Angela C. Anderson

Treatment of pediatric migraine headaches: A randomized, double-blind trial of prochlorperazine versus ketorolac

STUDY OBJECTIVE We compare the effectiveness of intravenous ketorolac and intravenous prochlorperazine in the treatment of pediatric migraine headaches. METHODS We performed a prospective, randomized, double-blind clinical trial in 2 pediatric emergency departments (EDs) within childrens hospitals. Children aged 5 to 18 years presenting to the ED with migraine headaches were eligible for the study. Contraindications to either medication or the inability to complete the pain score resulted in exclusion. Children were randomized to receive intravenous ketorolac (0.5 mg/kg; maximum 30 mg) or intravenous prochlorperazine (0.15 mg/kg; maximum 10 mg). All children also received a normal saline solution bolus. Successful treatment was defined as a 50% or greater reduction in the Nine Faces Pain Scale score at 60 minutes. If a less than 50% improvement occurred by 60 minutes, the child received the other medication. Forty-eight-hour follow-up telephone calls were made to each family to assess recurrence and late side effects. RESULTS Sixty-two children were enrolled: 33 initially received prochlorperazine, and 29 initially received ketorolac. By 60 minutes, 16 (55.2%) of 29 of those who received ketorolac and 28 (84.8%) of 33 of those who received prochlorperazine were successfully treated (difference=30%; 95% confidence interval [CI] 8% to 52%). Fifty-six (93.3%) of the 60 children who completed the study were successfully treated by the studys conclusion. Approximately 30% of each group had a recurrence of some headache symptoms. Only 2 children reported side effects, both mild and self-limited. CONCLUSION In children, intravenous prochlorperazine is superior to intravenous ketorolac in the acute treatment of migraine headaches.

Effect of delay in presentation on rate of perforation in children with appendicitis

INTRODUCTION Appendicitis is the most common emergency operation in children. The rate of perforation may be related to duration from symptom onset to treatment. A recent adult study suggests that the perforation risk is minimal in the first 36 hours and remains at 5% thereafter. We studied a pediatric population to assess symptom duration as a risk factor for perforation. METHODS We prospectively studied all children older than 3 years who underwent an appendectomy over a 22-month period. RESULTS Of 202 patients undergoing appendectomies, 197 had appendicitis. Median age was significantly lower in the perforated group, but temperature and leukocytosis were not. As expected, length of hospital stay was longer in the perforated group (4-13 vs 2-6 days). The incidence of perforation was 10% if symptoms were present for less than 18 hours. This incidence rose in a linear fashion to 44% by 36 hours. Prehospital delays were greater in patients with perforated appendicitis. However, in-hospital delay (from presentation to surgery) was less than 5 hours in the perforated group and 9 hours in the nonperforated group. DISCUSSION Appendiceal perforation in children is more common than in adults and correlates directly with duration of symptoms before surgery. Perforation is more common in younger children. Unlike in adults, the risk of perforation within 24 hours of onset is substantial (7.7%), and it increases in a linear fashion with duration of symptoms. In our experience, however, perforation correlates more with prehospital delay than with in-hospital delay.

Effect of Metoclopramide Dose on Preventing Emesis After Oral Administration of N-Acetylcysteine for Acetaminophen Overdose

OBJECTIVE To determine the effect of the metoclopramide dose on the prevention of vomiting of N-acetylcysteine in acetaminophen overdose. METHODS Patients with acetaminophen ingestions receiving metoclopramide prior to emergency department administration of N-acetylcysteine were included. Emergency Department and poison center records were reviewed for administration of metoclopramide pre-N-acetylcysteine and incidence of subsequent vomiting. The treatment group was defined as patients receiving high-dose metoclopramide (20-50 mg intravenously) prior to the loading dose of N-acetylcysteine. Controls were patients receiving standard-dose (< 20 mg intravenously) metoclopramide prior to loading dose of N-acetylcysteine. Outcome was vomiting within 60 minutes of N-acetylcysteine administration. RESULTS Twelve of 19 patients (63%) receiving standard-dose metoclopramide vomited N-acetylcysteine. Only 5 of 23 patients (22%) receiving high-dose metoclopramide vomited N-acetylcysteine (crude odds ratio: 6.2; 95% CI [1.3-30.3]). After controlling for confounding in the logistic regression model, the effect of high-dose metoclopramide in preventing vomiting of N-acetylcysteine remained significant (adjusted odds ratio: 17.0; 95% CI [2.6-110.0]). CONCLUSION This study supports the efficacy of high-dose metoclopramide to prevent emesis after the oral loading dose of N-acetylcysteine.

Three scenarios to teach difficult discussions in pediatric emergency medicine: sudden infant death, child abuse with domestic violence, and medication error.

Within an emergency medicine (EM) environment, the pace of clinical care delivery rarely allows time to stop and observe extended interactions between trainees and patients, or to provide feedback on communication skills. Once residency and fellowship conclude, however, these same trainees will be required to manage complicated medical and social interactions independently. In particular, unique challenges in the realm of patient-doctor interaction arise in the field of pediatric emergency medicine (PEM), with most clinical encounters involving both a child and their caregiver. Whether delivering bad news to a family or screening and managing cases of suspected child abuse, child neglect or domestic violence, many physicians report having no formal training in communicating effectively and compassionately under difficult conditions.1–4 It is imperative to consider and prepare future physicians for the emotional relationship between the (pediatric) patient and the family when caring for the family unit, especially in emergent situations and times of crisis. The occurrence of medical error presents another tremendously challenging situation for physicians and requires sophisticated communications skills. Despite clinicians’ best preventive and conscientious efforts, various elements can lead to a medical error, and the physicians involved will need to disclose and discuss the event with the family. Once again, few physicians have had formal training in managing these situations.5 To improve training in PEM physician communications during difficult discussions, we created a hybrid medical simulation program, a combination of standardized patients and high-fidelity medical simulation. The primary objective was to educate EM residents and PEM fellows on the communication skills necessary to engage in difficult discussions when caring for children in an emergency department setting. Authors will present three scenarios developed for an educational activity designed to focus on difficult discussion communication skills in PEM.

Obtaining a faculty position in academic emergency medicine

The purpose of this article is to help explore the general aspects of finding an attending position in academic emergency medicine. Previous studies have examined the academic expectations of individuals in both emergency medicine residencies 1,2 and pediatric emergency medicine fellowship programs. 3,4 . The present goal is to look beyond postgraduate training in pediatric emergency medicine and to present a general framework for acquiring an attending position. This will also serve as an aid in finding a job that will launch ones academic career in pediatric emergency medicine. The followings areas will be addressed: 1) networking, 2) preparing a curriculum vitae, and 3) questions to consider during the interview process.

Contamination Rates of Two Blood Cultures Drawn Through the Same Intravenous Line |[bull]| 385

Background: To avoid additional venipuncture, blood cultures (BC) are often drawn and set aside when placing an intravenous line (IV), wasting BC bottles. If BCs could be drawn through indwelling IVs without an increased rate of contamination, later blood draws for culture samples would provide a viable alternative.