Genie E. Roosevelt

Pediatric Marijuana Exposures in a Medical Marijuana State

IMPORTANCE An increasing number of states are decriminalizing the use of medical marijuana, and the effect on the pediatric population has not been evaluated. OBJECTIVE To compare the proportion of marijuana ingestions by young children who sought care at a childrens hospital in Colorado before and after modification of drug enforcement laws in October 2009 regarding medical marijuana possession. DESIGN Retrospective cohort study from January 1, 2005, through December 31, 2011. SETTING Tertiary-care childrens hospital emergency department in Colorado. PARTICIPANTS A total of 1378 patients younger than 12 years evaluated for unintentional ingestions: 790 patients before September 30, 2009, and 588 patients after October 1, 2009. MAIN EXPOSURE Marijuana ingestion. MAIN OUTCOMES AND MEASURES Marijuana exposure visits, marijuana source, symptoms, and patient disposition. RESULTS The proportion of ingestion visits in patients younger than 12 years (age range, 8 months to 12 years)that were related to marijuana exposure increased after September 30, 2009, from 0 of 790 (0%; 95% CI, 0%-0.6%) to 14 of 588 (2.4%; 95% CI, 1.4%-4.0%) (P < .001). Nine patients had lethargy, 1 had ataxia, and 1 had respiratory insufficiency. Eight patients were admitted, 2 to the intensive care unit. Eight of the 14 cases involved medical marijuana, and 7 of these exposures were from food products. CONCLUSIONS AND RELEVANCE We found a new appearance of unintentional marijuana ingestions by young children after modification of drug enforcement laws for marijuana possession in Colorado. The consequences of unintentional marijuana exposure in children should be part of the ongoing debate on legalizing marijuana.

A Comparison of Oral Dexamethasone With Oral Prednisone in Pediatric Asthma Exacerbations Treated in the Emergency Department

The aim of this study was to determine if 2 doses of oral dexamethasone are as effective as a 5-day course of oral prednisone in preventing relapse for pediatric asthma exacerbations. Patients presenting to the emergency department with an asthma exacerbation were randomized to receive 0.6 mg/kg of dexamethasone or 2 mg/kg of prednisone in a prospective, double-blind study. The primary outcome was relapse within 10 days, and the secondary outcome was vomiting in the emergency department. Eighty-nine patients completed the study: 38 in the prednisone group and 51 in the dexamethasone group. In all, 3 patients in the prednisone group (8%) and 8 patients in the dexamethasone group (16%) required an unscheduled follow-up visit (P = .27). In all, 7 patients in the prednisone group (18%) and 5 patients in the dexamethasone group (10%) had vomiting ( P = .24). No difference was found in the relapse rate or incidence of vomiting between patients given prednisone and dexamethasone for pediatric asthma exacerbations.

The Effect of Ketamine on Intraocular Pressure in Pediatric Patients During Procedural Sedation

OBJECTIVES Ketamine is one of the most commonly used procedural sedation and analgesia (PSA) agents in pediatric emergency departments (PEDs). It is considered a very safe and reliable agent, with limited respiratory suppression, hemodynamic effects, and adverse outcomes. However, physicians are often reluctant to use ketamine for patients with eye injuries due to a concern that ketamine might increase intraocular pressure (IOP). The objective was to measure IOP in previously healthy children receiving ketamine for PSA for a reason other than eye injury. METHODS This was a prospective noninferiority study of patients seen in an academic tertiary care childrens hospital emergency department (ED) who required ketamine for PSA. The authors measured IOP in the right eye as soon as possible after ketamine had been administered and then at 2.5, 5, and 10 minutes after ketamine had been administered. RESULTS Eighty patients were enrolled (28 between 1 and 5 years of age, 26 between 6 and 10 years, 26 between 11 and 15 years); 49 (61%) were male. Procedures requiring PSA included fracture/dislocation reduction (63%), abscess incision and drainage (16%), laceration repair (11%), dental abscess incision and drainage (6%), and other (4%). The mean total ketamine dosage was 1.6 mg/kg (95% confidence interval [CI] = 1.4 to 1.7). The mean initial IOP was 17.5 mm Hg (95% CI = 16.4 to 18.6 mm Hg) and at 2.5 minutes was 18.9 mm Hg (95% CI = 17.9 to 19.9 mm Hg). The mean difference was 1.4 mm Hg (95% CI = 0.4 to 2.4 mm Hg). Using a noninferiority margin of 2.6 mm Hg (15%), noninferiority (no significant elevation in IOP) was demonstrated with 95% confidence between the first and second readings. CONCLUSIONS  Ketamine does not significantly increase IOP in pediatric patients without eye injuries receiving typical PSA dosages in the PED. Further study should assess its safety in patients with ocular injury.

Epidemiology of Bacteremia in Febrile Infants Aged 60 Days and Younger

Study objective To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN). Methods We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia. Results Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections (E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis. Conclusion The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

THE LIMITED UTILITY OF SCREENING LABORATORY TESTS AND ELECTROCARDIOGRAMS IN THE MANAGEMENT OF UNINTENTIONAL ASYMPTOMATIC PEDIATRIC INGESTIONS

BACKGROUND Suspected ingestions are a common chief complaint to the emergency department although the majority of ingestions by children are insignificant. OBJECTIVE Assess the utility of screening laboratory tests and Electrocardiograms (ECGs) in unintentional asymptomatic pediatric poisonings. METHODS Retrospective chart review at a tertiary care childrens hospital and a regional poison center of patients less than 12 years of age using ICD-9 codes from January 2005 through December 2008. Laboratory or ECG results requiring intervention and/or direct treatment, a non-RPC subspecialty consultation, and/or prolonged Emergency Department stay was considered changed management. RESULTS Five hundred ninety five suspected ingestions met our criteria. The median age was 2.6 years (IQR 1.6, 3.0 years) and 56% were male. One laboratory test or ECG was obtained in 233 patients (39%). Of 24 screening ECGs, 32 complete blood counts and 34 blood gases, none were clinically significant. Fifty-two patients received screening metabolic panels, 3 were abnormal and 2 changed management (anion gap metabolic acidosis with unsuspected salicylate ingestions). None of the 127 (21%) screening acetaminophen levels changed management. Two of sixty-five (13%) screening salicylate levels changed management. Three screening urine toxicology tests on patients with altered mental status were positive without ingestion history. No patient under the age of 12 years with normal vital signs and normal mental status had positive screening tests. CONCLUSIONS Screening laboratory tests and ECGs were of limited utility and rarely changed management despite being ordered in a significant number of patients. Screening tests are rarely indicated in unintentional overdoses in children who are asymptomatic.

Little Boy Black and Blue

Tooth decay is common in US children, especially for children in low-income families. More than half of second-grade children have cavities. Therefore, root canal procedures are becoming more common in children. We report a case of a 2-year-old boy with a rare complication of a root canal procedure secondary to sodium hypochlorite toxicity. Sodium hypochlorite, a commonly used root canal irrigant, and its toxicity are reviewed.

Pediatric Case Exposure During Emergency Medicine Residency

While emergency medicine (EM) physicians treat the majority of pediatric EM (PEM) patients in the United States, little is known about their PEM experience during training. The primary objective was to characterize the pediatric case exposure and compare to established EM residency training curricula among EM residents across five U.S. residency programs.