Bruce L. Klein

A comprehensive review of naloxone for the emergency physician.

Naloxone has enjoyed long-standing success as a safe and effective opioid antagonist and has been invaluable in defining the role of endogenous opioid pathways in the response to pathological states such as sepsis and hypovolemia. We look forward to exciting research to further elucidate these pathways and to improve outcome by modulating the patients physiological response to these stresses.

Pseudotumor Cerebri and Coma in Vitamin D — Dependent Rickets:

Correspondence to: Dr. G. Alpan, Department of Pediatrics, St. Luke’s-Roosevelt Hospital Center, Amsterdam Avenue at 114th Street, New York, New York 10025, U.S.A. Pseudotumor cerebri (PC) is characterized by increased intracranial pressure, normal cerebrospinal fluid (CSF) and the exclusion of intracranial space-occupying lesions, hydrocephalus or obstruction of cranial venous drainage. PC occurs with a variety of conditions including chronic hypoxia, postinfectious states, following head trauma or otitis media.’ Endocrinopathies sometimes associated with PC include: prolonged steroid therapy, rapid reduction in steroid dosage,3 hyperthyroidism,4 initiation of levothyroxine therapy for hypothyroidism,l hypoparathyroidism,l and adrenal insufficiency.’ We report the unusual occurrence of PC in a 20-month old infant with vitamin D-

Age and outcome in pediatric cervical spine injury: 11-year experience

Age-related outcome in children with cervical spine injury has not been previously reported. We performed a retrospective chart review of all children with cervical spine injury who presented to a childrens hospital during an 11-year period; 73 patients were identified. Their mean age was 8.6 years, with bimodal peaks at 2 to 4 and 12 to 15 years. Sixty-seven percent of the injuries were traffic-related, resulting from motor vehicle crashes affecting passengers, pedestrians, or bicyclists. Distraction and subluxation injuries were the most common injuries in children aged eight years or younger, whereas fractures were more common in older children. Younger children sustained more severe injuries than older children, as measured by the Revised Trauma Score, Injury Severity Score, and Trauma Score-Injury Severity Score estimated probability of survival, and were more likely to sustain injuries to higher levels of the cervical spine. Deaths occurred exclusively in children eight years old or younger, but the rate of occurrence of neurologic disability was similar in both groups: 26% in those eight years old and under, and 25% in those more than eight years old. The mortality in younger patients was not caused exclusively by the higher level of cervical injury, but it occurred more often in the presence of head injury and multiple trauma.

Management of pediatric trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Childrens Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

The use of high-dose epinephrine for patients with out-of-hospital cardiopulmonary arrest refractory to prehospital interventions

Objective: To determine if high-dose epinephrine (HDE) used during out-of-hospital cardiopulmonary arrest refractory to prehospital interventions improves return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcomes. Methods: A multicenter randomized controlled trial was conducted between May 1991 and October 1996 to compare the effectiveness of HDE versus standard-dose epinephrine (SDE) in patients having out-of-hospital cardiopulmonary arrest refractory to prehospital resuscitation efforts. Cardiopulmonary arrest was classified as medical or traumatic. Two hundred thirty patients were enrolled in 7 pediatric emergency departments. Ages ranged from newborn to 22 years. Seventeen patients met exclusion criteria. Patients were assigned to receive HDE (0.1 mg/kg for the initial dose and 0.2 mg/kg for subsequent doses) or SDE (0.01 mg/kg). The main end points evaluated were return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcome. Results: One hundred twenty-seven patients received HDE (32 trauma patients), and 86 patients received SDE (27 trauma patients). Among medical patients, 24 (25%) of 95 experienced return of spontaneous circulation in the HDE group as compared with 9 (15%) of 59 in the SDE group (P = 0.14, χ2 = 2.17, relative risk = 1.66 [0.83-3.31]). Sixteen (17%) of 95 HDE patients and 5 (8%) of 59 SDE patients survived at least 24 hours (P = 0.14, χ2 = 2.16, relative risk = 1.99 [0.77-5.14]). Nine survivors to discharge received HDE, and 2 received SDE (P = 0.21, Fisher exact test, relative risk = 2.75 [0.61-12.28]). There were no long-term survivors among the trauma patients. Eight of 11 long-term survivors had severe neurological outcomes defined by the Glasgow Outcome Scale (2/2 SDE, 6/9 HDE; P = 0.51, Fisher exact test). Conclusion: HDE does not improve or diminish return of spontaneous circulation, 24-hour survival, long-term survival, or neurological outcome compared with SDE in out-of-hospital cardiopulmonary arrest.

Single-Dose Ceftriaxone Versus 10 Days of Cefaclor for Otitis Media

We conducted a controlled clinical trial to determine the efficacy of single-dose intramuscular ceftriaxone for the treatment of acute otitis media. Fifty-four children aged 18 months to 6 years with clinical and tympanometric evidence of otitis media were randomized to receive either 50 mg/kg ceftriaxone or 10 days of oral cefaclor 40 mg/kg/day. Resolution of symptoms and clinical and tympanometric appearance of the tympanic membrane at follow-up visits were used to determine outcome. Thirty-one children received ceftriaxone and 23 received oral cefaclor. There were no treatment failures. There were no significant differences between groups in persistence of effusion or recurrence of acute otitis media. We conclude that a single intramuscular dose of ceftriaxone compares favorably with 10 days of oral cefaclor for the treatment of acute otitis media.

Conscious sedation of the pediatric patient for suturing: a survey.

No single drug or combination of drugs was used routinely in pediatric emergency departments to sedate children for suturing. A meperidine-promethazine-chlorpromazine “cocktail” was chosen most frequently. Many physicians were dissatisfied with the method they selected, however, leading some to experiment with newer medications such as fentanyl. The American Academy of Pediatrics (AAP) guidelines for the elective use of conscious sedation, specifically, those regarding monitoring during sedation and discharge post sedation, were not adhered to uniformly. Further study of conscious sedation in children is needed.

A comparison of the initial to the later stream urine in children catheterized to evaluate for a urinary tract infection.

Background To avoid potential contamination, it is recommended that the first few drops of urine be discarded when obtaining a catheterized urine sample from a child being evaluated for a urinary tract infection (UTI). The existing evidence to make such a recommendation is scant. Our goal, therefore, was to determine whether the urinalysis, Gram stain, and culture results were significantly different from the initial and later urine samples collected from catheterized children. Methods A prospective diagnostic discrimination between early and later urine samples was conducted on a convenience sample of pediatric patients being evaluated for a UTI in an urban emergency department. Results of the urinalysis, Gram stain, and quantitative culture were compared between the early and later stream urine samples. Results Data from 86 children were analyzed. Four of 80 patients had a false identification of low colony count bacteruria from the early but not from the later stream. For patients with negative cultures, the early stream was also more likely to falsely identify ≥ 5 wbc/hpf (P< 0.01) or bacteruria (P< 0.05) on urinalysis than the later stream. Conclusions There is a small but potentially meaningful contamination of the early stream urine compared with the later stream in young children catheterized to evaluate for a urinary tract infection.

Drowning and near-drowning in children and adolescents: a succinct review for emergency physicians and nurses

TARGET AUDIENCE This Continuing Medical Education (CME) activity is intended for anyone who treats pediatric drowning and near-drowning victims or who provides injury prevention counseling. Although targeted at emergency physicians and nurses in particular, we believe other healthcare providers— including critical care doctors and nurses, pediatricians, family practitioners, respiratory therapists, and paramedics—will find it informative.

Use of activated charcoal in a simulated poisoning with acetaminophen: A new loading dose for N-acetylcysteine?

STUDY OBJECTIVESnTo investigate the ability of a supranormal dose of N-acetylcysteine to overcome the effects of activated charcoal on N-acetylcysteine bioavailability and to determine the effects of activated charcoal on serum acetaminophen levels.nnnDESIGN, SETTING, AND PARTICIPANTSnTen healthy adult volunteers participated in a controlled cross-over experiment. During phase I (control), subjects ingested 3 g acetaminophen, followed one hour later by the normal loading dose of N-acetylcysteine (140 mg/kg). During phase II (charcoal), subjects ingested 3 g acetaminophen, followed one hour later by 60 g activated charcoal and a supranormal loading dose of N-acetylcysteine (235 mg/kg).nnnMAIN OUTCOME MEASURESnSerum levels of N-acetylcysteine were measured every 30 minutes for six hours. A serum acetaminophen level was measured at four hours.nnnRESULTSnThe area under the curve for N-acetylcysteine was significantly higher for phase II than phase I (P < .05, two-tailed paired t-test). Peak N-acetylcysteine and time to peak were not significantly different. The four-hour serum acetaminophen level was significantly lower for phase II than phase I (P < .05, two-tailed paired t-test). Diarrhea occurred during both phases, but N-acetylcysteine was otherwise well tolerated.nnnCONCLUSIONnThese results suggest that activated charcoal can be used safely for victims of acetaminophen overdose. A beneficial effect in preventing acetaminophen absorption can be expected if it is given within one hour after ingestion. If N-acetylcysteine is needed because of a toxic serum acetaminophen level, bioavailability can be ensured by increasing the N-acetylcysteine loading dose from 140 mg/kg to 235 mg/kg.