David S. Greenes

Biphasic Anaphylactic Reactions in Pediatrics

Objectives. The objectives of this study were to: 1) determine the incidence of biphasic reactions in children with anaphylaxis; 2) establish what risk factors can predict progression to a biphasic reaction; and 3) assess the utility of inpatient observation for patients whose anaphylaxis appears to have resolved. Methods. We performed a retrospective analysis of all children admitted to Childrens Hospital inpatient service between 1985 and 1999 with acute anaphylaxis. Data were collected from the medical records regarding past medical history, presenting signs and symptoms, treatment, and hospital course. Patients were considered to have resolution of anaphylaxis if they were documented to have cessation of all symptoms and needed no therapy for at least 1 hour. Biphasic reactions were defined as a worsening of symptoms requiring new therapy after resolution of anaphylaxis. Significant biphasic reactions were defined as those requiring oxygen, vasopressors, intubation, subcutaneous epinephrine, or unscheduled bronchodilator treatments. Patients were considered to benefit from a 24-hour observation period if they had a significant biphasic reaction within 24 hours of admission. Results. Of 108 anaphylactic episodes, 2 (2%) were fatal, and 1 (1%) was a protracted anaphylactic reaction. Among the remaining 105 children with resolution of anaphylaxis, 6 (6%) [95% confidence (CI): 2, 12] had biphasic reactions, of which 3 (3%) [95% CI: .6, 8] were significant. Of those who had a biphasic reactions, the median time from the onset of symptoms to the initial administration of subcutaneous epinephrine was 190 minutes, versus 48 minutes for those without a biphasic reaction. Patients with or without biphasic reactions did not differ significantly in the incidence of initial epinephrine use, initial steroid use, or serious respiratory or cardiovascular symptoms on initial presentation. Two of 105 (2%) [95% CI: .2, 7] patients clinically benefitted from a 24-hour observation period. Conclusions. We found an overall incidence of biphasic reactions of 6%, and an incidence of significant biphasic reactions of 3%, among pediatric patients admitted with anaphylaxis. Delayed administration of subcutaneous epinephrine was associated with an increased incidence of biphasic reactions. Approximately 2% of patients with anaphylaxis potentially benefitted from a 24-hour period of observation after symptoms had resolved.

Clinical indicators of intracranial injury in head-injured infants.

Objectives. 1) To determine whether clinical signs of brain injury are sensitive indicators of intracranial injury (ICI) in head-injured infants. 2) To determine whether radiographic imaging of otherwise asymptomatic infants with scalp hematoma is a useful means of detecting cases of ICI. 3) To determine whether head-injured infants without signs of brain injury or scalp hematoma may be safely managed without radiographic imaging. Methods. We performed a 1-year prospective study of all infants younger than 2 years of age presenting to a pediatric emergency department with head trauma. Data were collected on historical features, physical findings, radiographic findings, and hospital course. Follow-up telephone calls were made 2 weeks after discharge to assess for any late deterioration. Results. Of 608 study subjects, 30 (5%) had ICI; 12/92 (13%) infants 0 to 2 months of age had ICI, compared with 13/224 (6%) infants 3 to 11 months of age, and 5/292 (2%) infants 12 months of age or older. Only 16/30 (52%) subjects with ICI had at least one of the following clinical symptoms or signs of brain injury: loss of consciousness, history of behavior change, seizures, emesis, depressed mental status, irritability, bulging fontanel, focal neurologic findings, or vital signs indicating increased intracranial pressure. Of the 14 asymptomatic subjects with ICI, 13 (93%) had significant scalp hematoma. Among subjects who had head computed tomography, significant scalp hematoma had an odds ratio of 2.78 (95% confidence interval: 1.15,6.70) for association with ICI. A total of 265 subjects (43%) were asymptomatic and had no significant scalp hematoma. None (95% confidence interval: 0,1.2%) required specific therapy or had any subsequent clinical deterioration. Conclusions. Clinical signs of brain injury are insensitive indicators of ICI in infants. A substantial fraction of infants with ICI will be detected through radiographic imaging of otherwise asymptomatic infants with significant scalp hematomas. Asymptomatic infants older than 3 months of age who have no significant scalp hematoma may be safely managed without radiographic imaging.

Low risk of bacteremia in febrile children with recognizable viral syndromes.

BACKGROUND Previous studies of occult bacteremia in febrile children have excluded patients with recognizable viral syndromes (RVS). There is little information in the literature regarding the rate of bacteremia in febrile children with RVS. OBJECTIVE To determine the rate of bacteremia in children 3 to 36 months of age with fever and RVS. METHODS We performed a retrospective analysis of all patients 3 to 36 months of age with a temperature > or =39 degrees C seen during a 5 1/2-year period in the Emergency Department of a tertiary care pediatric hospital. From this group those with a discharge diagnosis of croup, varicella, bronchiolitis or stomatitis and no apparent concomitant bacterial infection were considered to have an RVS. The rate of bacteremia was determined for those subjects with RVS who had blood cultures. RESULTS Of 21,216 patients 3 to 36 months of age with a temperature > or =39 degrees C, 1347 (6%) were diagnosed with an RVS. Blood cultures were obtained in 876 (65%) of RVS patients. Of patients who had blood cultures, true pathogens were found in only 2 of 876 (0.2%) subjects with RVS [95% confidence interval (CI) 0.01, 0.8%]. The rate of bacteremia was 1 of 411 (0.2%) for subjects with bronchiolitis, O of 249 (0%) for subjects with croup, O of 123 (0%) for subjects with stomatitis and 1 of 93 (1.1%) for subjects with varicella. CONCLUSIONS Highly febrile children 3 to 36 months of age with uncomplicated croup, bronchiolitis, varicella or stomatitis have a very low rate of bacteremia and need not have blood drawn for culture.

Occult Intracranial Injury in Infants

STUDY OBJECTIVES The objectives of this study were as follows: (1) to determine whether clinical symptoms and signs of brain injury are sensitive indicators of intracranial injury (ICI) in infants admitted with head trauma, (2) to describe the clinical characteristics of infants who have ICI in the absence of symptoms and signs of brain injury, and (3) to determine the clinical significance of those ICIs diagnosed in asymptomatic infants. METHODS We conducted a retrospective analysis of all infants younger than 2 years of age admitted to a tertiary care pediatric hospital with acute ICI during a 6(1/2)-year period. Infants were considered symptomatic if they had loss of consciousness, history of behavior change, seizures, vomiting, bulging fontanel, retinal hemorrhages, abnormal neurologic examination, depressed mental status, or irritability. All others were considered to have occult ICI. RESULTS Of 101 infants studied, 19 (19%; 95% confidence interval [CI] 12%, 28%) had occult ICI. Fourteen of 52 (27%) infants younger than 6 months of age had occult ICI, compared with 5 of 34 (15%) infants 6 months to 1 year, and none of 15 (0%) infants older than 1 year. Eighteen (95%) infants with occult ICI had scalp contusion or hematoma, and 18 (95%) had skull fracture. Nine (47%) infants with occult ICI received therapy for the ICI. No infants with occult ICI (0%) (95% CI 0, 14%) required surgery or medical management for increased intracranial pressure. Only 1 subject (5%) with occult ICI had any late symptoms or complications: a brief, self-limited convulsion. CONCLUSION We found that 19 of 101 ICIs in infants admitted with head trauma were clinically occult. All 19 occult ICIs occurred in infants younger than 12 months of age, and 18 of 19 had skull fractures. None experienced serious neurologic deterioration or required surgical intervention. Physicians cannot depend on the absence of clinical signs of brain injury to exclude ICI in infants younger than 1 year of age.

Clinical significance of scalp abnormalities in asymptomatic head-injured infants.

Objectives 1) To identify clinical features indicating a high risk of skull fracture (SF) and associated intracranial injury (ICI) in asymptomatic head-injured infants. 2) To develop a clinical decision rule to determine which asymptomatic head-injured infants require head imaging. Methods We performed a prospective cohort study of all asymptomatic head-injured infants 0–24 months of age presenting to the emergency department of an urban children’s hospital. Infants were considered asymptomatic if they had no clinical signs of brain injury, or of basilar or depressed SF. Among subjects who had head imaging, we assessed the utility of age, scalp hematoma size, and scalp hematoma location for predicting SF and ICI. Results Of 422 study patients, 45 (11%) were diagnosed with SF and 13 (3%) with ICI. In the 172 subjects who had head imaging, there was a stepwise relationship between hematoma size and likelihood of SF. Parietal and temporal hematomas were highly associated with SF; frontal hematomas were not. There was a trend toward higher rates of SF in younger patients. Both large scalp hematoma and parietal hematoma were associated with ICI. Using these data, we developed a clinical decision rule to determine which asymptomatic infants need head imaging. In our study population, this rule has a sensitivity of 0.98 and specificity of 0.49 for SF, and it detects all 13 cases of ICI. The clinical rule calls for imaging in 146/422 (35%) study subjects. Conclusions Among asymptomatic head-injured infants, the risk of SF and associated ICI is correlated with scalp hematoma size, hematoma location, and weakly with patient age. We propose a clinical decision rule that could identify most cases of SF and ICI while not requiring head imaging for most patients. This decision rule should be validated in other study populations.

Infants with isolated skull fracture: what are their clinical characteristics, and do they require hospitalization?

STUDY OBJECTIVE We sought to identify the historical factors and physical examination findings typical of infants who have sustained isolated skull fracture (ISF)--in the absence of associated intracranial injury--after head trauma. We also assessed the risk of clinical deterioration (and therefore the need for inpatient observation) in infants with ISF. METHODS We conducted a retrospective analysis of all patients younger than 2 years admitted to a tertiary care pediatric hospital with a diagnosis of ISF over a 3-year period. RESULTS During the study period, 101 infants with radiographically proven ISF were admitted to the hospital. Falls were the most common reported mechanism of injury (n = 90 [89%]). Many falls involved short distances: 18 patients (18%) fell less than 3 feet. Nonaccidental trauma was suspected in only 10 patients (10%). Seventy-two patients (71%; 95% confidence interval [CI], 61%, 79%) had at least one of the clinical signs considered potential indicators of serious head injury: initial loss of consciousness, seizures, vomiting, lethargy, irritability, depressed mental status, and focal neurologic findings. In 97 patients (96%; 95% CI, 89%, 98%), local findings of head injury (palpable fracture, soft-tissue swelling, or signs of basilar skull fracture) were noted on physical examination. None of the patients (0%; 95% CI, 0%, 3%) demonstrated clinical decline during hospitalization. All were neurologically normal on discharge. CONCLUSION A diagnosis of ISF should be considered even in infants with minor mechanisms of head injury who appear well. However, infants with ISF rarely present without local signs of head injury on physical examination. If no other specific clinical concerns necessitate hospital admission, infants with ISF who have reliable caretakers may be considered for discharge home.

THE RELATIONSHIP OF DEPRESSION TO DISSOCIATION IN PATIENTS WITH BULIMIA NERVOSA

Dissociative Experiences Survey scores were compared between bulimics with and without depression, and among depressed patients with and without bulimia. An association is noted between depression and dissociation, confounding the previously noted relationship between bulimia nervosa and dissociation.

Validation of a clinical score to predict skull fracture in head-injured infants.

Objectives: To validate a previously derived clinical score that uses clinical signs to determine which head-injured infants are at risk of skull fracture. The clinical score is calculated on the basis of the patients age, the scalp hematoma size, and the location of the hematoma, with a total value between 0 and 8. Methods: We performed a prospective observational study of children younger than 2 years with blunt head trauma presenting to an urban pediatric emergency department. Among subjects who had head imaging performed (validation set), we assessed the utility of our clinical score to detect skull fracture and intracranial injury. Results: In the 203 patients with imaging, 51 (25%) were diagnosed with skull fracture and 29 (14%) with intracranial injury. A clinical score of 4 or greater identified 90% (46/51) of patients with skull fracture with a sensitivity of 0.90 (95% confidence interval [CI], 0.78-0.96) and a specificity of 0.78 (95% CI, 0.70-0.84). A clinical score of 3 or greater identified 93% (27/29) of those with an intracranial injury with a sensitivity of 0.93 (95% CI, 0.76-0.99) and a specificity of 0.42 (95% CI, 0.35-0.50). A score of 3 or greater identified 100% of intracranial injury among asymptomatic patients. Conclusions: We have validated our clinical scoring system as an accurate way of determining an infants risk of skull fracture. Whereas a clinical score of 4 or greater maximizes the trade-off between sensitivity and specificity for identifying skull fracture, a clinical score of 3 or greater may be preferable for detecting intracranial injury.

Potential impact of a computerized system to report late-arriving laboratory results in the emergency department.

Background Results of some laboratory tests for Emergency Department (ED) patients return hours to days after the patient is discharged. Inadequate follow-up for these late-arriving results poses medical and legal risks. We have developed, but not yet implemented, a computerized system called the Automated Late-Arriving Results Monitoring System (ALARMS). ALARMS scans the hospital’s laboratory and ED registration databases to generate an electronic daily log of all late-arriving abnormal laboratory results for ED patients. Objective To determine the potential impact of ALARMS by assessing our ED’s current quality of documented follow-up of late-arriving laboratory results. Methods We applied ALARMS retrospectively, to find all abnormal late-arriving laboratory results returned between 5/1/96 and 4/30/98 for ED patients for the following three tests: serum lead levels, Chlamydia cultures, or urine pregnancy tests. Medical records were reviewed for documentation of follow-up, which was considered appropriate if a clinician noted the abnormal result and documented a follow-up plan within 1 week after the result became available. Medical records were also reviewed for any evidence of complications attributable to delayed or inadequate follow-up. Results Over the 2-year study period, no appropriate follow-up was documented in 6/18 (33%) cases of elevated lead levels, 3/4 (75%) cases of late-arriving positive pregnancy tests, and 23/39 (59%) cases of positive Chlamydia cultures. One case of a positive Chlamydia culture, for which there was no documented follow-up, was associated with subsequent development of pelvic inflammatory disease. Conclusion Our current system of documented follow-up for late-arriving laboratory results has deficiencies. ALARMS, a computerized system of alerts for emergency physicians, has the potential to substantially improve documented follow-up of late-arriving laboratory results in the ED.

Decisionmaking in pediatric minor head trauma

Which patients with minor head injury require computed tomography (CT) of the head? The question is well suited for the development of a clinical decision rule. Five percent to 10% of patients presenting to an emergency department with minor head injury have traumatic brain injury.1,2 A small fraction of those patients will deteriorate if not diagnosed and treated in a timely fashion.3 The remaining patients (>90%) do not have traumatic brain injury and would ideally be managed without CT. Unnecessary use of CT in these patients leads to unnecessary exposure to ionizing radiation and likely to increased health care costs.4,5 In the 1990s, some US centers began performing CT in all cases of minor head injury.1,3,6,7 In contrast, a multicenter Canadian study of minor head injury found that rates of CT utilization ranged from 5% to 20%.8 This variation in CT utilization rates—from 5% in some Canadian hospitals to 100% in some US hospitals—illustrates the medical community’s uncertainty about which patients require CT. With worries about potentially lethal missed traumatic brain injury balanced against worries about the health and economic costs of unnecessary CT,4,5,9 how should we proceed? A good clinical decision rule could bring order to this chaos. Because missed traumatic brain injury may have tragic consequences, the ideal clinical decision rule should have near-perfect sensitivity for detecting P E D I A T R I C S / E D I T O R I A L