Christine M. Walsh-Kelly

The effect of oral midazolam on anxiety of preschool children during laceration repair.

Preschool age children often experience marked anxiety and physical pain during laceration repair. Locally infiltrated anesthetics or topical tetracaine, adrenaline, and cocaine (TAC) usually control the physical pain but have little or no effect on anxiety. Midazolam is a short-acting benzodiazepine with anxiolytic, hypnotic, and antegrade amnestic effects. In a double-blind, randomized clinical trial, we evaluated the efficacy of midazolam in alleviating anxiety during laceration repair in children less than 6 years old. On admission to the emergency department, anxiety level was determined on a scale of 1 to 4 based on a predetermined behavior criteria. Patients with high anxiety level (3 or 4) received a single oral dose of either midazolam (0.2 mg/kg) or placebo. The anxiolytic effect of midazolam was considered adequate if the anxiety level decreased two or more points (from 4 to less than or equal to 2 or from 3 to 1) during laceration repair. In the midazolam group (30), 70% of the children had a two-point or more decrease in anxiety level compared with 12% in the placebo group (25) (P less than .0001). No respiratory depression or other complications were noted in the midazolam group. We conclude that a single oral dose of midazolam (0.2 mg/kg) is a safe and effective treatment for alleviating anxiety in children less than 6 years old during laceration repair in the ED.

Prehospital pediatric endotracheal intubation performance review.

Pediatric prehospital care was reviewed over a one year period to determine success rate, causes of unsuccessful attempts, and complications of performing endotracheal intubation. The Milwaukee County Emergency Medicine Technician-Paramedics (EMT-Ps) responded to 1467 pediatric (<19 years of age) patient calls. This accounted for 11% of the patients who received EMT-P care during the study period. Of the 63 patients requiring pediatric endotracheal intubation, 49 (78%) were successfully intubated. Of the 42 pulseless nonbreathing (PNB) patients, 39 (93%) were successfully intubated. Of the 21 patients judged to be in impending respiratory failure, 10 (48%) were successfully intubated. Common difficulties in intubating the PNB patient included inability to visualize the glottis and cords secondary to mucus and/or vomitus, use of inappropriately small endotracheal tubes, and accidental extubation during transport. Difficulties in intubating impending respiratory failure patients included patient resistance and seizure activity. We recommend that the EMT-P training curriculum include a review of these difficulties and that prehospital pediatric endotracheal intubation performance be monitored and reviewed with the EMT-Ps.

Pediatric intraosseous infusions: Impact on vascular access time

A 1-year retrospective chart review was performed to evaluate the effect of intraosseous infusions (IO) on the time required to establish vascular access in pediatric patients requiring immediate vascular access for resuscitation. Eighty-one patients were identified, including 29 pulseless and non-breathing and 52 noncardiopulmonary arrest children, who required intravenous fluids or medication for resuscitation. Comparing the results with a previous review, the IO method effectively reduced the time needed to establish vascular access in the arrested group when standard techniques failed, particularly in the child less than 2 years old. The IO method was not used effectively in the non-arrest group, as evidenced by a significantly greater mean time required to establish vascular access. There were no significant complications related to the IO procedure. Nine (50%) of the patients receiving IO fluids or medication had clinical and/or laboratory evidence that these substances reached the central circulation. Early use of IO infusion in the resuscitation is recommended for not only the arrested patient, but also the critical nonarrested patient requiring immediate vascular access.

Emergency department revisits for pediatric acute asthma exacerbations: association of factors identified in an emergency department asthma tracking system.

Objective: To identify clinical variables associated with a greater likelihood of emergency department (ED) revisit for acute asthma within 7 days after an initial ED visit for acute asthma exacerbation. Methods: Cross-sectional study of subjects from a prospectively enrolled cohort of children aged 0 to 18 years with physician-diagnosed asthma in the ED Allies Tracking System. Demographics and data on quality of life, health care utilization, environmental factors, chronic asthma severity, and ED management were collected. Emergency department revisits for acute asthma within 7 days of a prior visit resulting in discharge were compared with those without a revisit, using &khgr;2 and t tests and logistic regression. Results: Four thousand two hundred twenty-eight ED asthma visits were enrolled; 3276 visits resulted in discharge. Persistent asthma was identified in 66% of visits. Emergency department revisits within 7 days of a prior visit occurred following 133 (4.1%) visits. There were no significant differences in environmental factors or ED management between visits with and without an ED revisit. In univariate analysis factors associated with a greater revisit likelihood included age younger than 2 years, black race or Hispanic ethnicity, persistent asthma, public insurance, lower quality of life, and greater health care utilization in the prior 12 months. Variables independently significant (P < 0.05) in logistic regression were chronic asthma severity classified as persistent, age younger than 2 years, and lower asthma quality of life. Conclusions: Although our design precludes drawing causal inference, our results suggest that children younger than 2 years or with persistent asthma or lower asthma quality-of-life scores are at greater risk for ED revisits after acute ED asthma care.

Emergency Department Allies: A Controlled Trial of Two Emergency Department–Based Follow-up Interventions to Improve Asthma Outcomes in Children

OBJECTIVE. We sought to study the impact of emergency department (ED)–based intensive primary care linkage and initiation of asthma case management on long-term, patient-oriented outcomes for children with an asthma exacerbation. METHODS. Our study was a randomized, 3-arm, parallel-group, single-blind clinical trial. Children aged 2 through 17 years treated in a pediatric ED for acute asthma were randomly assigned to standard care (group 1), including patient education, a written care plan, and instructions to follow up with the primary care provider within 7 days, or 1 of 2 interventions. Group 2 received standard care plus assistance with scheduling follow-up, while group 3 received the above interventions, plus enrollment in a case management program. OUTCOMES. The primary outcome was the proportion of children having an ED visit for asthma within 6 months. Other outcomes included change in quality-of-life score and controller-medication use. RESULTS. Three hundred fifty-two children were enrolled; 78% completed follow-up, 69% were black, and 70% had persistent asthma. Of the children, 37.8% had a subsequent ED visit for asthma, with no difference among the treatment groups (group 1: 38.4%; group 2, 39.2%; group 3, 35.8%). Children in all groups had a substantial, but similar, increase in their quality-of-life score. Controller-medication use increased from 69.4% to 81.4%, with no difference among the groups. CONCLUSION. ED-based attempts to improve primary care linkage or initiate case management are no more effective than our standard ED care in improving subsequent asthma outcomes over a 6-month period.

Patient-controlled analgesia for sickle cell pain crisis in a pediatric emergency department

Objective To determine whether a protocol to start patient-controlled analgesia (PCA) in the emergency department (ED-PCA) would shorten the length of time between narcotic bolus doses and PCA initiation as compared with standard inpatient initiation of PCA (IP-PCA). Also, to compare patient satisfaction and inpatient length of stay for the 2 groups. Methods To improve care, we developed a protocol to institute ED-PCA after an initial bolus dose of narcotics. This was a nonrandomized pilot study. Patient records were reviewed for location of PCA initiation, time from narcotic bolus to initiation of PCA, and length of stay. A brief patient/parent satisfaction survey was collected. Results Sixty-nine records were reviewed. Patients treated using the protocol had initiation of PCA therapy within 35 ± 7 minutes from the last bolus narcotic dose in the emergency department versus 211 ± 17 minutes for nonprotocol patients. Forty-eight of 50 patient surveys indicated preference for starting ED-PCA; 2 did not have a preference. No complications were identified in either group. Conclusions A protocol to initiate PCA for sickle cell patients in a pediatric emergency department shortened the time of its initiation and was preferred by patients.

Clinical impact of radiograph misinterpretation in a pediatric ED and the effect of physician training level

Radiograph interpretation in the pediatric emergency department (ED) is commonly performed by pediatric emergency medicine (PEM) attendings or physicians-in-training. This study examines the effect of physician training level on radiograph interpretation and the clinical impact of false-negative radiograph interpretations. Data were collected on 1,471 radiographs of the chest, abdomen, extremity, lateral neck, and cervical spine interpreted by PEM attendings, one PEM fellow, one physician assistant, and emergency medicine, pediatric and family practice residents. Two hundred radiographs (14%) were misinterpreted, including 141 chest (16%), 24 extremity (8%), 20 abdomen (12%), 14 lateral neck (18%), and 1 cervical spine radiograph (2%). Physicians-in-training misinterpreted 16% of their radiographs versus 11% for PEM attendings (P = .01). Twenty (1.4%) radiographs had clinically significant (false-negative) misinterpretations, including 1.7% of physician-in-training and 0.8% of attending interpretations (P = 0.15). No morbidity resulted from the delay in correct interpretation. Radiograph misinterpretation by ED physicians occurs but is unlikely to result in significant morbidity.

The role of abdominal x-rays in the diagnosis and management of intussusception

The management of intussusception requires early diagnosis and reduction with either barium enema or surgical intervention. Supine and erect abdominal radiographs are often obtained prior to ordering a barium enema. In many pediatric centers, the critical, initial interpretation of these radiographs is made by nonradiologists and, in most instances, by pediatric emergency physicians. We determined the sensitivity and specificity of abdominal radiographs in diagnosing intussusception when interpreted by these physicians. Six full-time pediatric emergency physicians evaluated 126 radiographs from 42 patients with intussusception, 42 in whom the disease was clinically suspected but ruled out, and 42 in whom the final radiology report was “normal.” These were presented to pediatric emergency physicians in a blinded, randomized sequence without any additional clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% (range, 71–93%), and the mean specificity was 58% (range, 48–69%). This compares favorably to the sensitivity of signs and symptoms, and we conclude that plain and upright abdominal films are a useful adjunct for the clinician evaluating patients for suspected intussusception.

Clinical predictors of bacterial versus aseptic meningitis in childhood

STUDY OBJECTIVE To assess the reliability of meningeal signs and other physical findings in predicting bacterial and aseptic meningitis at various ages. DESIGN Children requiring lumbar puncture were evaluated prospectively for meningeal signs and other physical parameters before lumbar puncture. SETTING Emergency department of Childrens Hospital of Wisconsin. PARTICIPANTS One hundred seventy-two children, aged 1 week to 17 years, with meningitis (53 bacterial and 119 aseptic). MEASUREMENTS AND MAIN RESULTS Nuchal rigidity was present in 27% of infants aged 0 to 6 months with bacterial meningitis versus 95% of patients 19 months or older (P = .0001). Three percent of infants 0 to 6 months old with aseptic meningitis had nuchal rigidity versus 79% of patients 19 months or older (P = .0005). Seventy-two percent of infants 12 months of age or younger with bacterial meningitis has at least one positive meningeal sign versus 17% of infants with aseptic meningitis (P = .0001). Eighty-five percent of children older than 12 months with meningitis had at least one positive meningeal sign, 93% with bacterial meningitis, and 82% with aseptic meningitis. CONCLUSION Despite a lack of meningeal signs, a high index of suspicion for meningitis is essential when evaluating the febrile infant 12 months of age or younger.

Latex Allergy: A Patient and Health Care System Emergency

Latex allergy, an IgE-mediated reaction to proteins retained in finished natural rubber latex products, has become one of the most pervasive problems in medicine. Latex allergy has resulted in death, progressive asthma, severe food allergy from cross-reactivity, and disability of health care professionals with the accompanied loss of self-esteem and income from their inability to work in their chosen profession. This article reviews the risks of latex allergy and proposes strategies for prevention and management of the problem.