Gary J. Browne

Concussive head injury in children and adolescents related to sports and other leisure physical activities

Objective: To compare the characteristics of children and adolescents with concussive head injury (CHI) sustained during organised sports or other leisure physical activity. Methods: This was a case series study reviewing the medical records retrospectively over a four year period of children 6–16 years presenting to the emergency department with a CHI after participating in sport and/or recreation activity. Results: There were 592 cases of sport and recreation related concussion over the study period (2000–2003). Most of the patients (n  =  424, 71.6%) were male, with half (n  =  304, 51.4%) being older than 10 years of age. A total of 152 (25.7%) cases of CHI were related to playing sports. Most cases (71.2%) were mild concussion. The cause of injury was a fall (n  =  322, 54.4%) or a collision. Nearly a quarter of the children (n  =  143, 24.2%) were admitted to hospital, with imaging performed in 134 (22.7%). Most children were treated appropriately and no adverse events were reported. Conclusions: A severe CHI in a child is six times more likely to have resulted from organised sport than from other leisure physical activities. Outcomes for CHI in children is excellent, although their management places a considerable burden on emergency services. The need for activity restriction and the benefits of this in reducing long term cognitive effects of CHI are uncertain.

Effectiveness of a croup clinical pathway in the management of children with croup presenting to an emergency department.

Objective:  The aim of this study was to evaluate the safety and effectiveness of a clinical pathway for croup in an emergency department (ED).

A short stay or 23-hour ward in a general and academic children's hospital : Are they effective?

Objective We evaluated the usefulness of a short stay or 23-hour ward in a pediatric unit of a large teaching hospital, Westmead Hospital, and an academic Children’s hospital, The New Children’s Hospital, to determine if they are a useful addition to the emergency service. Methods This is a descriptive comparison of prospectively collected data on all children admitted to the short stay ward at Westmead Hospital (WH) during 1994 and the short stay ward at the New Children’s Hospital (NCH) during 1997–98. These hospitals service an identical demographic area with the latter (NCH) a tertiary referral center. The following outcome measures were used: length of stay, appropriateness of stay, rate of admission to an in-hospital bed, and rate of unscheduled visits within 72 hours of discharge. Adverse events were reported and patient follow-up was attempted at 48 hours after discharge in all cases. Results The short stay ward accounted for 10.3% (Westmead Hospital) and 14.7% (New Children’s Hospital) of admissions, with 56% medical in nature, 30% surgical, and the remainder procedural or psychological. Admission patterns were similar, with asthma, gastroenteritis, convulsion, pneumonia, and simple surgical conditions accounting for most short stay ward admissions. The short stay ward increased hospital efficiency with an average length of stay of 17.5 hours (Westmead Hospital) compared to 20.5 hours (New Children’s Hospital). The users of the short stay ward were children of young age less than 2 years, with stay greater than 23 hours reported in only 1% of all admissions to the short stay ward. The rate of patient admission to an in-hospital bed was low, (4% [Westmead Hospital] compared to 6% [New Children’s Hospital]), with the number of unscheduled visits within 72 hours of short stay ward discharge less than 1%. There were no adverse events reported at either short stay ward, with parental satisfaction high. The short stay ward was developed through reallocation of resources from within the hospital to the short stay ward. This resulted in estimated savings of

Randomized, double-blind, placebo-controlled trial of intravenous salbutamol and nebulized ipratropium bromide in early management of severe acute asthma in children presenting to an emergency department

1/2 million (Westmead Hospital) to

Clinical pathway using rapid rehydration for children with gastroenteritis

2.3 million (New Children’s Hospital) to the hospital, due to more efficient bed usage. Conclusion This data demonstrates the robust nature of the short stay ward. At these two very different institutions we have shown improved bed efficient and patient care in a cost-effective way. We have also reported on greater parental satisfaction and early return of the child with their family to the community.

Femoral nerve block for femoral shaft fractures in a paediatric Emergency Department: can it be done better?

Background In acute severe asthma, treatment must be initiated early to reverse the pathophysiology that may render airways less responsive to bronchodilation. The addition of nebulized ipratropium bromide to initial emergency department therapy improves pulmonary function, but it is unclear whether this approach results in earlier hospital discharge. The early use of bolus intravenous salbutamol has also been shown to improve outcome, including earlier discharge. We therefore assessed the relative benefits of intravenous salbutamol and nebulized ipratropium bromide in the early management of acute severe asthma in children by a double-blind, randomized, controlled trial. Methods This study was undertaken at a tertiary children’s hospital, The Children’s Hospital at Westmead, The Royal Alexandra Hospital for Children, Westmead, Sydney, Australia. Only children with severe acute asthma as determined by the National Asthma Campaign guidelines criteria and pulmonary index were included. All children received initial nebulized salbutamol therapy (2.5–5 mg salbutamol in 4 mL of normal saline depending on age) at initial emergency department presentation. If asthma remained severe 20 mins later, an intravenous cannula was inserted and intravenous methylprednisolone (1 mg/kg) was administered to all children receiving nebulized salbutamol every 20 mins. Children were then randomized to one of three groups: intravenous salbutamol (15 &mgr;g/kg as a single bolus over 10 mins), ipratropium bromide (250 &mgr;g), or intravenous salbutamol plus ipratropium bromide. All observers were blinded to treatment groups. Children were randomly assigned to receive a single-dose intravenous bolus of either saline or salbutamol and either nebulized saline or ipratropium bromide determined by a number generated randomly in the hospital pharmacy. The primary outcomes were recovery time and discharge time of each group. Respiratory and hemodynamic monitoring were continuous during the first 2 hrs of the study and then children were monitored clinically for 24 hrs. Results A total of 55 children with acute severe asthma were entered into the study over an 18-month period. The three groups were similar demographically, with a mean age of 5.9 yrs, and mean duration of attack of 19.6 hrs. No side effects or treatment intolerance were reported. Children in the groups that received intravenous salbutamol had a significant reduction in recovery time to achieving second hourly inhaled salbutamol (p = .008) compared with those administered inhaled bronchodilator alone. The addition of ipratropium bromide to intravenous salbutamol provided no significant further benefit in terms of nebulizer therapy (intravenous salbutamol compared with intravenous salbutamol plus ipratropium bromide). Children administered intravenous salbutamol ceased supplemental oxygen therapy earlier than those administered ipratropium alone at 12 hrs postrandomization (p = .0003). Children administered intravenous salbutamol could be discharged from the hospital 28 hrs earlier than those administered ipratropium bromide (p = .013). Conclusion Children administered intravenous salbutamol for severe acute asthma showed a more rapid recovery time, which resulted in earlier discharge from the hospital than those administered inhaled ipratropium bromide. There was no additional benefit obtained by combining ipratropium bromide and intravenous salbutamol administration.

Primary cardiac arrest following sport or exertion in children presenting to an emergency department: chest compressions and early defibrillation can save lives, but is intravenous epinephrine always appropriate?

Objective:  To determine in the Emergency Department (ED) the efficacy of a clinical pathway using rapid rehydration for children moderately dehydrated as a result of acute gastroenteritis.

Isolated extradural hematoma in children presenting to an emergency department in Australia.

Background: The relatively simple technique of administering a femoral nerve block is known to be quick, safe and effective in providing prolonged analgesia to children with femoral shaft fracture. Although medical literature supports its use in the emergency setting, no studies have been conducted on how this is undertaken in practice. Objective: The aim of this study is to describe the practice of femoral nerve block in previously well children who present to our Emergency Department with femoral shaft fracture. Setting: This study was conducted at the Emergency Department of a tertiary paediatric hospital in Sydney, Australia. Methods: A retrospective descriptive study was conducted by gathering data on all patients presenting to the Emergency Department between 1 January 1996 and 1 July 2001 with traumatic fracture to the femoral shaft. Whether femoral nerve block had been performed in the emergency setting; the time taken for femoral nerve block to be performed; the type of local anaesthetic used; the dose of local anaesthetic administered, and the level of training and area of expertise of doctors performing the femoral nerve block were determined from the clinical records. One-way analysis of variance and Students t-tests were conducted to compare the average dosages of local anaesthetic used by the different medical sub-specialities involved. Students t-tests were applied to analyse the time differences for performing femoral nerve block between emergency- and non-emergency-based medical staff. Results: The majority (111) of the 117 patients who met the inclusion criteria for the study had isolated femoral shaft fractures (94.9%). Femoral nerve blocks were performed in 97 of our study patients (82.9%). No correlation was found between the age of the child and the time taken for a femoral nerve block. In 76 cases in which a femoral nerve block was given (64.9%), a member of staff external to the Emergency Department performed the procedure. The average time taken for a femoral nerve block to be performed for non-Emergency Department medical staff was significantly longer than for Emergency Department medical staff. In only 37 cases (31.9%), was a femoral nerve block administered within an hour of the time of triage. Doses used by non-anaesthetists were lower than those used by anaesthetists. Conclusion: There is unnecessary delay in carrying out this procedure for children with fractures to the femoral shaft. A significant degree of reliance on staff external to the Emergency Department was reported. This paper supports increased training and supervision to promote the more widespread and prompt use of femoral nerve blocks as an important standard of care for the Emergency Department.

The pulmonary index score as a clinical assessment tool for acute childhood asthma

Objectives The objective of this study was to describe the characteristics and outcome of pediatric patients presenting to an emergency department (ED) following out-of-hospital primary cardiac arrest (OHPCA), to determine if long-term survival is influenced by specific resuscitation interventions. Methods This was a prospective observational study of cases of OHPCA during sport or exertion in young patients presenting to an ED over a 5-year period. Cases were identified from a resuscitation database, which documented patient demographics, nature of event, emergency treatment, response times, and clinical progress. These data were analyzed to determine outcomes. Results Nine children were identified who presented following OHPCA during the study period. The mean age was 10.7 (±4.2) years. All were subsequently diagnosed with an underlying primary cardiac disorder. Six patients (66.6%) survived to make a full recovery. All patients who survived had received early chest compressions (within 5 minutes) and early defibrillation (within 10 minutes). The initial cardiac arrest rhythm in all survivors had been an electrically cardiovertable rhythm. Five (83%) of the 6 survivors did not receive epinephrine during resuscitation. Conclusions The importance of early chest compressions and defibrillation in collapsed young athletes is highlighted in this report. These interventions can result in full long-term neurological recovery. Use of epinephrine in these patients may be dangerous. We suggest that special consideration should be given to this subgroup of patients in the development of future resuscitation guidelines.

Near fatal envenomation from the funnel-web spider in an infant.

Background Isolated extradural hematoma (EDH) is becoming more frequently recognized in emergency departments (EDs) in children. We describe the natural history of children with isolated EDH presenting to a large Children’s Hospital ED. Methods This is a descriptive case series study using a retrospective review of the medical records of children presenting to the ED with a diagnosis of isolated EDH over 8 years. Comparison was made with children having other injuries in addition to EDH. The cause, nature of injury, presentations to hospital, management, outcome, and any association with nonaccidental injuries (NAI) were analyzed. Results Of the 35 cases with a final diagnosis of isolated EDH initially presenting to the ED, 70% were over 3 years of age (mean 6.6 years), and 60% were boys. A fall of less than half a meter was the cause of isolated EDH in 51.4% of patients. The remaining cases resulted from a fall from a height greater than half a meter (17.1%), a motor vehicle accident (11.4%), being hit by an object (8.6%), a bicycle accident (5.7%), and a skateboard accident (5.7%). Children younger than 3 years presented within 24 hours of injury in 70% of cases, compared with 65% of older children. In 95% of cases, presentation was nonspecific, suggesting a medical rather than a surgical problem. This resulted in a delay in seeking emergency care and a delay in final diagnosis for these patients. Surgical drainage was required in 68.6% of cases, with older children being more likely to be managed conservatively. In 23.4% of cases, minor residual neurologic deficit occurred; there were no cases of serious long-term problems. There were no cases of NAI in the children studied. Conclusion This report highlights falls as a common cause of isolated EDH in children. Delay in presentation for clinical assessment is common, because many children have nonspecific presentation that is suggestive of a medical problem. No cases of NAI were reported in this study.