Cindy Ganis Roskind

Controversies in the evaluation and management of minor blunt head trauma in children.

Purpose of review We present data from recently conducted research regarding controversial aspects of the evaluation and management of children with minor blunt head trauma. Recent findings Clinicians frequently but at times indiscriminately perform computed tomography scans for children with minor blunt head trauma resulting in potentially harmful radiation exposure. Recent guidelines recognize the limited but increasing data available to make strong recommendations regarding appropriate neuroimaging decisions. Investigators have derived and validated clinical prediction models to accurately identify patients with substantial traumatic brain injury, though no clear definitive rule exists. Children younger than 2 years appear to have a higher risk of intracranial injury following minor head trauma. These patients can be difficult to assess, with the evidence suggesting the need for a more conservative approach to diagnostic imaging. We present current and accepted definitions of concussion along with risk factors and treatment for postconcussion syndrome. Current return-to-play guidelines suggest that athletes who have sustained concussion should not resume play until symptoms have resolved because of the possibility, though rare, of second impact syndrome. Summary Research in the management of children with minor head trauma is actively evolving. We present a review of recent developments that can influence current clinical practice.

Controversies in rapid sequence intubation in children

Purpose of review Rapid sequence intubation is the method of choice for intubation of the emergency department patient. The purpose of the present review is to address several controversies pertaining to emergency department rapid sequence intubation of children. Recent findings The topics covered in this review include the determination of the appropriate clinician to perform emergency department intubation, the use of atropine and lidocaine as premedications, the choice of sedative agents depending upon the clinical scenario, and the choice of neuromuscular blockade agent. Concerning these topics,The literature supports that emergency department physicians, with appropriate training, successfully perform intubation in most patients.Limited data exist to determine the appropriate use of atropine and lidocaine for rapid sequence intubation.Etomidate has clearly become a preferred sedative for rapid sequence intubation with a low risk of cardiovascular side effects. Thiopental and propofol may more readily provide adequate sedation as compared with etomidate but both have the potential to reduce blood pressure.Succinylcholine arguably remains the preferred neuromuscular blockade agent for rapid sequence intubation in most children. The side effects of succinylcholine occur in relatively predictable circumstances. Rocuronium is a commonly used nondepolarizing paralytic agent but its prolonged duration of action must be weighed against the risk of side effects associated with succinylcholine. Summary Though more research is needed, the available data allow for the development of protocols that will result in a rational, scenario-based approach to rapid sequence intubation in children.

Validation of the modified Vesikari score in children with gastroenteritis in 5 US emergency departments.

Objectives: The burden of acute gastroenteritis (AGE) in US children is substantial. Research into outpatient treatment strategies has been hampered by the lack of easily used and validated gastroenteritis severity scales relevant to the populations studied. We sought to evaluate, in a US cohort, the reliability, construct validity, and generalizability of a gastroenteritis severity scale previously derived in a Canadian population, the modified Vesikari score (MVS). Methods: We conducted a prospective, cohort, clinical observational study of children 3 to 48 months of age with acute gastroenteritis presenting to 5 US emergency departments. A baseline MVS score was determined in the emergency department, and telephone follow-up 14 days after presentation was used to assign the follow-up MVS. We determined reliability using inter-item correlations; construct validity via principal component factor analysis; cross-sectional construct validity via correlations with the presence of dehydration, hospitalization, and day care and parental work absenteeism; and generalizability via score distribution among sites. Results: Two hundred eighteen of 274 patients (80%) were successfully contacted for follow-up. Cronbach &agr; was 0.63, indicating expectedly low internal reliability because of the multidimensional properties of the MVS. Factor analysis supported the appropriateness of retaining all variables in the score. Disease severity correlated with dehydration (P < 0.001), hospitalization (P < 0.001), and subsequent day care (P = 0.01) and work (P < 0.001) absenteeism. The MVS was normally distributed, and scores did not differ among sites. Conclusions: The MVS effectively measures global severity of disease and performs similarly in varying populations within the US health care system. Its characteristics support its use in multisite outpatient clinical trials.

Test characteristics of the 3-view abdominal radiograph series in the diagnosis of intussusception.

Objectives: To determine the test characteristics of the 3-view abdominal radiograph series to exclude intussusception in children presenting to the pediatric emergency department. Methods: We performed a single-center retrospective review of children for whom supine, prone, and lateral decubitus abdominal radiographs were performed as part of our standard diagnostic evaluation for intussusception. A pediatric radiologist masked to the patients clinical data and outcome reviewed all radiographs. The criterion evaluated was whether air was visualized in the ascending colon on each of the 3 radiograph views. We determined the presence or absence of intussusception hierarchically by definitive radiological study report, surgical operative note, or clinical outcome. Results: We analyzed 179 patients, of whom 27 (15.1%) were diagnosed with intussusception. The test characteristics of the 3-view radiograph series in the diagnosis of intussusception when all 3 views had air in the ascending colon were sensitivity of 100% (95% confidence interval [CI] 87-100), specificity of 18.4% (95% CI, 12.3-24.6), likelihood ratio for a negative test of 0 (95% CI, 0.01-1.53), and negative predictive value (NPV) of 100% (lower bound 95% CI, 98%). When at least 2 views had air in the ascending colon, the test characteristics were sensitivity of 96.3% (95% CI, 89.2-100), specificity of 41.4% (95% CI, 33.6-49.3), likelihood ratio for a negative test of 0.09 (0.01-0.62), and NPV of 98.4 (95% CI, 95.2-100). Conclusions: Using specific criteria, the presence of air in the ascending colon on 2 or 3 abdominal radiograph views has the potential to substantially decrease the likelihood of or exclude intussusception.

Accuracy of plain radiographs to exclude the diagnosis of intussusception.

Objectives To prospectively determine the test characteristics of the 3-view abdominal radiograph to decrease the likelihood of ileocolic intussusception. Methods We conducted a prospective cross-sectional study of children aged 3 months to 3 years suspected of having intussusception at a children’s hospital emergency department. Clinicians obtained supine, prone, and left lateral decubitus radiographs. We determined the presence or absence of intussusception by air enema, ultrasound, operative report, or clinical follow-up. A masked pediatric radiologist reviewed all radiographs. The criteria evaluated were whether air was visualized in the ascending colon on each view and in the transverse colon on the supine view. Results Nineteen (14.8%) of 128 patients had intussusception. Using air in the ascending colon on all 3 views as the diagnostic criteria, the test characteristics of the 3-view radiograph were sensitivity, 100% (95% confidence interval [CI], 79.1–100); specificity, 17.4% (95% CI, 11.1–26.1); negative predictive value, 100% (95% CI, 79.1–100); and likelihood ratio of a negative test, 0. When 2 or more of 3 views had air in the ascending colon, sensitivity decreased to 89.5% (95% CI, 75.7–100) and specificity improved to 45.0% (95% CI, 35.6–54.3). Air in the transverse colon had moderate sensitivity, 84.2% (95% CI, 67.8–100), but further improved specificity, 63.3% (95% CI, 54.2–72.4). Conclusions The presence of air in the ascending colon on the 3-view abdominal radiograph can decrease the likelihood of or exclude intussusception. When clinical suspicion is low, the presence of specific criterion on a 3-view abdominal radiograph series may obviate the need for further studies.

Evaluating cost awareness education in US pediatric emergency medicine fellowships.

Objectives The Accreditation Council for Graduate Medical Education mandates pediatric emergency medicine (PEM) fellowships to incorporate medical care cost teaching into the curriculum; however, there are no studies evaluating cost awareness of PEM fellows. Our objectives were to evaluate cost education during fellowship and assess fellows’ knowledge and attitudes regarding costs. Methods We conducted an anonymous electronic survey of US PEM fellows in April-June 2009. Results We received 161 (63%) of 253 responses. Respondents represented all 3 years of training and all regions of the United States. Asked if the Accreditation Council for Graduate Medical Education requires cost education, 35% responded no, and 44% were uncertain. More than 80% of fellows reported no formal cost education. More than 65% believed physicians should receive cost education during fellowship, and 75% felt the current amount of education is insufficient. Pediatric emergency medicine fellows showed low accuracy and considerable variability when estimating costs of tests and medications. Median fellows’ estimate for a complete blood count was

Medicina de urgencia

50 (interquartile range,

Scratching the surface: a review of skin and soft tissue infections in children.

55), where actual cost is

Blunt cervical spine injury in children

32. Only 23% were within 25% of the true cost. Similarly, the proportions of fellows estimating within 25% of actual cost were small for electrolytes (10%), blood culture (12%), and erythrocyte sedimentation rate (22%). The same held true for the following medications: trimethoprim-sulfamethoxazole (28%), Cefdinir (31%), and cefixime (10%). Ability to predict costs did not improve with year of training. Conclusions Pediatric emergency medicine fellows report little formal teaching on cost issues, and their ability to estimate costs is poor. However, they are receptive to more education on this important issue.

Nuking the radiation: minimizing radiation exposure in the evaluation of pediatric blunt trauma.

Este capitulo esta dedicado a Steve Miller, MD, cuya vida termino tragicamente el 19 de octubre de 2004. Steve era nuestro prestigioso y respetado jefe de division, un colega apreciado y un amigo irreemplazable. Su memoria vivira en las personas que conocio, los estudiantes a los que enseno y las palabras que escribio.