Dee Hodge

Coin ingestion: does every child need a radiograph?

We studied 80 children who presented to the emergency department (ED) with a complaint of coin ingestion to determine whether radiographs are necessary in all situations and to determine which symptoms or signs are predictive of esophageal coins. Radiographs were considered positive if the coin was in the esophagus. Radiographs were positive in 25 (31%) of patients, of whom 11 (14%) had no symptoms or signs in the ED. Fifty-five (69%) of the 80 patients had subdiaphragmatic foreign bodies (44 [55%]), or no foreign bodies (11 [14%]) seen on films. Fourteen (18%) of the children required removal of the coin. Variables correlating with positive radiograph, in order of significance, included localization, choking at ingestion, drooling in the ED, vomiting, and chest pain (P less than .05). Symptom type was predictive of radiographic findings, and it may be predictive of need for removal. All 14 patients with symptoms or signs in the ED had positive films, as compared to 11 of 66 (16.6%) with no symptoms (chi square = 33.555; P less than .001). Although this relationship is significant, the finding of esophageal foreign body in 17% of patients with no symptoms leads us to recommend that all patients have a chest radiograph if coin ingestion is suspected.

Intraosseous infusion flow rates in hypovolemic “pediatric” dogs

We tested a 20-gauge, 2 1/2-inch spinal needle and a 13-gauge, 3 1/2-inch bone marrow needle with Ringers lactate delivered by gravity and 300 mm Hg pressure in vitro and in hypovolemic puppies to ascertain in vivo intraosseous flow rates and to determine the effects of catheter size and anatomic factors on flow rate. In vitro flow was significantly faster than in vivo flow (P = .001). In vivo, mean flow rates were 11 mL/min for the 20-gauge needle and 13 mL/min for the 13-gauge needle by gravity. The mean flows by 300 mm Hg pressure for the same needles were 24 mL/min and 29 mL/min. While the in vivo flow rates were significantly greater for the 13-gauge versus the 20-gauge needle, the differences were not clinically significant (2 mL/min difference by gravity and 5 mL/min difference by pressure). The clinically comparable in vivo rates for the two needles tested indicated that the rates are dependent on flow through the bone marrow rather than the size of the needle. The data suggest that while intraosseous infusion is a rapid technique for gaining vascular access, the flow rates achieved may not be sufficient for the definitive treatment of severe hypovolemic or hemorrhagic shock alone.

Pediatric catheter flow rates

The flow rates of the 18- to 24-gauge catheters most commonly used in pediatrics were studied to determine which catheters and infusion techniques allowed for rapid volume replacement in infants and children. As expected, short, large-diameter catheters were found to have a higher flow rate, and flows under pressure in the largest catheters tested were up to 17 times greater than in a longer, smaller diameter catheter. Catheters designed for peripheral venous insertion in children showed an 18 to 164% increase in flow rate when compared with the same gauge catheters designed for central venous use. Thus, intravenous access via a central vein does not guarantee more rapid fluid infusion unless the use of the central vein permits the insertion of a catheter larger in diameter than any that could be placed peripherally. Knowledge of the flow rates determined for the various catheters in this study will assist the physician in optimizing fluid resuscitation of the critically ill or injured child.

Guidelines for pediatric equipment and supplies for emergency departments

[Committee on Pediatric Equipment and Supplies for Emergency Departments, National Emergency Medical Services for Children Resource Alliance: Guidelines for pediatric equipment and supplies for emergency departments. Ann Emerg Med January 1998;31: 54-57.].

The bacteriologically battered baby: Another case of munchausen by proxy

We present a case in which a mother who had had self-inflicted infections as a teenager also caused life-threatening infections in her year-old child. After testing for and treating various immunologic deficiencies without success, it was apparent that the infection was caused by contamination of intravenous sites. Strict isolation of the patient, with restricted and observed visitations by the mother, was the critical step in stopping the infections. Because the woman took her child to several emergency departments, this case is presented to alert emergency personnel to this entity and to explain some of the dynamics and the social issues that cause the problem.

Predictors of Pediatric Emergency Patients Discharged Against Medical Advice

Based on a retrospective 5-year medical record review, this study characterizes factors associated with patients discharged against medical advice (AMA) from a tertiary pediatric emergency department (ED) and compares rates of return to the ED and admission to the hospital with those of patients routinely discharged. Data from 94 patients discharged AMA are compared with those of 188 control patients. Pediatric patients at risk for discharge AMA are older than 15 years (odds ratio [OR], 3.561; 95% confidence interval [CI], 1.695-7.482), self-register independent of a parent (OR, 3.100; 95% CI, 1.818-152.770), arrive by ambulance (OR, 2.761; 95% CI, 1.267-6.018), involve a consultant (OR, 2.592; 95% CI, 1.507-4.458), and have a chief complaint of abdominal pain (OR, 3.095; 95% CI, 1.154-8.303). Negative predictors include urgent triage (OR, 0.155; 95% CI, 0.039-0.618), a chief complaint of upper respiratory tract illness or otitis media (OR, 0.229; 95% CI, 0.075-0.702), and discharge diagnoses of infection (adjusted OR, 0.053; 95% CI, 0.004-0.767), disease of the nervous system and sense organs (adjusted OR, 0.066; 95% CI, 0.005-0.898), respiratory illness (adjusted OR, 0.072; 95% CI, 0.007-0.718), and gastrointestinal disease (adjusted OR, 0.050; 95% CI, 0.006-0.419). Certain key elements of discharge AMA are well documented, including consequences of discharge AMA (74.5%) and instructions for care (54.3%). Other elements such as alternative therapies (1.1%) are poorly documented. Patients discharged AMA have a significantly higher return rate (24.5%) within 15 days compared with patients who have routine discharge (6.4%) (χ2 = 18.85, P < .001). Ninety-six percent of patients who return to the ED have the same chief complaint at both visits if discharged AMA compared with 50% of patients who are discharged routinely (P = .003), with 25% admission rates at the time of second visit for both types of discharges. Adolescents who register themselves are at increased risk for discharge AMA. Patients who are triaged as urgent or nonurgent or who have minor illnesses are likely to be dispositioned routinely. Patients discharged AMA are more likely to return to the ED with the same complaint than patients who are routinely discharged.

Risk Factors for Extremely Long Length-of-Stay Among Pediatric Emergency Patients

Objective: Over time, we observed more visits in our pediatric emergency department with length-of-stay (LOS) of more than 10 hours, whereas our mean LOS was approximately 3 hours. We sought to characterize factors associated with this extremely long LOS. Methods: Eighty-one visits with LOS more than 10 hours were identified from January 1, 2001, to June 30, 2003. In this retrospective study, we compared these cases with 405 randomly selected age-matched controls with LOS less than 10 hours (5 controls per case). Results: The groups were similar for sex, visit month, arrival mode, and level of training of the supervising physician. Cases more frequently arrived during night shifts (30% vs 13%) and had laboratory tests (93% vs 32%), radiological studies (83% vs 34%), procedures (28% vs 15%), sedations (24% vs 4%), subspecialty consultations (84% vs 20%), chief complaints of abdominal pain (42% vs 6%) and diagnoses of appendicitis (10% vs 1%), and had a greater hospitalization rate (67 vs 19%). Although more cases involved white patients (57% vs 31%), race was not associated with LOS more than 10 hours in adjusted analysis. In multivariable analysis, longer waiting time (odds ratio [OR], 1.013; 95% confidence interval [CI], 1.007-1.019), night shift arrival (OR, 5.0; 95% CI, 1.9-12.8), higher triage acuity (lowest acuity: OR, 0.003; 95% CI, 0.0-0.286), radiology study other than radiographs (OR, 18.0; 95% CI, 7.5-43.1), and subspecialty consultation (OR, 7.6; 95% CI, 3.2-18.3) were associated with LOS more than 10 hours. Conclusions: In our pediatric emergency department, risk factors for LOS more than 10 hours included longer waiting time, night shift arrivals, high triage acuity, radiology studies, and subspecialty consultations. These factors may also be important considerations for quality improvement initiatives at other institutions.

Equipping and Preparing the Office for Emergencies

It is the practitioners responsibility to have a prepared office to aid the emergently ill child. Basic equipment and staff training are essential. The pediatrician and family practitioner are on the front lines of pediatric emergency care and, with minimal equipment and training, can serve a vital role in the initial stabilization of the critically ill child.

Child homicide: emergency department recognition.

Homicide is escalating as a cause of sudden death in childhood. With the ever-rising rate of child abuse in the United States, the emergency physician is increasingly likely to encounter cases of attempted homicide. In order to improve survival in such cases, the emergency department (ED) staff must be alert to the subtle signs and symptoms of this form of trauma and be prepared to institute life-saving therapy. We reviewed 12 cases of child homicide seen in our ED between 1981 and 1983 and summarized the findings on these unfortunate children. The typical victim was a young child in the second half of the first year or in the second year of life. The most common forms of fatal injury were CNS injury and abdominal trauma. In both types of injuries, there were often subtle findings on external physical examination. It was important for the physician to have a high index of suspicion based on a protean chief complaint, a lack of preceding history of illness, the time of presentation to the ED, and more subtle physical findings such as minor skin bruising, retinal hemorrhage, and distended abdomen. A low hematocrit was also suggestive of traumatic cause for the childs critical state. In addition, autopsy findings for the 12 patients are presented.

Trauma to elbows, knees, and ankles

In summary, the emergency department or office-based physician should distinguish first between inflammation and injury. A clinical diagnosis of fracture should be made before obtaining and reading films. Comparison views help to resolve doubt. A neurologic examination should be documented before undertaking reduction. Finally, if in doubt, a splint for 24 to 48 hours until an orthopedic opinion is available causes no harm.