Douglas Smith

Prehospital pediatric endotracheal intubation performance review.

Pediatric prehospital care was reviewed over a one year period to determine success rate, causes of unsuccessful attempts, and complications of performing endotracheal intubation. The Milwaukee County Emergency Medicine Technician-Paramedics (EMT-Ps) responded to 1467 pediatric (<19 years of age) patient calls. This accounted for 11% of the patients who received EMT-P care during the study period. Of the 63 patients requiring pediatric endotracheal intubation, 49 (78%) were successfully intubated. Of the 42 pulseless nonbreathing (PNB) patients, 39 (93%) were successfully intubated. Of the 21 patients judged to be in impending respiratory failure, 10 (48%) were successfully intubated. Common difficulties in intubating the PNB patient included inability to visualize the glottis and cords secondary to mucus and/or vomitus, use of inappropriately small endotracheal tubes, and accidental extubation during transport. Difficulties in intubating impending respiratory failure patients included patient resistance and seizure activity. We recommend that the EMT-P training curriculum include a review of these difficulties and that prehospital pediatric endotracheal intubation performance be monitored and reviewed with the EMT-Ps.

Prehospital countershock treatment of pediatric asystole

Prehospital care was retrospectively reviewed in 117 pulseless nonbreathing (PNB) pediatric patients (0 to 18 years of age) to determine the effects of immediate countershock treatment of asystole. Of 90 (77%) children with an initial rhythm of asystole, 49 (54%) received countershock treatment. Rhythm change occurred in ten (20%) of the asystolic children who received countershock treatment. Three of the countershocked asystolic children were successfully resuscitated, but none survived. Rhythm change occurred in nine (22%) of the asystolic children not countershocked. Six were successfully resuscitated, and one survived. The two groups (countershocked asystole v noncountershocked asystole) did not differ significantly in age, sex, witnessed arrest, witnessed arrest with bystander basic life support (BLS), prehospital endotracheal intubation, both intubation and vascular access success, or diagnosis. However, prehospital vascular access was successfully established in a significantly greater number of countershocked patients (P less than .05). The mean times to the scene, at the scene, and to the hospital for the countershocked v noncountershocked asystolic patients were 6.2, 23.8, and 6.1 v 5.9, 14.7 and 7.0 minutes. The mean time at the scene was significantly greater in the countershock group (P less than .001). The successful performance of prehospital endotracheal intubation was significantly associated with rhythm change (P less than .05). Patients age, witnessed arrest, witnessed arrest with bystander BLS, successful establishment of prehospital vascular access, diagnosis, and countershock treatment were not significantly associated with rhythm change. In conclusion, prehospital countershock treatment prolonged prehospital care time and was not associated with rhythm change in asystolic children. Therefore, prehospital countershock treatment of asystolic children is not recommended.

Efficacy of a Protocol to Distinguish Risk of Serious Bacterial Infection in the Outpatient Evaluation of Febrile Young Infants

A study of 534 febrile infants ages 4 to 8 weeks evaluated for sepsis assessed the efficacy of the Milwaukee Protocol (MP) for selecting patients at low risk for serious bacterial infection (SBI) who might benefit from outpatient management. Two groups were compared: 1) Infants with uncompromised presentation (UP) who met all MP criteria received ceftriaxone 50 mg/kg and were discharged, then reevaluated within 24 hours. 2) Infants with compromised presentation (CP) who did not meet MP criteria were hospitalized for antibiotic therapy pending culture results. Of 391 CP patients, 23 (5.9%) had SBI; of 143 UP patients, 1 (0.7%) had SBI (P <.02). The MP criteria had a sensitivity of 96% and a 99% negative predictive value for distinguishing SBI outcome. The only UP patient with SBI was afebrile and had a negative repeat blood culture after 24 hours, and recovered with no complications. Managing UP infants as outpatients avoided 48 to 72 hours of hospitalization, decreasing health-care costs by an estimated total of

Relationship of Fever Magnitude to Rate of Serious Bacterial infections in Infants Aged 4-8 Weeks:

465,170.

The Clinical Characteristics and Infectious Outcomes of Febrile Infants Aged 8 to 12 Weeks

We correlated the height of fever with underlying infectious etiology in 683 consecutive febrile infants aged four to eight weeks who received outpatient evaluation for sepsis during a five-year period. The relative number of infants with fever was inversely proportional to fever height, as 51 % had a temperature 38.1 - 38.9°C, 45% had a temperature 39 - 39.9°C, and 4% had a temperature >40°C [hyperpyrexia]. There were 34 cases of serious bacterial infections [SBI], including 16 cases of urinary tract infection, 8 cases of bacteremia, 6 cases of bacterial meningitis, and 4 cases of Salmonella enteritis. The rate of SBI increased in direct proportion to fever height, being 3.2% in those with a temperature 38.1-38.9°C, 5.2% in those with a temperature 39-39.9°C, and 26% in those with a temperature >40°C. The 6.8% rate of SBI in those with fever >39°C was significantly greater than the 3.2% rate in those with fever <39°C [p <0.035]; and the 26% rate of SBI in those with hyperpyrexia was significantly greater than the 4.1 % rate in those with fever <40°C [p <0.000004]. In identifying those with SBI, the presence of hyperpyrexia had a sensitivity of 21 %, specificity of 97%, positive-predictive value of 25%, and negative-predictive value of 96%. The rate of SBI in febrile infants aged four to eight weeks is proportional to the height of fever documented at the time of evaluation; yet the predictive-value of hyperpyrexia in identifying individual infants with SBI is low. It is important that all febrile infants aged four to eight weeks receive complete evaluation for sepsis, regardless of height of fever.

Correlating Changes in Body Temperature With Infectious Outcome in Febrile Children Who Receive Acetaminophen

We reviewed 356 consecutive cases of febrile infants aged 8 to 12 weeks who received outpatient evaluation for sepsis over 4 years. Thirty-three infants (9.3%) had a serious bacterial infection (SBI), including bacterial meningitis, bacteremia, urinary tract infection (UTI), and Salmonella enteritis. The SBI rate, which was directly proportional to fever height, was significantly greater for infants with hyperpyrexia (35%) than those with lesser degrees of fever (7.7%) and for infants with peripheral blood leukocytosis (total WBC count ≥ 15,000/mm3; 25%) than those with lesser total WBC counts (5.8%). An attending-level physician judged that 67% of infants with SBI appeared to be well, including five of eight cases (63%) of bacteremia, 14 of 17 cases (82%) of UTI, and all three cases of Salmonella enteritis, whereas all five patients with bacterial meningitis appeared to be ill. Urinalysis abnormalities indicative of UTI were present in 15 of 17 infants (88%) who had this infection. SBIs are not uncommon in febrile infants aged 8 to 12 weeks and occur significantly more often in those with either hyperpyrexia or peripheral blood leukocytosis.

Systemic Infection Due to Group B Beta-Hemolytic Streptococcus in Children A Review of 75 Outpatient-Evaluated Cases During 13 Years

We reviewed the body-temperature patterns of 140 children ages 2 to 24 months who had fever >39.0°C, received acetaminophen 10 to 15 mg/kg, and had their temperatures remeasured 60 to 90 min later. The children comprised three groups: 22 had bacterial meningitis; 59, isolated bacteremia; and 59, nonbacterial febrile illness. Percentages of patients who became afebrile (temperature < 38.0°C) after receiving acetaminophen were not significantly different among the three groups. Differences in mean temperature decrease after antipyretic was given were significant within each group but not between groups. An inverse relation (P < .004) between patient age and magnitude of temperature was revealed by the following formula: °C of defervescence = 1.66 -(0.028 x patient age in months). Thus, highly febrile young children with and without invasive bacterial infections who receive a therapeutic dose of acetaminophen experience a significant temperature drop after 60 to 90 min but do not commonly defervesce to an afebrile state. The degree of defervescence is age-dependent and does not distinguish between infectious outcomes.

Correlating CBC profile and infectious outcome. A study of febrile infants evaluated for sepsis.

We reviewed 75 outpatient cases of systemic infection due to group B beta-hemolytic streptococcus (GBS) evaluated during a 13-year period. Patient ages ranged from five days to eight months; 75% were younger than two months. Early-onset (<seven days of age) GBS disease occurred in 10% of the patients, and late-onset GBS disease in 90%. The racial distribution was 60% black, 35% white, and 5% Hispanic. Symptoms included fever, irritability, lethargy, and altered-feeding pattern which lasted less than 24 hours in 88% of patients. On presentation, 33% were afebrile (eight had GBS meningitis); 32% did not appear ill (six had GBS meningitis). Of the total, 40% had GBS meningitis, of these, a greater proportion had either early-onset GBS disease or neutropenia. Infection other than meningitis was identified in 24% of all patients: pneumonia (six cases), cellulitis/adenitis (six cases), osteomyelitis/septic arthritis (five cases), and otitis media (one case). All patients survived. Systemic GBS infection in an outpatient population can involve infants up to eight months old, is more common in blacks than in whites, can be present without fever or compromised appearance, and usually has low mortality.

Relationship of temperature pattern and serious bacterial infections in infants 4 to 8 weeks old 24 to 48 hours after antibiotic treatment

The cases of 1,009 febrile infants who were evaluated for sepsis as outpatients during a seven-year period were reviewed to correlate their complete blood count (CBC) profiles with the infectious outcomes. Eighty-one infants had serious bacterial infections (SBIs); the remainder (928) were culture-negative. The infants with SBIs had a significantly greater mean total white blood cell (WBC) count and absolute band count (ABC) than did those who were culture-negative, whereas the difference in mean percent of polymorphonuclear leukocytes was not significant. The sensitivity of the ABC was significantly superior to that of total WBC count in predicting the outcome of SBI. The diagnostic data provided by the ABC can aid physicians in determining the predictive value of CBC profiles for infectious outcome in febrile infants receiving outpatient sepsis evaluation.

Standardized instructions : do they improve communication of discharge information from the emergency department ?

STUDY OBJECTIVEnA new management approach to selected febrile infants 4 to 8 weeks old evaluated for possible sepsis is outpatient ceftriaxone therapy, with subsequent re-evaluation 24 to 48 hours after presentation. This study assessed whether the temperature profile of such infants during the 24- to 48-hour period after treatment distinguished those with from those without serious bacterial infections (SBIs).nnnDESIGNnProspective, descriptive clinical study.nnnPARTICIPANTSnOne hundred sixty-one febrile infants 4 to 8 weeks old.nnnSETTINGnAn urban pediatric emergency department and hospital.nnnMEASUREMENTS AND MAIN RESULTSnAll infants underwent a sepsis evaluation (lumbar puncture, CBC/blood culture, and urinalysis/urine culture) and were hospitalized for at least 48 hours. Temperatures were measured on presentation and then every four hours during hospitalization. All infants received parenteral third-generation cephalosporin antibiotic therapy, and none received antipyretic medication unless fever was documented. Fever (rectal temperature of more than 38.0 C) was documented during the 24- to 48-hour period after presentation in 28 infants (17.6%)--one of a total of 18 infants (5.6%) with SBI and 27 of a total of 143 infants (19%) without SBI (alpha, more than .2: power .30). All bacterial isolates in cases of SBI were susceptible to third-generation cephalosporin antibiotics. All repeat blood and urine cultures that were performed in infants with bacteremia or urinary tract infections, respectively, were negative 24 hours after presentation.nnnCONCLUSIONnInfants 4 to 8 weeks old who remain febrile during the 24 to 48-hour period after presentation and initiation of parenteral antibiotic therapy are less likely to have SBI. This study did not have sufficient power for this difference to be statistically significant.