Edward P. Junkins

Propofol sedation by emergency physicians for elective pediatric outpatient procedures

STUDY OBJECTIVE We describe the efficacy of propofol sedation administered by pediatric emergency physicians to facilitate painful outpatient procedures. METHODS By using a protocol for patients receiving propofol sedation in an emergency department-affiliated short-stay unit, a prospective, consecutive case series was performed from January to September 2000. Patients were prescheduled, underwent a medical evaluation, and met fasting requirements. A sedation team was present throughout the procedure. All patients received supplemental oxygen. Sedation depth and vital signs were monitored while propofol was manually titrated to the desired level of sedation. RESULTS There were 291 separate sedation events in 87 patients. No patient had more than 1 sedation event per day. Median patient age was 6 years; 57% were male patients and 72% were oncology patients. Many children required more than 1 procedure per encounter. Most commonly performed procedures included lumbar puncture (43%), intrathecal chemotherapy administration (31%), bone marrow aspiration (19%), and bone biopsy (3%). Median total propofol dose was 3.5 mg/kg. Median systolic and diastolic blood pressures were lowered 22 mm Hg (range 0 to 65 mm Hg) and 21 mm Hg (range 0 to 62 mm Hg), respectively. Partial airway obstruction requiring brief jaw-thrust maneuver was noted for 4% of patient sedations, whereas transient apnea requiring bag-valve-mask ventilation occurred in 1% of patient sedations. All procedures were successfully completed. Median procedure duration was 13 minutes, median sedation duration was 22 minutes, and median total time in the short stay unit was 40 minutes. CONCLUSION Propofol sedation administered by emergency physicians safely facilitated short painful procedures in children under conditions studied, with rapid recovery.

A Prospective Evaluation of the Clinical Presentation of Pediatric Pelvic Fractures

BACKGROUND We sought to describe pediatric, blunt trauma patients with pelvic fracture (PF) and to evaluate pelvis examination sensitivity and specificity. METHODS We conducted a prospective study of blunt trauma patients at a Level I pediatric trauma center. A pediatric emergency medicine physician attempted to diagnose a PF, solely on the basis of the history and pelvis examination. Patients with blunt trauma but no pelvic fracture (NPF) were used as controls. RESULTS We enrolled 140 patients (16 PF, 124 NPF), and no significant differences were found regarding median age, gender, injury mechanism, acuity, and medical outcome. Approximately 25% of PF patients had iliac-wing fractures; 37%, single pelvic ring; 25%, double pelvic ring; and 13%, acetabular fractures. Eleven patients with PF had an abnormal pelvis examination (69% sensitivity), compared with six NPF patients (95% specificity, negative predictive value 0.91). CONCLUSION Pediatric patients with PF have low mortality and few complex fractures. The pelvis examination appears to have both high specificity and negative predictive value.

The clinical presentation of pediatric pelvic fractures

Background Few studies have addressed the presentation and clinical impact of pediatric pelvic fractures. We sought to describe pediatric blunt trauma patients with pelvic fracture (PF) and to evaluate the sensitivity and specificity of physical examination at presentation for diagnosis. Methods Retrospective analysis of all PF and control (NPF) patients from our pediatric institution over an 8-year period. Results A total of 174 patients (88 PF, 86 NPF) were included. Median patient age was 8 years (range, 3 months to 18 years), with 54% males. The most common mechanisms of injury for PF patients were automobile-related accidents (75%). There were 140 patients (87%) who were transported by air or ground medical services. At presentation, approximately 16% of PF patients had a Glasgow Coma score of <15, a mean Revised Trauma Score of 7.49, and a median Injury Severity Score (ISS) of 9. Thirty-one PF patients (35%) had an ISS of >15 indicating severe, multiple injuries. Sixty-eight PF patients (77%) had severe isolated injuries (Abbreviated Injury Scale 1990 value of >3); 11% of PF patients required transfusions, and 2% died. Fifteen PF patients (17% ) had no pelvic ring disruption; 39 (43%) had a single pelvic ring fracture, 22 (2%) had two pelvic ring fractures, 2 (2%) had acetabular fractures, and 10 (11%) had a combination of pelvic fractures. An abnormal physical examination of the pelvis was noted in 81 patients with PF (92% sensitivity, 95% confidence interval [CI] = 0.89–0.95), 15 NPF patients had an abnormal examination (79% specificity, 95% CI = 0.74–0.84). The positive predictive value of the pelvis examination was 0.84, and the negative predictive value was 0.89. The most common abnormal pelvis examination finding was pelvic tenderness in 65 PF patients (73%). A total of seven PF patients had a normal examination of the pelvis; four had a depressed level of consciousness (defined as GCS <15), and six patients had a distracting injury. Conclusions Pediatric blunt trauma patients with pelvic fracture represent a severely injured population but generally have lower transfusion rates and mortality than noted in adult studies. The pelvis examination appears to be sensitive and specific in this retrospective study. However, an altered level of consciousness and/or distracting injuries may affect examination sensitivity and specificity. Based on this retrospective study, we cannot advocate eliminating pelvic radiographs in the severely injured, blunt trauma patient. Prospective studies are recommended.

The clinical presentation of pediatric thoracolumbar fractures: a prospective study.

BACKGROUND Thoracolumbar spine (TLS) fractures are rare in the pediatric population but may result in significant morbidity, necessitating a prompt diagnosis. No formal recommendations have been made for screening pediatric trauma patients for TLS fractures; early diagnosis has traditionally relied on clinical parameters extrapolated from adult data. METHODS From March 2004 to April 2005 patients presenting to a level one pediatric trauma center were consecutively enrolled. Clinicians were asked to assess eligible patients and prospectively state their TLS examination findings and degree of clinical suspicion for fracture. RESULTS A total of 228 patients were enrolled (mean age of 8.2 years), 16 with TLS fractures. Clinical performance of the TLS spine examination diagnosed a fracture with a sensitivity of 81% (95% CI: 0.57, 0.93), specificity of 68% (0.62, 0.74), and odds ratio of 9.38 (2.59, 34.01). A clinicians degree of suspicion detected a TLS fracture with a sensitivity of 56% (95% CI: 0.33, 0.77), specificity of 82% (0.77, 0.87), and odds ratio of 6.08 (2.13, 17.37). CONCLUSIONS The clinician is able to clinically diagnose TLS fractures in pediatric trauma patients with good sensitivity and average specificity, however, TLS fractures were missed. Screening radiographs may still be required until larger studies confirm these findings.

Injuries sustained by students in shop class

Objective. Injuries in the school environment are a serious public health problem. Injuries occurring within the school shop class are a part of this problem that has received little to no attention. The purpose of our study was to describe the epidemiology of shop class injuries in Utah public schools for the years 1992–1996. Methods. Utah statewide grades 7 through 12 school injury data for 1992–1996 were used. The data were generated from a standardized Student Injury Report form completed by school personnel immediately after the occurrence of an injury on school premises that: 1) caused loss of at least one half of a day of school; and/or 2) warranted medical attention and treatment. Shop injuries were defined as injuries that occurred in industrial art classes, vocational educational classes, or automotive classes. To determine the medical outcome and hospital charges associated with shop class injuries, we linked the Student Injury Report database to Utah statewide emergency department (ED) records (available for 1996 only), and to Utah statewide hospital inpatient discharge records (1992–1996). Results. During 1992–1996, 14 133 students in grades 7 through 12 were injured at school, of which 1008 (7.1%) were injured during a shop class. The majority (88.4%) of shop injuries involved equipment use. Equipment was misused in 37.9% and malfunctioned in 3.5% of the incidents. The leading injuries reported for shop equipment were lacerations (70.9%), burns (6.0%), and abrasions (4.6%), whereas the leading for nonequipment injuries were lacerations (45.4%), fractures (9.2%), and pain/tenderness (6.7%). In 1996, 167 students were injured in a shop class and 45 (26.9%) visited an ED as a result of the shop injury. Equipment was a factor in 88.9% of the shop injuries admitted to the ED. Table saws (15.0%), other saws (15.0%), and band saws (12.5%) were involved in nearly one half of the equipment injuries. Equipment was misused in 44.7% and malfunctioned in 10.5% of the incidents resulting in an ED visit. The majority (64.4%) of students sustained an open wound injury. The total ED charges were

Differences in herbal and dietary supplement use in the Hispanic and non-Hispanic pediatric populations.

16 571. For 1992–1996, 1008 students were injured in a shop class, 7 (.7%) required inpatient hospital care. Six of the students were injured using a table saw and 1 sustained injuries attributable to automotive cleaning fluid. Equipment was used improperly in 4 of the table saw injuries. Six of the students sustained hand injuries, with 3 suffering a traumatic amputation of a finger or thumb. The total inpatient charges were

Repeat Patients to the Emergency Department in a Statewide Database

26 747. Conclusion. School shop injuries have a great impact on students, their families, and schools because of the loss of productivity for the student and the financial impact. Many of the injuries are preventable. These findings stress the need for school administrators, teachers, and students to develop and improve safety policies and practices in school shop classes. In addition, the findings may provide useful information to pediatricians and enable them to better inform patients of risks in school shop classes.

Capnography and Depth of Sedation During Propofol Sedation in Children

Background: Complementary and alternative medical therapies are becoming increasingly popular in the general population. Objective: To describe the cultural differences in the use of herbal and dietary supplements in the Hispanic and non-Hispanic-Caucasian outpatient pediatric populations. Methods: Questionnaires were administered over a 2-month period to a convenience sample of adolescents and parents of patients younger than 12 years, presenting to an emergency department, an urban private pediatric practice, and a community-based clinic. Results: There were 643 surveys completed. Ethnic distribution was 65% Caucasian, 27% Hispanic, 2% Pacific Islander, and 1% each Asian, African American and Native American. Mean respondent age was 30.8 years. Mean child age was 4.6 years; 51% were male. Use of nonprescribed dietary supplements was significantly greater in Hispanic (33%) versus Caucasian children (9%) (P < 0.01); most commonly used supplements were herbal teas (56%) and echinacea (14%). More Hispanic respondents reported receiving information on herbal preparations from a family member compared with non-Hispanic patients (56.0% vs. 18.7%). Complementary and alternative medicine use had not been discussed with a health care provider by 38% of the total users and 47% of those thought it not important to do so. Conclusions: There is significant use of complementary and alternative medicine in the pediatric population, and herbal and dietary supplement use varies between Hispanic and Caucasian children. In addition, this dietary supplement use is often not discussed with health care providers. These factors should be taken into consideration by all health care providers.