Funda Kurt

Does age affect presenting symptoms in children with carbon monoxide poisoning

Objective Previous studies have reported on a link between carboxyhemoglobin (COHb) levels and the severity of presenting findings. However, studies on pediatric populations evaluating the effect of age on presenting symptoms are severely lacking. The aim of this study was to investigate the presence of any link between age and presenting symptoms in children with carbon monoxide (CO) poisoning. Methods This retrospective study was undertaken in Ankara Children’s Hematology and Oncology Hospital, a tertiary care center, between January 2007 and March 2010. The medical records of patients aged between 0 and 16 years with a confirmed diagnosis of CO poisoning, defined as the presence of a COHb level of more than 5%, were evaluated. Relevant information such as age, sex, source of CO, coaffected family members, month of presentation, time of presentation and presenting symptoms, duration of oxygen treatment in the emergency department, need for admission to an inpatient ward or intensive care unit, Glasgow Coma Scale scores, and administered treatments during follow-up was recorded for each patient on preprepared forms. For the purpose of comparison, patients were divided into 2 groups based on COHb levels (group 1, 5%–25%; group 2, >25%). Comparisons were also made after dividing patients into 3 age groups: infants (0–3 years), preschool and early-school children (4–8 years), and adolescents (9–16 years). Results The records of 261 patients were deemed sufficient for inclusion in the final analysis, 149 (57.1%) of which were female, and 112 (42.9%) were male, with a median age of 7.0 years (range, 1 month to 16 years) and a mean COHb level 16.9% (SD, 7.8%). Two hundred eighteen patients (83.5%) had a COHb between 5% and 25% on presentation, whereas the remaining 43 patients (16.5%) had a presenting COHb of greater than 25%. Neurologic symptoms such as headache, syncope, seizures, and confusion were encountered more frequently in the COHb greater than 25% group compared with the group with 5% to 25% COHb levels, with adolescents having more severe symptoms than do younger patients. Conclusions In this study, we managed to demonstrate the presence of more severe symptoms in patients with a COHb level of 25% or greater. Further analysis revealed that severe symptoms were more pronounced in adolescents and that the severity of symptoms increased with age.

New challenges of the pediatric emergency department: synthetic cannabinoids

To the Editor, In recent years, the frequency of use of synthetic cannabinoid (SC) has increased in the adolescent age group (1). While it is known as “K2”, “Spice”, “Aroma”, ”Mr.Smiley”, “Zohai”, “Eclipse”, “Black Mamba”, “Red X Dawn”, “Blaze”, the name “Bonzai” has come to the forefront in our country (2). Synthetic cannabinoids are sprayed on plants, are sold in packages with warnings including “natural plant mixture”, “incense”, ‘’not for human use” and is consumed like cigarette (3). It is important to recognize poisonings due to this kind of substances the content and dosage of which are unclear and to perform appropriate interventions. In this article, it was aimed to present a 17-year old male patient who presented to the pediatric emergency department after usage of SC after obtaining verbal consent and to draw attention of physicians working in pediatric emergency departments to this issue. A 17-year old male patient was brought to the pediatric emergency department by 112 ambulence because of headache, muscle aches, nervousness, restlessness and drowsiness following use of SC. The Glascow coma scale was found to be 15 and systemic examination and vital findings were found to be normal. It was learned that he was using depakin because of epilepsy and had no additional illness. In his history, it was learned that he started to use SC approximately 6 months ago, obtained the substance from street vendors and used SC like cigarette. He was not using any other illegal substance or alcohol. He did not attend the school and was working as an errand-boy in industry. Complete blood count, blood biochemistry and electrocardiography were found to be normal. It was thought that his complaints arised from SC. Nervousness and restlessness improved after 5 mg oral diazepam. No additional problem developed during the 6-hour follow-up period. He was discharged to be referred to the Alcohol and Substance Addicts Research and Treatment Center. A significant increase has occured in substance abuse and related mortality in recent years. In our country, 12 deaths related with substance abuse were reported in 2000, whereas this figure reached 147 in 2007 (4). The frequency is increasing in the adolescence because of low price and easy accessibility. The issue is in the news in visual and printed media almost everyday and a growing number of cases present to emergency departments. Adolescents may abuse substance because of many different reasons. Individual risk factors include antisocial personality, agressiveness, hyperacitivity and chronic diseases. Environmental risk factors include intra-familial violence, parents who abuse illegal substances, weak family bonds and exposure to abuse. Social risk factors include easy accessibility of illegal subtances, poverty, unemployment and a high rate of crime in the area of residence (5). In our case, presence of underlying epilepsy and working as an employee in industry instead of attending the school were thought to be risk factors. In the diagnosis, the most important clue is a history of usage of SC. In patients with cognitive, behavioral and mood disorders, usage of SC should be suspected, if sympatomimetic findings are present additionally. The signs and symptoms reported after use of synthetic cannaboid are shown in Table 1. The laboratory tests are generally within the normal limits, but they should be performed to find additional pathologies. SC can not be determined with standard toxicological screening tests. Table 1. Signs and symptoms reported after use of synthetic cannabinoid (1) The mainstay of treatment consists of supportive therapy. Patients should be monitored in a quiet and calm room at an appropriate temperature and treatment should be planned according to the clinical findings. It has been shown that agitation improves with long-acting benzodiazepines and dystonia improves with diphenhydramine (1). It is important to interrogate patients in terms of abuse of additional substances other than SC and to perform additional therapeutical interventions if necessary. Following urgent treatment and follow-up patients should be referred to appropriate psychiatry and substance addiction treatment centers.

A Rare Cause of Chest Pain in an Adolescent Patient in the Pediatric Emergency Department: Spontaneous Pneumomediastinum

Spontaneous pneumomediastinum (SPM), is a rare and benign entity in the pediatric population. Alveolar rupture as a result of increased intrathoracic pressure due to an asthma attack, vomiting or Valsalva maneuvers (e.g., forceful cough, shouting), is the most frequent reason. Here, we report a 14-year-old male patient who presented to the pediatric emergency department with chest pain and was diagnosed with SPM, and discuss the clinical and radiological characteristics as well as the management of SPM.

Demographic Characteristics and Treatment Costs of Immigrant Patients in the Pediatric Emergency Department

Objective: After the war in Syria, it is planned to investigate the refugee children’s (from diffrent counties coming to Turkey), emergency service admission features and evaluating outpatient and inpatient costs. Material and Methods: Demographic, clinical characteristics and treatment costs of asylum seekers who applied to our pediatric emergency department from March 2011 to March 2016, the period of the civil war in Syria, were examined retrospectively. Results: During the study period, 7551 (1.3%) of the 569.540 applications for emergency services were asylum seekers and the total number of patients was 1740. Of the 1740 patients who received one of the recurrent referrals; 975 were Syrian (56.0%), 474 were Iraqi (24.4%) and 341 were Afghan (19.6%). 1005 of the cases were male and the mean age was 59.16 ± 59.27 months (017year 1 month). The most frequent admission reasons were respiratory system complaints (50.2%), gastrointestinal system complaints (34.7%) and fever (31.6%). 129 of the patients had an underlying disease (7.4%). At least one test was done in all cases. 60.7% of the patients were diagnosed with infection-related disease. These were URTI, AGE, tonsillitis, bronchiolitis, pneumonia and otitis respectively. In other cases, consultation was requested in 255 cases (14.7%). 182 (10.1%) of the patients were followed up with emergency observation. Mean

Strengthening the role of children's emergency services in the prevention of peer abuse.

To the Editor, Peer abuse is harmful and agressive behavior exerted continuously and recurrently by an individual or a group on another person of about the same age who is weaker in which strength is abused. This agressive behavior may emerge with different clinical pictures ranging from emotional trauma to physical trauma and even mortality (1). Children who are exposed to peer abuse and especially the ones with findings of physical injury present to pediatric emergency services. Pediatric emergency physicans should play the role of a bridge by providing assessment of the findings of physical trauma of the child who is the victim as well as assessment of acute and potential chronic psychiatric problems. This case was presented to increase the level of awareness of the physicans who work in emergency services which are the primary centers where children exposed to peer abuse are presented. A 17-year old girl who was attecked in school presented to the pediatric emergency service in accompaniment of her parents. It was learned that the subject was exposed to verbal attack primarily and physical attack secondarily. On physical examination, no pathological finding was observed except for tenderness and limitation in mobility in the neck. Her radiological tests were found to be normal. A forensic report was prepared and the subject was started to be folowed up by the Child Psychiatry and Child Protection Unit. It was learned that the subject was recorded to another school 3 months ago because of change of residence. The family stated that their daughter did not wish to attend school recently, her academic success decreased and they evaluated this status as the adaptation process for the new school. In the interview with the subject, it was learned that she was being indirectly abused (threats, insinuations and glares) for about three months by a group who terrorized school and exhibited agressive behavior. In the following interviews, it was learned that the subject was molested by hand by an adult male who was a friend of the family three years ago, but she could not tell this event to anybody since she was scared. The subject is still being followed up by the Child Protection Unit and Department of Child Psychiatry. Peer abuse is an important public health problem. Repeated attitudes and behaviors directed to harm a weaker individual at about the same age by a stronger individual and group are evaluated as peer abuse (2, 3). In individuals who are exposed to peer abuse, increased risks of depression, anxiety, substance abuse, suicide attempt and delinquency are observed frequently in addition to physical trauma (3, 4). In addition, it should be kept in mind that children who present to emergency services with repeated non-specific physical complaints might have been exposed to peer abuse (1). Children who are found to have unexplained physical injuries, who have low academic success, who have learning difficulty, who do not wish to attend school and who appear sad and depressive are under risk (1, 3). It has been emphasized that peer abuse is a considerably serious threat for our country and prevention and intervention programs should be developed. Our subject was exposed to verbal abuse primarily and physical abuse secondarily. It was learned that the academic success of our subject considerably decreased in the new school she started and she did not wish to attend school. However, these early warning signs which were interpreted as a school adaptation process were ignored by the family and early intervention and suppport were delayed. Therefore, such complaints should be cared about and the subjects should be evaluated in terms of peer abuse. Child victims are usually sensitive and anxious and have a low self-confidence. Children who have weak family relations, who have been exposed to neglect and abuse, who have chronic disease or disability constitute the target group for peer abuse (3, 5, 6). Our subject had no physical defect, but she had been exposed to sexual abuse before, hid this event, since she was scared and blamed herself. The self-confidence of our subject who was not supported at the time of this first event she experienced decreased, her strenght to cope with other problems decreased and she became a target for peer abuse. Peer abuse should not be evaluated as a transient, harmless and normal part of development by physicans working in emergency services who primarily meet child victims. Accordingly, the care of the children in question should not be terminated at discharge and a multidisciplinary approach together with child psychiatry and social units should be planned and initiated. If physicans working in pediatric emergency departments recognize peer abuse and start the necessary initiatives supporting the child at risk, they would play a very important part in solution of this public health problem. Therefore, the level of awareness of physicians working in pediatric emergency services should be increased in the scope of peer abuse prevention and intervention programs.