Elisabeth Guenther

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.

Annual Risk of Death Resulting From Short Falls Among Young Children: Less Than 1 in 1 Million

OBJECTIVE. The objective of the work was to develop an estimate of the risk of death resulting from short falls of <1.5 m in vertical height, affecting infants and young children between birth and the fifth birthday. METHODS. A review of published materials, including 5 book chapters, 2 medical society statements, 7 major literature reviews, 3 public injury databases, and 177 peer-reviewed, published articles indexed in the National Library of Medicine, was performed. RESULTS. The California Epidemiology and Prevention for Injury Control Branch injury database yielded 6 possible fall-related fatalities of young children in a population of 2.5 million young children over a 5-year period. The other databases and the literature review produced no data that would indicate a higher short-fall mortality rate. Most publications that discuss the risk of death resulting from short falls say that such deaths are rare. No deaths resulting from falls have been reliably reported from day care centers. CONCLUSIONS. The best current estimate of the mortality rate for short falls affecting infants and young children is <0.48 deaths per 1 million young children per year. Additional research is suggested.

Death, Child Abuse, and Adverse Neurological Outcome of Infants After an Apparent Life-Threatening Event

OBJECTIVES. Apparent life-threatening events in infants constitute a significant challenge for health care providers. Apparent life-threatening event evaluation and management are poorly defined, and outcomes have not been clearly determined. Our objectives were to characterize short- and long-term risks for death, child abuse, and abnormal neurological outcomes of infants after an apparent life-threatening event and to identify clinical features that are predictive of these outcomes. METHODS. We collected data from infants ages birth to 12 months of age who were hospitalized after an apparent life-threatening event during a 5-year time period. Patients were evaluated for subsequent death, child abuse, or adverse neurological outcome (chronic epilepsy or developmental delay). RESULTS. A total of 471 patients met inclusion criteria and were followed an average of 5.1 years. Two patients died after developing chronic epilepsy and severe developmental delay. Fifty-four (11%) patients were diagnosed as being a victim of child abuse, but only 2 were identified at initial presentation. There were 23 (4.9%) patients with adverse neurological outcomes, including 17 (3.6%) with chronic epilepsy and 14 (3.0%) with developmental delay. Of those who developed chronic epilepsy, 71% returned within 1 month of the initial apparent life-threatening event with a second event. Neurological evaluation at the time of the apparent life-threatening event had low yield for predicting those who would develop chronic epilepsy. CONCLUSIONS. Infants who suffer an apparent life-threatening event are at risk for subsequent child abuse and adverse neurological outcomes. Deaths were uncommon and only occurred in the setting of severe developmental delay and seizure disorders. Neurological evaluation during hospitalization for a first apparent life-threatening event is of low yield, but close follow-up is essential.

Prediction of child abuse risk from emergency department use.

OBJECTIVE To examine whether pre-abuse rates and patterns of emergency department (ED) visits between children with supported child abuse and age-matched control subjects are useful markers for abuse risk. STUDY DESIGN A population-based case-control study using probabilistic linkage of four statewide data sets. Cases were abused children <13 years of age, identified between January 1, 2002, and December 31, 2002. For each case, a birth date-matched, population-based control was obtained. Outcome measures were rate ratios of ED visits in cases compared with control subjects. RESULTS Cases (n = 9795) and control subjects (n = 9795) met inclusion criteria; 4574 cases (47%) had an ED visit; thus linked to the ED database versus 2647 control subjects (27%). The crude ED visit rate per 10,000 person-days of exposure was 8.2 visits for cases compared with 3.9 visits for control subjects. Cases were almost twice as likely as control subjects (adjusted rate ratio = 1.8; 95% CI, 1.5, 1.8) to have had a prior ED visit. Leading ED discharge diagnoses were similar for both groups. CONCLUSIONS Children with supported child abuse have higher ED use before abuse diagnosis, when compared with the general pediatric population. However, neither the rate of ED use nor the pattern of diagnoses offers sufficient specificity to be useful markers of risk for abuse.

Abusive Head Trauma in Children Presenting with an Apparent Life-Threatening Event

OBJECTIVE To identify rates of abusive head trauma and associated clinical risk factors in patients with an apparent life-threatening event (ALTE). STUDY DESIGN Retrospective study of infants, 0 to 12 months, admitted for an apparent life-threatening event (ALTE; 1999-2003). Patients with abusive head trauma were identified at presentation or on follow-up; statistical analysis identified characteristics associated with abusive head trauma. RESULTS Of 627 patients with ALTE, 48% were male. Nine (1.4%) were diagnosed with abusive head trauma, of whom 5 were diagnosed in the emergency department. All cases detected in the emergency department had physical examination findings indicative of abusive head trauma. Patient age, male sex, or ethnicity were not significantly different between those with and without abusive head trauma. More children with abusive head trauma had a documented 911 call (56% vs 22%, P = .029), vomiting (56% vs 19%, P = .018), or irritability (22% vs 3%, P = .033). Multivariate analysis revealed odds ratio for abusive head trauma were 4.9 with a 911 call (P = .037), 5.3 with vomiting (P = .024), and 11.9 with irritability (P = .0197). CONCLUSIONS Abusive head trauma is in the differential for infants with an ALTE, although almost half of the cases are missed by current emergency department management. Vomiting, irritability, or a call to 911 are significantly associated with heightened risk for abusive head trauma.

Gastric trichobezoar: an important cause of abdominal pain presenting to the pediatric emergency department.

Abdominal pain is a common presenting complaint of children seen in urgent care settings. It is the manifestation of a wide variety of disease processes ranging from benign to immediately life-threatening. Gastric bezoars are among the etiologies of chronic childhood abdominal pain that, when undiagnosed, may result acutely in serious complications, including gastric ulceration, bleeding and perforation, intussusception, and small bowel obstruction. To reinforce the importance of including this entity in the differential diagnosis of abdominal pain, we present the case of a 10-year-old girl with a history of chronic epigastric complaints who was ultimately presented with acute small bowel obstruction following fragmentation and distal migration of her gastric trichobezoar. Finally, we review and briefly summarize the current literature regarding the etiology, diagnosis, and management of this disorder in children.

Pediatric emergency medicine physicians' current practices and beliefs regarding mental health screening.

Background: Only 20% of children with mental health issues are identified and receiving appropriate treatment nationally. The emergency department (ED) may represent a significant opportunity to provide selective pediatric mental health screening to an at-risk population. Objective: To describe the current standard of care and perceived limitations among pediatric emergency medicine (PEM) physicians regarding mental health screening. Methods: A 23-question survey on screening practices for pediatric mental illness (PMI) was sent to PEM physician participants identified through the American Academy of Pediatrics Section on Emergency Medicine mailing list. Results: Of the 576 physicians meeting our inclusion criteria, 384 (67%) surveys were returned. Eighty-six percent of respondents indicated screening for PMI in 10% or less of their eligible patients. Overall, 43% of respondents indicated screening only if the chief complaint was psychiatric in nature. The remaining 217 physicians most commonly screened for depression (83%), suicidality (76%), and substance abuse (67%). Only 9% of physicians stated that they used evidence-based medicine in determining their screening practices. Women physicians (odds ratio, 1.94; 95% confident interval, 1.08-3.47) and those using evidence-based medicine (odds ratio, 3.88; 95% confidence interval, 1.92-7.85) were more likely to conduct screening. Significant limitations to screening identified by respondents include the following: time limitations (93%), absence of a validated screening tool (62%), limited resources (46%), and lack of training (44%). Eighty-eight percent of physicians believe that a validated and standardized screening tool would improve their ability to identify PMI. Conclusions: Routine PMI screening is conducted infrequently by most PEM physicians. Improved physician education/training and the development of a validated ED-specific mental health screening tool would assist PEM physicians in the early detection of PMI.

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.

Randomized Prospective Study to Evaluate Child Abuse Documentation in the Emergency Department

OBJECTIVES The objective was to determine whether an educational intervention for health care providers would result in improved documentation of cases of possible physical child abuse in children <36 months old treated in the emergency department (ED) setting. METHODS This study had a statewide group-randomized prospective trial design. Participating EDs were randomized to one of three intervention groups: no intervention, partial intervention, or full intervention. Medical records for children <36 months of age were abstracted before, during, and after the intervention periods for specific documentation elements. The main outcome measure was the change in documentation from baseline. Generalized estimating equations (GEEs) were used to test for intervention effect. RESULTS A total of 1,575 charts from 14 hospitals EDs were abstracted. Hospital and demographic characteristics were similar across intervention groups. There were 922 (59%) injury visits and 653 (41%) noninjury visits. For each specific documentation element, a GEE model gave p-values of >0.2 in independent tests, indicating no evidence of significant change in documentation after the intervention. Even among the 26 charts in which the possibility of physical abuse was noted, documentation remained variable. CONCLUSIONS The educational interventions studied did not improve ED documentation of cases of possible physical child abuse. The need for improved health care provider education in child abuse identification and documentation remains. Future innovative educational studies to improve recognition of abuse are warranted.

Seizures In Children Following an Apparent Life-threatening Event

The characteristics of seizures and epilepsy in infants who have had an apparent life-threatening event have been poorly defined. Our objective was to characterize in depth the cohort of patients with apparent life-threatening events who developed seizures. We collected data from infants hospitalized for an apparent life-threatening event, and evaluated patients for subsequent seizures or chronic epilepsy. Of 471 patients with an apparent life-threatening event, 25 (5.3%) had seizures and 17 (3.6%) developed chronic epilepsy. There was no increased risk for febrile seizures. Abnormal brain magnetic resonance imaging results and developmental delay were only found in those patients who developed chronic epilepsy. Of those who developed chronic epilepsy, 47% were diagnosed with seizures within 1 week of their apparent life-threatening event. The discharge diagnosis at the time of the apparent life-threatening event was poorly predictive of those who developed seizures. In most cases the cause of chronic epilepsy was unknown, although cortical dysplasias made up a significant percentage (12%).