Benoit Bailey

CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury

Background: There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury. Methods: For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13–15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity. Results: Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%–100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%–99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT. Interpretation: The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.

Lipid emulsions in the treatment of acute poisoning: a systematic review of human and animal studies

Objective. To assess the evidence regarding the efficacy and safety of intravenous fat emulsion (IFE) in the management of poisoned patients. Methods. We performed a systematic review of the literature with no time or language restriction. The electronic databases were searched from their inception until June 1, 2009 (Medline, EMBASE, ISI web of science, Biological abstract, LILACS, ChemIndex, Toxnet, and Proquest). We also examined the references of identified articles and the gray literature. The target interventions eligible for inclusion were administration of any IFE before, during, or after poisoning in human or animals. All types of studies were reviewed. Eligibility for inclusion and study quality scores, based on criteria by Jadad and the STROBE statement, were evaluated by independent investigators. The primary outcome was mortality. Secondary outcomes included neurologic, hemodynamic, and electrocardiographic variables, as well as adverse effects. Results. Of the 938 publications identified by the search strategies, 74 met the inclusion criteria. We identified 23 animal trials, 50 human, and 1 animal case reports. Overall, the quality of evidence was weak and significant heterogeneity prevented data pooling. Available data suggest some benefits of IFE in bupivacaine, verapamil, chlorpromazine, and some tricyclic antidepressants and beta-blockers toxicity. No trial assessed the safety of IFE in the treatment of acute poisoning. Conclusion. The evidence for the efficacy of IFE in reducing mortality and improving hemodynamic, electrocardiographic, and neurological parameters in the poisoned patients is solely based on animal studies and human case reports. The safety of IFE has not been established.

Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation.

ObjectivesTo summarize and compare different prognostic criteria used to determine need for liver transplantation in patients with fulminant hepatic failure secondary to acetaminophen poisoning. Data SourcesStudies published in the literature that investigated criteria for hepatic transplantation secondary to acetaminophen-induced liver failure as identified by a preestablished MEDLINE strategy (1966 through October 2001). Study SelectionStudies were included if 2 × 2 tables could be reconstructed and if they did not assume that patients undergoing transplantation would have eventually died had they not received the transplant. Data ExtractionRelevant articles were reviewed by two authors independently. Discrepancies or disagreements, if any, on the inclusion or exclusion of studies were resolved by consulting the third author. Data SynthesisKing’s criteria (pH < 7.30 or prothrombin time of >100 secs plus creatinine of >300 &mgr;mol/L plus encephalopathy grade of ≥3) were evaluated in nine studies, pH < 7.30 in four, prothrombin time of >100 secs in three, prothrombin time of >100 secs plus creatinine of >300 &mgr;mol/L plus encephalopathy grade of ≥3 in three, creatinine of >300 &mgr;mol/L in two, and one each for increase in prothrombin time day 4, factor V of <10%, Acute Physiology and Chronic Health Evaluation (APACHE) II score of >15, and Gc-globulin of <100 mg/L. King’s criteria were more sensitive than pH: 69% (95% confidence interval, 63–75) vs. 57% (95% confidence interval, 44–68). Their specificities were, however, comparable: 92% (95% confidence interval, 81–97) vs. 89% (95% confidence interval, 62–97). APACHE II score of >15 had the highest positive likelihood ratio (16.4) and the lowest negative likelihood ratio (0.19) but was evaluated in only one study. The accuracy measures of all other criteria were lower than that of King’s criteria or pH < 7.30. ConclusionsPresently, available criteria are not very sensitive and may miss patients requiring transplantation. Future studies should further evaluate the efficacy of the APACHE II criteria.

Glucagon in β‐Blocker and Calcium Channel Blocker Overdoses: A Systematic Review

Abstract Background. Glucagon is usually accepted as part of the standard treatment in the management of patients with β‐blocker and calcium channel blocker overdoses. Methods. A systematic review was done in order to evaluate the evidence supporting glucagon use in β‐blocker and calcium channel blocker overdoses. Studies evaluating glucagon for those uses were identified using the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register, MedLine, ToxLine, and EMBASE searches, as well as reviewing medical toxicology textbooks and references of identified articles. Only controlled studies of human or animal studies were included, the latter only when it was an in vivo model of acute poisoning. The quality of the included studies was assessed. Results. The search found no study in humans but identified 30 in animals. In the five studies of animal models of β‐blocker overdose included, glucagon appeared to consistently increase the heart rate at least transiently but appeared to have no effect on mean arterial pressure even though it possibly increased cardiac output. Its effect on the survival rate in animal models of β‐blocker overdose was unclear. In the six studies of animal models of calcium channel blocker overdose included, glucagon appeared to increase heart rate and cardiac output and reverse second and third degree AV blocks, all at least transiently. There appeared to be no effect of glucagon on mean arterial pressure although it did increase in one model. Glucagon appeared to have no effect on survival rate. The included studies for both overdoses were not blinded, had limited numbers of animals, and some had inadequate glucagon regime. Conclusion. The evidence supporting the use of glucagon in the management of patients with β‐blocker and calcium channel blocker overdoses is limited to animal studies.

Management of Anaphylactoid Reactions to Intravenous N-Acetylcysteine

STUDY OBJECTIVE To develop management guidelines for the treatment of anaphylactoid reactions to intravenous N-acetylcysteine (NAC) and to assess the safety of restarting the infusion after a reaction. METHODS In phased 1, we used a 6-year retrospective case series of hospitalized patients and a review of the literature to develop the management guidelines for anaphylactoid reactions to intravenous NAC. In phase 2, these guidelines were evaluated prospectively in our poison-control center. RESULTS In phase 1, the charts of 11 patients with anaphylactoid reactions (9 cutaneous and 2 systemic) were reviewed. In most cases, no treatment or treatment with diphenhydramine alone or with salbutamol was sufficient to continue or restart NAC infusion safely. On the basis of our findings in those patients and on published experience, we concluded that anaphylactoid reactions to intravenous NAC are dose-related and the antihistamines are useful in controlling and in preventing recurrence of anaphylactoid symptoms. We developed the following guidelines: flushing requires no treatment, urticaria should be treated with diphenhydramine, and NAC infusion should be continued in both cases. Angioedema and respiratory symptoms each require the administration of diphenhydramine and symptomatic therapy. In these cases, NAC infusion should be stopped but, when necessary, can be started 1 hour after the administration of diphenhydramine in the absence of symptoms. In phase 2, 50 patients (31 cutaneous and 19 systemic reactions) were treated prospectively with the use of these guidelines. Recurrence of symptoms occurred in only one case involving a deviation from the guidelines. The NAC infusion was restarted immediately after the administration of diphenhydramine in a patient who sustained a systemic reaction. CONCLUSION Non-life-threatening anaphylactoid reactions to intravenous NAC are treated easily and the infusion may be continued or restarted safely after the administration of diphenhydramine.

Prospective Controlled Study of Hydroxyzine and Cetirizine in Pregnancy

BACKGROUND Hydroxyzine has been used for many years for the treatment of allergic symptoms. Cetirizine, an active metabolite of hydroxyzine, has become very popular for the treatment of allergy symptoms because of its efficacy without the sedating effects of the parent compound. Little is known about the safety of hydroxyzine use during pregnancy, and there are no published reports on the effects of cetirizine on pregnancy outcome. OBJECTIVE To determine whether hydroxyzine and cetirizine are associated with any increased risk of malformations in humans. METHODS All pregnant women counseled by the Motherisk Program in Toronto on the use of hydroxyzine or cetirizine during their pregnancies were enrolled in a prospective, controlled, observational study. The control group consisted of pregnant women matched for age, smoking, and alcohol consumption who were counseled for non-teratogenic drug. RESULTS One hundred twenty women were followed after exposure to either hydroxyzine or cetirizine during pregnancy. Of these, 53 were exposed to hydroxyzine during organogenesis and 39 to cetirizine. There were no significant differences found between the hydroxyzine or cetirizine groups and the control groups in the pregnancy outcome: rate of livebirths, spontaneous or therapeutic abortion, or stillbirth. There was also no difference in the rates of major or minor anomalies, mean birth weight, mode of delivery, gestational age, or presence of neonatal distress. CONCLUSIONS The use of hydroxyzine and cetirizine does not appear to be associated with increased teratogenic risk.

Validation and properties of the verbal numeric scale in children with acute pain

&NA; Although the verbal numeric scale (VNS) is used frequently at patients’ bedsides, it has never been formally validated in children with acute pain. In order to validate this scale, a prospective cohort study was performed in children between 8 and 17 years presenting to a pediatric emergency department (ED) with acute pain. Pain was graded using the VNS, the visual analogue scale (VAS), and the verbal rating scale (VRS). A second assessment was done before discharge. We determined a priori that in order to be valid, the VNS would need to: correlate with the VAS (concurrent validity); decrease after intervention to reduce pain (construct validity); and be associated with the VRS categories (content validity). The VNS interchangeability with the VAS, its minimal clinically significant difference, and test–retest reliability were also determined. A total of 202 patients (mean age: 12.2 ± 2.6 years) were enrolled. The VNS correlated with the VAS: ric = 0.93, p < 0.001. There were differences in the VNS before versus after interventions (p < 0.001), and between VRS categories (mild versus moderate, p < 0.001; moderate versus severe, p < 0.001). The 95% limits of agreement (interchangeability) between VNS/VAS were outside the a priori set limit of ±2.0: −1.8, 2.5. The VNS minimal clinically significant difference was 1. The VNS had good test–retest reliability with 95% limits of agreement of −0.9 and 1.2. In conclusion, the VNS provides a valid and reliable scale to evaluate acute pain in children aged 8–17 years but is not interchangeable with the VAS.

Markers for bacterial infection in children with fever without source

Objectives To compare the diagnostic properties of procalcitonin (PCT), C reactive protein (CRP), total white blood cells count (WBC), absolute neutrophil count (ANC) and clinical evaluation to detect serious bacterial infection (SBI) in children with fever without source. Design Prospective cohort study. Setting Paediatric emergency department of a tertiary care hospital. Participants Children aged 1–36 months with fever and no identified source of infection. Intervention Complete blood count, blood culture, urine analysis and culture. PCT and CRP were also measured and SBI probability evaluated clinically with a visual analogue scale before disclosing tests results. Outcome measure Area under the curves (AUC) of the receiver operating characteristic curves. Results Among the 328 children included in the study, 54 (16%) were diagnosed with an SBI: 48 urinary tract infections, 4 pneumonias, 1 meningitis and 1 bacteraemia. The AUC were similar for PCT (0.82; 95% CI 0.77 to 0.86), CRP (0.88; 95% CI 0.84 to 0.91), WBC (0.81; 95% CI 0.76 to 0.85) and ANC (0.80; 95% CI 0.75 to 0.84). The only statistically significant difference was between CRP and ANC (Δ AUC 0.08; 95% CI 0.01 to 0.16). It is important to note that all the surrogate markers were statistically superior to the clinical evaluation that had an AUC of only 0.59 (95% CI 0.54 to 0.65). Conclusion The study data demonstrate that CRP, PCT, WBC and ANC had almost similar diagnostic properties and were superior to clinical evaluation in predicting SBI in children aged 1 month to 3 years.

Cardiac Monitoring Of Children With Household Electrical Injuries

STUDY OBJECTIVE Because death has occurred with injury involving voltage as low as 50 to 60 V (probably the result of arrhythmias), we wanted to evaluate the necessity of cardiac monitoring in children sustaining electrical injuries with 120 or 240 V. DESIGN The charts of 151 children who presented to the emergency department between April 1, 1989, and March 31, 1992, were reviewed. SETTING A tertiary care pediatric teaching hospital. RESULTS A total of 141 patients presented with 120-V electrical injuries. An ECG or a rhythm strip was performed in 93 patients (66%), and no arrhythmias were believed to have resulted from the electrical injury. Cardiac monitoring was done in 113 patients (80%) for a mean duration of 7.4 +/- 6.6 hours (median, 4 hours), and no arrhythmias were observed. Creatine phosphokinase levels were measured in 62 patients (44%) with a mean of 137 +/- 154 U/L (median, 96 U/L). The levels were elevated in 8 patients (12%), with no clinical significance. Follow-up was done in 112 patients (77%), and no significant adverse outcome was reported. There were only 10 patients in the 240-V group; no arrhythmias or adverse outcomes had occurred. CONCLUSION On the basis of our findings, initial cardiac evaluation (ECG) and monitoring do not appear to be necessary in children sustaining household electrical injuries (120 and 240-V); however, the significance of loss of consciousness, tetany, wet skin, or current flow that crossed the heart region could not be determined in our investigation. Therefore, cardiac monitoring should be performed if one of these factors is present.

Agreement among Pediatric health care professionals With the Pediatric Canadian Triage and Acuity Scale guidelines

Objectives: To compare triage level assignment, using case scenarios, in a pediatric emergency department between registered nurses (RNs) and pediatric emergency physicians (PEPs) based on the Pediatric Canadian Triage and Acuity Scale (P-CTAS) guidelines. To compare triage level assignment of the RNs and PEPs to that done by a panel of experts using the same P-CTAS guidelines. Methods: A cross-sectional questionnaire survey (55 case scenarios) was sent to all RNs and PEPs working in the emergency department after the P-CTAS was implemented. Participants were instructed to assign a triage level for each case. A priori, all cases were assigned a triage level by a panel of experts using the P-CTAS guidelines. Kappa statistics and the mean number (±1SD) of correct responses were calculated. Results: A response rate of 85% was achieved (29 RNs, 15 PEPs). The kappa level of agreement (95% CI) among RNs was 0.51 (0.50-0.52) and was 0.39 (0.38-0.41) among PEPs (P < 0.001). The mean number of correct responses (±1SD) for RNs was 64% ± 27% and for PEPs 60% ± 22% (P = 0.31). Levels of agreement did not vary according to experience or type of shift work done or work status of RNs and PEPs. Conclusions: With the introduction of the P-CTAS, the level of agreement and accuracy of triage categorization remained moderate for both RNs and PEPs. The reliability of the P-CTAS needs to be further assessed and the requirements for revisions considered prior to its widespread use.