Douglas S. Smith

Five-year experience in prehospital intraosseous infusions in children and adults.

STUDY OBJECTIVE To evaluate the ability of emergency medical technician-paramedic (EMT-P) units to become and remain proficient in the performance of the intraosseous infusion procedure. DESIGN AND SETTING Descriptive nonrandomized trial open to all patients meeting protocol criteria over a five-year period; prehospital urban and suburban area with a population of 951,000. PARTICIPANTS One hundred fifty-two consecutive patients (age range, newborn to 102 years) who had intraosseous infusion line placement attempted by EMT-Ps. INTERVENTION Jamshidi sternal intraosseous infusion needle placed in the proximal tibia bone marrow in patients requiring emergency vascular access for fluid and/or medication administration. RESULTS EMT-Ps performed 165 attempts on 152 patients with a five-year success rate of 76% per patient and 70% per attempt. Success rates per patient age group were 78%, 0 to 11 months; 85%, 1 to 2 years; 67%, 3 to 9 years; and 50%, 10 years or older. Success rates were significantly higher in children 3 years old compared with children and adults 3 or more years old (P = .04). Proficiency was maintained over the five-year study period. Infiltration was the most common complication, occurring in 14 patients (12%). Errors in landmark identification and needle bending were the most frequent identifiable causes for unsuccessful attempts. Evidence of clinical response to fluid or medication infused was noted in 28 patients (24%). CONCLUSION EMT-P units can successfully perform the intraosseous infusion line procedure in patients of all ages. Proficiency is maintained over time despite its infrequent use by individual EMT-Ps.

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.

Reliability of observation variables in distinguishing infectious outcome of febrile young infants.

We prospectively evaluated 7 observation variables (level of activity, level of alertness, respiratory status/effort, peripheral perfusion, muscle tone, affect, feeding pattern) which qualify patient clinical appearance in order to determine reliability in distinguishing the infectious outcome of 233 febrile infants ages 0 to 8 weeks. Each variable was graded either 1, 3, or 5, with a higher score indicative of a greater degree of compromise. All infants received physical examination and sepsis evaluation (lumbar puncture, complete blood count/blood culture, urinalysis/urine culture). The 3 outcome groups compared were 29 cases of serious bacterial infections, (+SBI; 10 with bacterial meningitis, 12 with bacteremia, 7 with urinary tract infection), 45 cases of aseptic meningitis (AM) and 159 cases culture-negative with normal cerebrospinal fluid (CN-NCSF). The mean score for each of the 7 variables was significantly greater in the +SBI group compared with both the AM and CN-NCSF groups (P < 0.05), whereas there was no significant difference in mean score for each of the 7 variables between the AM and CN-NCSF groups. Stepwise discriminant analysis identified 3 variables that best distinguished outcome: affect; respiratory status/effort; and peripheral perfusion, which constituted the Young Infant Observation Scale. The mean total Young Infant Observation Scale score generated from assessing these 3 variables was significantly greater (P = 0.0001) in the +SBI, group (9) compared with both the AM (5) and CN-NCSF (5) groups. A total Young Infant Observation Scale score > or = 7 had a sensitivity of 76%, specificity of 75% and negative-predictive value of 96% for outcome of +SBI.

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.

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.

Accidental cocaine intoxication in a nine-month-old infant: presentation and treatment

A case of a nine-month-old male who ingested cocaine is presented. The rarity of this type of ingestion, as well as the caretakers denial of the presence of cocaine in the household, made rapid diagnosis of this infants malady difficult. We present this case to alert physicians to the presentation and treatment of cocaine-intoxicated infants.

Pediatric sexual abuse management in a sample of children’s hospitals

Medical directors of pediatric emergency departments were surveyed by mail to determine the present role of their pediatric hospitals in general, and emergency departments in particular, in the evaluation and management of pediatric sexual assault and abuse. Seventy-four percent of the responses were from communities with an estimated yearly incidence of sexual abuse cases greater than 500. Sixty-eight percent of the communities had a designated pediatric sexual assault center. Thirty-two percent were affiliated with adult facilities and 68% with pediatric facilities. Of those hospitals responding, initial evaluation was most often performed in the emergency department in 77%. Most initial evaluations were performed by resident (PL-2 or above) level physicians (59%). The availability of nonphysician professionals, eg, social workers, was felt to be always or usually adequate in 57% and occasionally, rarely, or never adequate in 43%. Estimated physician time required for evaluations averaged less than 60 minutes in 52%, 60 to 90 minutes in 32%, and greater than 90 minutes in 16%. Other patients were felt to be always or frequently compromised in 34% and occasionally compromised in another 44%. The directors rated the abilities of their respective departments to evaluate and manage these patients as excellent in 33%, good in 33%, adequate in 29%, and inadequate in 4%.

CBC differential profile in distinguishing etiology of neonatal meningitis

A retrospective study of 72 infants under four weeks of age with meningitis evaluated over almost four years was performed to determine the predictive value of the CBC differential ratio (% lymphocytes + % monocytes/% polymorphonuclear leukocytes + % band forms) profile in distinguishing those with bacterial from those with a nonbacterial etiology. Of 18 neonates with bacterial meningitis, all had a ratio lower than one; of 54 neonates with aseptic or viral meningitis, 46 (85%) had a ratio greater than one. The difference between mean ratio values of the two groups was highly significant (P > 0.001). A CBC differential ratio less than one was more sensitive (100%) in initially identifying neonates with bacterial meningitis than were other traditionally utilized parameters, eg, presence of fever (50%), ill appearance (50%), hypoglycorrhachia (61%), elevated CSF protein (55%), or CSF Gram-stained smear revealing pathogenic organisms (45%). Statistical analysis revealed that a CBC differential ratio less than 1.5 will accurately predict all cases of neonatal bacterial meningitis with a confidence of 99.95%. The CBC differential ratio is an accurate index for distinguishing neonates with bacterial meningitis from those with nonbacterial meningitis. Utilization of this parameter in conjunction with other traditional factors is efficacious in predicting outcome.