Gail M. Stewart

Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department.

Objectives: Pediatric patients with cerebrospinal fluid shunts frequently present to the emergency department for evaluation of possible shunt malfunction. Most shunt studies appear in the neurosurgical literature. To our knowledge, none have reviewed presenting signs and symptoms of shunt malfunction in patients who present to the pediatric emergency department. The study objective was to evaluate the medical record of children with cerebrospinal fluid shunts who presented to a pediatric emergency department to determine if any signs and/or symptoms were predictive of shunt malfunction. Methods: A retrospective chart review was conducted on 352 pediatric patients aged 0 to 18 years, who presented to the pediatric emergency department between January 1, 1998, and December 31, 2002, with signs and/or symptoms that prompted an evaluation for possible shunt malfunction. Results: Univariate analysis of all signs and symptoms revealed lethargy (odds ratio, 1.99; 95% confidence interval, 1.15-3.42; P = 0.02) and shunt site swelling (odds ratio, 2.56, 95% confidence interval, 1.08-6.07, P = 0.03) to be significantly predictive of shunt malfunction. Logistic regression analysis continued to show significance for lethargy (odds ratio, 2.20; bias-corrected 95% confidence interval, 1.11-3.63) and shunt site swelling (odds ratio, 3.10; bias-corrected 95% confidence interval, 1.38-9.05), but found no other study variable to be significant. Bootstrap resampling validated the importance of the significant variables identified in the regression analysis. Conclusions: In this study, lethargy and shunt site swelling were predictive of shunt malfunction. Other signs and symptoms studied did not reach statistical significance; however, one must maintain a high index of suspicion when evaluating children with an intracranial shunt because the presentation of malfunction is widely varied. A missed diagnosis can result in permanent neurological sequelae or even death.

Trauma in infants less than three months of age

We evaluated the characteristics of traumatic injury and risk for subsequent trauma in infants less than three months of age (n = 111). Medical records were reviewed at presentation and one year later. Injury was due to abuse/neglect in 28%, whereas 72% were accidentally injured. Falls were the most common mechanism of accidental injury (67%). The percentage of infants with skull fractures was greater in the abuse/neglect group than in the accidental group (7/31 vs 7/80; P lt; 0.05) with a tendency toward more diastatic and multiple skull fractures (6/7 vs 2/7) as well as intracranial hemorrhages (3/7 vs 0/7). More infants in the abuse/neglect group suffered extremity fractures (4/31 vs 2/80; P lt; 0.05). Hospitalization was more frequent (12/31 vs 8/80; P lt; 0.001), as was social or protective service intervention (25/31 vs 17/80; P lt; 0.001), in the abuse/neglect group. The two groups showed no difference in the number of previous emergency department (ED) visits; however, the use of the ED declined significantly in the abuse/neglect group following the trauma (0.81 ± 1.2 vs 1.5 ± 2.1 visits; P lt; 0.05). The abuse/neglect group tended to have a greater number of subsequent traumatic injuries than those accidentally injured. Abuse/neglect should be considered in any seriously injured infant less than three months of age because of the likelihood of subsequent trauma.

Inter-rater Reliability for Noninvasive Measurement of Cardiac Function in Children

Introduction: A transcutaneous ultrasound monitor has recently been developed which noninvasively and quickly measures cardiac output. Validity and reliability testing has been reported in adults. No reliability testing has been undertaken in the pediatric population. Objective: Our objective was to evaluate the inter-rater reliability of a transcutaneous Doppler ultrasound technique to measure cardiac index (CI) and stroke volume index (SVI) in pediatric emergency department patients. Methods: An 8-month prospective observational study was conducted on a convenience sample of emergency department patients younger than 18 years old. Five raters were trained to use an ultrasound cardiac output monitoring device. Two raters, blinded to each others results, obtained independent measurements from the same patient within 15 minutes of each other. Inter-rater agreement was measured with the Pearson product correlation coefficient. Bland-Altman analysis demonstrated the extent of deviation from a line of agreement between raters. Results: Ninety-seven patients were enrolled. Major diagnostic categories included infection, trauma, and gastrointestinal disorders. There was significant inter-rater correlation for CI (r = 0.76; 95% confidence interval, 0.66-0.83; P < 0.0001) and SVI (r = 0.79; 95% confidence interval, 0.70-0.86; P < 0.0001). Bland-Altman analysis of CI measurements between 2 raters showed bias of 0.06, SD of bias 1.00, and 95% limits of agreement −1.91 to 2.02 L/min/m2. Stroke volume index showed bias of −0.5, SD of bias 11.01, and 95% limits of agreement −22.08 to 21.08 mL/m2. Conclusions: Transcutaneous Doppler ultrasound technique demonstrates acceptable inter-rater agreement for measuring CI and SVI in children.

Atlanto-Occipital Dislocation With Retroclival Hematoma in a Pediatric Patient Presenting to the Emergency Department

Atlanto-occipital dislocation is a rare, oftentimes fatal injury sustained from high-impact trauma. It is seen more often in children compared with adults. In the past decade, there are more pediatric survivors presenting to the emergency department for treatment. This case reviews the presentation, diagnosis, and treatment of a child who survived this injury.

Myasthenia gravis in an adolescent patient presenting to the pediatric emergency department.

Myasthenia gravis is a rare, chronic, autoimmune disorder characterized by postsynaptic dysfunction at the neuromuscular junction. The disease affects more females than males. We describe the case of a 17-year-old female adolescent with recurrent episodes of dysarthria and dysphagia and a history of aspiration pneumonia. A bedside edrophonium (Tensilon) test in our emergency department confirmed the diagnosis of myasthenia gravis.

Jaw mass in a pediatric patient

The aneurysmal bone cyst is an unusual cause of a jaw mass in children. Left untreated, this relatively benign lesion can lead to deformity and destructive bone changes. We report a nine-year-old patient with a large untreated aneurysmal bone cyst, and briefly discuss the differential diagnosis of head and neck masses in children.