Daniel M. Cohen

Pediatric Patients Requiring CPR in the Prehospital Setting

STUDY OBJECTIVE To determine the outcome of pediatric patients with prehospital cardiopulmonary arrest. DESIGN Chart review of all patients with prehospital cardiopulmonary arrest who were subsequently admitted to a pediatric emergency department from January 1988 to January 1993. Cardiopulmonary arrest was considered to have been present if assisted ventilation and chest compressions were performed on an apneic, pulseless patient. SETTING Pediatric ED. PARTICIPANTS Pediatric patients in prehospital cardiac arrest. RESULTS In all, 95 patients were identified. Fifty-six had initial hospital care at the pediatric ED (primary patients). The remaining 39 were transported to the pediatric ED after initial care of another institution (secondary patients). Forty-one percent of patients were younger than 1 year. Most arrests were respiratory in origin; asystole was the most common dysrhythmia. Fifteen patients (27%) survived to discharge. Fourteen of the survivors had return of spontaneous circulation before ED arrival. Thirty-three patients were in arrest on ED arrival; in 16 (48%) of these, return of spontaneous circulation subsequently developed in the ED, and 1 survived to discharge. Two survivors, including the survivor with return of spontaneous circulation in the ED, had severe neurologic sequelae. Ten (26%) of the secondary patients survived. All survivors had return of spontaneous circulation before arrival in the ED. Two survivors had severe neurologic sequelae. CONCLUSION Most successfully resuscitated pediatric arrest victims are resuscitated in the prehospital setting and do not suffer severe neurologic injury. Most patients who present to the ED in continued arrest and survive to discharge have severe neurologic injury.

Pediatric Pain Measurement Using a Visual Analogue Scale: A Comparison of Two Teaching Methods

The goals of this study were to evaluate the validity of the visual analogue scale (VAS) for young children and to compare a newly developed method of teaching children to use a VAS with one used in our previous studies. It was hypothesized that the new method would increase the number of children who understand the VAS and correctly mark their responses on the VAS line. The association between childs age and ability to understand the VAS was also evaluated. One hundred-six children with a laceration requiring sutures and receiving a lidocaine injection for local anesthesia participated in the study. They ranged in age from 5 to 14 years. Two outcome measures were used to assess the baseline and lidocaine injection pain: a 5-point Likert scale and a VAS. A calibration study was used to determine whether the subjects were able to use the VAS to make proportional judgments about their perceptions. Teaching method had no effect on the number of subjects who could correctly mark their responses on the VAS line, nor did it significantly increase the number of subjects who could understand the concept of the VAS. Subjects who were able to understand the VAS were significantly older (mean = 9.8 years, SD = 2.8) than those who did not (mean = 8.2 years, SD = 2.5). Overall, only about one third of the subjects were able to correctly mark the VAS and understand the concept of the VAS. Other measures of pain that are better understood by young children may be more valid indicators of pain than the VAS.

Multicenter clinical evaluation of the novel Alere™ i Influenza A&B isothermal nucleic acid amplification test.

BACKGROUND Rapid detection of influenza infection is important for patient management and timely anti-viral therapy. Rapid antigen detection tests for influenza have inferior sensitivity when compared to nucleic acid-based amplification tests. An isothermal nucleic acid amplification test that offers the potential for rapid molecular testing at the clinical point-of-care with simple equipment can improve influenza detection rates. OBJECTIVES To evaluate the performance of Alere™ i Influenza A&B isothermal nucleic acid amplification test to detect influenza A and B in comparison to viral cell culture as reference method. STUDY DESIGN A prospective, multicenter, clinical study to evaluate the clinical performance of the Alere™ i Influenza A&B assay in a point-of-care setting using prospectively enrolled specimens from both children and adults was conducted in seven sites. RESULTS In comparison with viral cell culture, the overall sensitivity and specificity of the Alere™ i Influenza A&B assay was 97.8% and 85.6% for the detection of influenza A, and 91.8% and 96.3% for the detection of influenza B, respectively. Following resolution of discrepant results by real-time RT-PCR the sensitivity and specificity of the Alere™ i Influenza A&B assay improved to 99.3% and 98.1% for influenza A, and 97.6% and 100% for influenza B, respectively. CONCLUSIONS The Alere™ i Influenza A&B isothermal nucleic acid amplification test is an ideal point-of-care test for influenza detection in children and adults due to its high sensitivity and specificity and ability to generate results within 15 min from specimen receipt.

Severe anaphylactic reaction after primary exposure to aprotinin

Aprotinin is widely used to prevent bleeding and reduce blood transfusions after open heart surgical procedures. Because it is a foreign protein, aprotinin has allergenic potential. We report a case of near-fatal anaphylactic reaction to primary aprotinin exposure in a child successfully treated using cardiopulmonary bypass support. The possibility of an allergic reaction must be considered whenever this drug is used.

Coronary artery fistula in the pediatric age group: A 19-year institutional experience

Ten patients with coronary artery fistulae were identified from records at Columbus Childrens Hospital between 1974 and 1993. Clinical presentations of patients were quite variable, from 1 day to 20 years of age. Symptoms ranged from none to severe cardiorespiratory failure requiring extracorporeal membrane oxygenation. Long term follow-up revealed one sudden death and one spontaneous closure of the fistula. This lesion should be ruled out in patients who present as extracorporeal membrane oxygenation candidates. Patients with mild forms of this lesion may be followed up medically if the left to right shunt is inconsequential, because spontaneous closure is a possibility. Because of the risk of sudden death, close long-term follow-up is mandatory even for operated patients, and antiplatelet therapy should be considered for these patients.

Performance of Rapid Streptococcal Antigen Testing Varies by Personnel

ABSTRACT Rapid carbohydrate antigen tests are frequently used to diagnose group A streptococcal (GAS) pharyngitis. Despite evidence of modest sensitivity in medical settings, rapid antigen tests are available to the public for self-testing. We sought to determine if the personnel performing a rapid streptococcal antigen test influence the tests performance characteristics. Throat swabs of pediatric patients performed for GAS pharyngitis in a tertiary-care childrens hospital network were included during two study periods in 2004 and 2005. The performance characteristics of a rapid carbohydrate antigen test were evaluated in three clinical settings against a nucleic acid probe test method according to the personnel performing the test (laboratory technologist versus nonlaboratory personnel). Between the study periods, nonlaboratory personnel from one site underwent retraining. Subsequently, the performance characteristics of the rapid antigen test were reassessed. The sensitivity of the rapid antigen test varied widely among the different testing sites (56 to 90%). Notably, test sensitivity was consistently greater when the test was performed by laboratory technologists than when it was performed by nonlaboratory personnel (P < 0.0001). Although the rapid antigen test sensitivity significantly improved after nonlaboratory personnel at one testing site were retrained (sensitivity before versus after retraining; P < 0.0001), the sensitivity remained greater in the laboratory technologist cohort (P < 0.0001). These data confirm the important relationship of the operator performing a rapid streptococcal antigen test with the tests accuracy, even in a clinical setting, where operator training is mandated. Therefore, its use outside the medical setting by lay persons cannot be recommended without culture backup.

Intrathoracic cystic hygroma: A report of three cases

Cystic hygromas are relatively uncommon benign tumors of the lymphatic system. The lesions frequently are apparent at birth, and more than 90% are detected before the end of the second year of life. Most commonly, cystic hygroma presents as a soft tissue mass in the posterior triangle of the neck, and only rarely does it extend into the mediastinum. Isolated intrathoracic hygromas are exceedingly rare and have been reported infrequently among children. Herein the authors review three cases of intrathoracic cystic hygroma, spanning a period of 30 years at their institution.

Electrical Injuries in a Pediatric Emergency Department

STUDY OBJECTIVE To examine the spectrum of electrical injuries and develop guidelines for management. DESIGN Retrospective review of charts compiled during a 6-year period (1988 through 1993). SETTING Pediatric emergency department. PARTICIPANTS Seventy-eight patients seen for electrical injuries. RESULTS Fifty-four percent of patients were boys, and the mean age of the patients was 5.3 years. Eighty-two percent sustained burns. We divided patients into those who were involved in major electrical current events (n = 8) (water contact and high voltage) and minor electrical current events (n = 70) (injury sustained while placing an object in an outlet or touching/plugging in a cord or during oral contact with a cord). Of the minor events, all burns (n = 61) involved less than 1% of body surface area. Eighteen patients sustained second-degree burns, and 19 sustained third-degree burns. Of the eight major-event patients, one had abnormal ECG/rhythm strip findings, two had abnormal urinalysis results, and six had abnormal levels of creatine phosphokinase. All eight were admitted. Of the 70 minor-event patients, 2 of 53 had abnormal ECG/rhythm strip findings, 1 of 48 had abnormal urinalysis results, and 2 of 40 had abnormal creatine phosphokinase levels. Thirty-six of the 70 minor-event patients were admitted. Patients involved in major events were more likely to undergo studies (P = .002), to have an abnormal result (P = .000008), and to be hospitalized (P = .008). In minor-event patients, hospitalization was limited to observation and the fitting of oral appliances. CONCLUSION Children involved in electrical events are usually exposed to low-voltage household current resulting in minor injury. Asymptomatic children with minor electrical injuries do not require laboratory evaluation or hospitalization.

Pediatric bronchioloalveolar carcinoma: A favorable pediatric malignancy?

Primary pulmonary tumors are infrequent in children. Bronchioloalveolar carcinoma has been documented rarely in the pediatric population. Before this report, there have been only three cases of bronchioloalveolar carcinoma in patients less than 16 years of age. Our two cases represent two of the youngest cases (ages 6 and 15 years) reported with bronchioloalveolar carcinoma. They illustrate many of the typical findings of this disease including clinical presentation, diagnostic difficulty, and better prognosis compared with other pulmonary malignancies. This neoplasm appears to have a favorable outcome in childhood.

CLINICIAN PERCEPTIONS OF AN ELECTRONIC MEDICAL RECORD DURING THE FIRST YEAR OF IMPLEMENTATON IN EMERGENCY SERVICES

Objectives: The objectives of this study were to measure clinician perceptions of the recently implemented electronic medical record (EMR) system in a pediatric emergency department and off-site urgent care centers and to determine how user perceptions changed over time. Methods: Physicians and nurses from the emergency department/urgent care center were recruited to complete an online survey at 3 points in time: 30 to 89 days (wave 1), 90 to 179 days (wave 2), and 180 to 270 days after implementation (wave 3). Potential predictors of initial satisfaction studied included effort expectancy, performance expectancy, social support, and facilitating conditions, along with user demographics and general attitudes toward technology. Bivariate relationships with satisfaction were assessed using the Wilcoxon rank sum test and correlation analysis. A final multivariate linear regression model was calculated. Change in satisfaction over time was tested using a Wilcoxon signed rank test. Results: A total of 71 clinicians completed the surveys. Initial satisfaction was strongly associated with perceptions of training and support (facilitating conditions) and with perceived usefulness (performance expectancy). Satisfaction was not associated with user sex, age, or role (physician vs nurse). No significant change was found in any satisfaction measure at wave 2 or 3; however, satisfaction with functionality trended higher and satisfaction with reliability trended lower over the course of use. Conclusions: Satisfaction with an EMR at its launch generally persisted through the first year of use. Implementation plans must maximize the likelihood of achieving positive early impressions of training, support, and performance to engender high user satisfaction with the EMR.