Ghazala Q. Sharieff

Management of pediatric trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Childrens Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

Ketamine-propofol combination sedation for fracture reduction in the pediatric emergency department.

Objectives To evaluate the time of onset and recovery from and the efficacy and safety of intravenous ketamine-propofol sedation for reduction of forearm fractures in the pediatric emergency department setting. Study Design Prospective, observational pilot study. Methods Children presenting to an urban pediatric emergency department requiring sedation for closed reduction of forearm fractures received ketamine 0.5 mg/kg and propofol 1 mg/kg. We measured time intervals from drug administration to reduction, recovery, and attainment of discharge criteria, and obtained ratings of depth of sedation, pain, and ease of reduction. A follow-up survey elicited patient recall, parental satisfaction, and delayed complications. Complications were recorded during the procedure and by chart review. Results Reduction was successful in 19 of 20 patients with one requiring open reduction. Median time intervals measured from initiation of ketamine injection were 5 minutes to reduction completion, 10 minutes to first purposeful response, and 38 minutes to suitability for discharge. Three patients recalled reduction or casting, but in no case was reduction reported to be the most painful aspect of visit. Emergency physicians and orthopedic residents rated sedation and ease of reduction favorably. Complications included mild hypoxia, vomiting, and transient ataxia. No apnea, hemodynamic compromise, dysphoria, or injection pain occurred. Conclusions In this pilot study, the combination of ketamine and propofol provided effective sedation with rapid recovery and no clinically significant complications for children requiring closed reduction of forearm fractures.

The Management of Children with Gastroenteritis and Dehydration in the Emergency Department

BACKGROUND Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain. OBJECTIVE To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis. DISCUSSION The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported. CONCLUSIONS In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.

Abdominal surgical emergencies in infants and young children

Surgical emergencies can be missed easily in children, who are not always able to volunteer relevant information. Awareness of the entities discussed in this review might help the EP uncover subtle clues to early diagnoses that might not be initially apparent. Ill-appearing children who have abdominal pain and vomiting should be considered to have ischemic or necrotic bowel until proven otherwise. Possible diagnoses include volvulus, intussusception, and necrotizing enterocolitis. Bilious vomiting, especially in a young infant, should be considered to be an indication of a high bowel obstruction such as midgut volvulus, which warrants immediate surgical consultation. Significant rectal bleeding with abdominal pain can result from intussusception, volvulus, or an inflamed Meckels diverticulum. Rectal bleeding with unstable vital signs can result from an upper GI bleed (eg, peptic ulcer disease). Painless rectal bleeding can result from a Meckels diverticulum, polyps, arteriovenous malformation, or a tumor. Examination of the genitalia is imperative, especially in boys, to exclude the possibility of an incarcerated hernia or testicular torsion.

Midazolam for the treatment of out-of-hospital pediatric seizures☆

Objective. To assess the effectiveness and safety of intravenous (IV) and intramuscular (IM) midazolam in the treatment of pediatric seizures by paramedics. Methods. All cases in which paramedics treated patients under the age of 18 years with midazolam for seizures per county protocol were evaluated over a one-year period. Prehospital records were reviewed for treatment and reassessment, while the subgroup of patients who were transported to Childrens Hospital were followed up for emergency department (ED) outcome. Results. Midazolam was administered to 86 pediatric patients with ages ranging from 2 months to 14 years for the treatment of seizures per county protocol. There were 54 IV doses and 32 IM doses delivered. Of the 86 patients, post-intervention reevaluation was documented for 74 patients (86%) representing 49 IV and 25 IM doses. Improvement was reported for 91% (67/74) of patients. Greater success was reported with IV drug administration (47/49, 96%) as compared with 80% (20/25) with IM administration (p < 0.05). Four patients (three treated IM and one IV) had respiratory compromise necessitating field airway management. All four patients had respiratory compromise documented prior to midazolam administration. Forty-four patients were treated at Childrens Hospital. Seven were intubated in the ED after having been given additional medications for seizures. None were intubated on arrival and none were felt to require intubation secondary to midazolam-induced respiratory depression. Conclusion. Prehospital IV midazolam is an effective intervention for pediatric seizures, while IM midazolam was associated with a 20% failure rate, with both having minimal risk of respiratory compromise.

Can portable bedside fluoroscopy replace standard, postreduction radiographs in the management of pediatric fractures?

OBJECTIVE To determine the accuracy of portable bedside fluoroscopy in documenting postreduction fracture alignment in the pediatric emergency department (ED). DESIGN/SETTING Prospective trial in an urban pediatric ED. PARTICIPANTS Convenience sample of 80 pediatric patients requiring ED reduction of isolated long bone fractures. METHODS Patients who underwent closed fracture reduction using portable fluoroscopic guidance (FluoroScan) in the ED were enrolled in the study. Postreduction images were obtained using both bedside fluoroscopy and conventional radiographs. A pediatric orthopedic subspecialist, blinded to clinical outcome, reviewed the fluoroscopic and radiographic images for adequacy of alignment and rated the utility of conventional radiography for fracture management. RESULTS The patients were 2.5 to 16 years of age (mean 8.3). Distal radial and radioulnar fractures comprised 96% (76/80) of cases. Sixty-three percent of the fractures were displaced, and the mean angulation of the primary fracture site was 24 degrees . Fluoroscopy was found to be 100% sensitive (75/75 cases) and 100% specific (5/5 cases) in predicting postreduction fracture position when compared to conventional radiographs. Intra-rater observer agreement on the necessity of conventional postreduction radiographs was 0.92 (95% CI 0.82-1.00) using the kappa coefficient. In no case did postreduction radiographs alter acute fracture management. CONCLUSIONS Bedside fluoroscopy with printed fluoroscopic images are highly reliable in evaluating fracture reduction and can replace conventional radiography in documenting adequate distal forearm fracture reduction when there is no intraarticular involvement.

Rapid medical assessment: improving pediatric emergency department time to provider, length of stay, and left without being seen rates.

Objectives This article aimed to study the impact of a rapid medical assessment (RMA) program on patient flow and left without being seen (LWBS) rates in a pediatric emergency department (ED). RMA is designed to evaluate and discharge uncomplicated patients quickly or initiate diagnostic workup and treatment before the patient is placed in an ED bed. Methods Rapid medical assessment was initiated January 1, 2008 with an assigned midlevel provider. We compared 6 months of data from January 1 to June 30, 2007 (pre-RMA), to January 1 to June 30, 2008 (post-RMA). Data studied were obtained from a tracking system and include the time to provider, ED length of stay, and the LWBS rate. t Test was used to compare results, and &khgr;2 test was used to compare LWBS rates. Results During the study period, there were 28,360 patients seen in 2007 and 32,053 in 2008. Time to provider mean time was 80 minutes (median = 57) in 2007 and 53 minutes (median = 39) in 2008, with a difference of 27 minutes (95% confidence interval, 25–28 minutes). Mean length of stay in 2007 was 239 minutes (median = 220) compared to 181 minutes (median = 162) in 2008, with a difference of 58 minutes (95% confidence interval, 56–60 minutes). The LWBS rate decreased from 9% in 2007 to 3% in 2008 (&khgr;2 P < 0.01). Conclusions Rapid medical assessment is an effective way to improve patient flow and reduce the LWBS rate. A decrease in the LWBS rate allows the ED to provide health care to these potentially high-risk patients.

Electrocardiographic manifestations: pediatric ECG.

Interpretation of pediatric electrocardiograms (ECGs) can be challenging for the Emergency Physician. Part of this difficulty arises from the fact that the normal ECG findings, including rate, rhythm, axis, intervals and morphology, change from the neonatal period through infancy, childhood, and adolescence. These changes occur as a result of the maturation of the myocardium and cardiovascular system with age. Along with these changes, up to 20% of pediatric ECGs obtained in the acute setting may have clinically significant abnormal findings. This article will discuss the approach to the interpretation of ECGs in children, the age-related findings and alterations on the normal pediatric ECG, and those ECG abnormalities associated with pediatric cardiac diseases, including the variety of congenital heart diseases seen in children.

Oral Analgesia Before Pediatric Ketamine Sedation is not Associated with an Increased Risk of Emesis and Other Adverse Events

The objective of this study was to determine the association between recent administration of oral analgesics and frequency of adverse events during ketamine sedation in pediatric patients undergoing fracture reduction in the emergency department (ED). This retrospective study was conducted in the ED of a large, urban pediatric teaching hospital. Subjects were patients aged <or= 18 years seen between November 1, 2004 and October 31, 2005 who received ketamine sedation for fracture reduction. Patients with and without prior oral analgesia within 6 h of ED presentation were compared with respect to emesis and other post-sedation complications. Of 471 evaluable patients who underwent ketamine sedation, 201 received oral analgesia within 6 h. The groups with and without recent oral analgesia were similar in age, weight, and fasting duration for solid foods. Ketamine doses (in mg/kg) were slightly greater in the no prior oral analgesic group (1.40 mg/kg vs. 1.54 mg/kg, respectively, mean difference 0.15 [95% confidence interval (CI) -0.26 to -0.03]). Among patients receiving oral analgesia, 10 of 201(5%) experienced emesis, in contrast to 7 of 270 (2.6%) in the no oral analgesic group, (difference in proportions 2.4% [95% CI -1.1 to 6.5]). Total adverse events were comparable for groups receiving oral analgesia (5%) or no oral analgesia (5.6%, difference in proportions -0.6% [95% CI -4.7% to 3.9%]). No association was found between administration of oral analgesia before procedural sedation and anesthesia and the frequency of emesis or other adverse events.

Afebrile Pediatric Seizures

Most well-appearing children who have had an afebrile seizure can be managed as outpatients with instructions for an outpatient electroencephalogram and primary care physician follow-up. Laboratory studies are needed only in children younger than 6 months, in patients with prolonged seizures or altered level of consciousness, or in those with history of a metabolic disorder or dehydration. Emergent neuroimaging is not recommended in children with a first unprovoked afebrile seizure, although studies should be considered in children with a predisposing condition or focal seizures if younger than 3 years.