjects were identified; mean age of 9 years (±6 years). The etiology of altered mental status was immediately established in 114 subjects (34%, 95% CI 29, 39). Among the remaining eligible subjects (N = 222), a definite or probable cause of altered mental status was identified in 82% (N = 182, 95% CI 76, 86) of cases and the etiology remained “unknown” in 18% (N = 40, 95% CI 14, 24). Only 10% of diagnostic tests performed were abnormal and contributed to a diagnosis. The median number of diagnostic tests per patient was 6 (IQR 3, 8). Conclusions Etiologies of altered mental status in children varied widely and often an underlying diagnosis was not found. Broad diagnostic testing was commonly performed although the overall yield was low.

A Rare Cause of Right Lower Quadrant Pain in an 11-Year-Old Female

An 11-year-old premenarchal female with a history of constipation, sickle cell trait, and obesity presented to the emergency department with 5 days of abdominal pain. Her pain began in the right lower quadrant (RLQ) and remained localized without radiation. The pain was described as dull, aching, intermittent, and worse with straining. It was associated with mild anorexia. She had regular, soft bowel movements, and had tried taking a stool softener without relief of the pain. She had no fever, nausea, vomiting, diarrhea, dysuria, or vaginal bleeding. On physical examination, the patient was afebrile with a heart rate of 88 beats per minute, blood pressure 110/74 mm Hg, respiratory rate of 20 breaths per minute, and oxygen saturation of 97% on room air. Her weight was 71 kg. She was generally well appearing. Her mucous membranes were moist, breathing was nonlabored, and no cardiac murmur was appreciated. Her abdomen was soft and nondistended with normal bowel sounds. She had focal tenderness in the RLQ without rebound tenderness or guarding. The pain was mildly accentuated with hopping. She had a positive Psoas sign but negative Rovsing and obturator signs. There were no masses or hepatosplenomegaly. She had no costovertebral angle tenderness. Laboratory values were as follows: white blood cell count 9.5 × 10/L with 57% neutrophils, 34% lymphocytes, 4% monocytes, 2% eosinophils, and 2% atypical lymphocytes; hemoglobin 12.7 g/dL; hematocrit 36.3 mg/dL; and platelets 251 × 10/L. A serum chemistry was unremarkable. Urinalysis revealed a specific gravity of 1.015, pH 6.0, leukocyte esterase 2+, nitrites negative, protein negative, glucose negative, ketones negative, 5 white blood cells per high-power field (HPF), <1 red blood cell per HPF, and 1 squamous epithelial cell per HPF. A urine Gram stain was negative. An abdominal radiograph (Figure 1) showed a moderate stool burden and no air fluid levels. An abdominal ultrasound (Figure 2) demonstrated an avascular ovoid hypoechoic structure in the RLQ, with dimensions 3.0 × 0.9 × 2.2 cm, that corresponded to the point of maximal tenderness. There was a small amount of free fluid in the cul-de-sac. The appendix was not identified. The ovaries had normal arterial and venous Doppler flow. The kidneys were normal in size and echogenicity. 674523 CPJXXX10.1177/0009922816674523Clinical PediatricsHoffmann et al research-article2016

Picture of the month--quiz case. Plastic bronchitis.

A N 11-MONTH-OLD BOY PRESENTED TO THE emergency department with a 24-hour history of barking cough and sudden onset of increased work of breathing. The family reported that his respiratory difficulty acutely worsened after a bout of forceful coughing shortly prior to arrival. On examination, the patient was ill appearing. His vital signs revealed a respiratory rate of 50 breaths/min and oxygen saturation of 76% on room air. The patient was in moderate respiratory distress, with grunting and retractions noted. There was no stridor. Auscultation of the chest revealed decreased breath sounds on the left. A portable chest radiograph was obtained (Figure 1).