Grace M. Young

Silver nitrate burns following treatment for umbilical granuloma

Three infants treated for umbilical granuloma with silver nitrate suffered chemical burns to the periumbilical area which prompted visits to the emergency department. Treatment was conservative, and the outcome was good in all cases. We recommend caution when applying silver nitrate to the umbilicus, careful drying of the umbilical exudate to prevent spillage, and discussion with parents that burns may occur but apparently are not serious. The possibility of secondary infection is discussed.

Status epilepticus in children. The acute management.

Status epilepticus is a common pediatric emergency that may result in significant morbidity and mortality. This article provides a clinical update on generalized tonic-clonic status epilepticus in children and a practical approach to their initial stabilization and pharmacologic management. Only an organized approach to the initial stabilization and management of the child in status epilepticus will help prevent unnecessary complications and death.

Management of children with epiglottitis during transport: analysis of a survey

Because nationally accepted guidelines for the management of children with epiglottitis during transport have not been published, we surveyed physicians attending the 1990 Pediatric Critical Care Transport Leadership Conference in order to delineate current practices and to test for correlations between complications and methods of management. A 22-item questionnaire was distributed, addressing demographics, availability and composition of a designated transport team, methods of airway management, use of medications for sedation or paralysis, monitoring techniques, and complications encountered during transport. Forty-three of the 49 attendees completed the questionnaire (87.8%). Almost all were attending physicians (60.9% pediatric intensivists, 29.3% pediatric emergency physicians) practicing in tertiary care facilities (58.5% in childrens hospitals, 41.5% in general hospitals). Eighty-three percent of centers had designated transport teams. For transfer of a child with suspected epiglottitis from a physicians office, virtually all respondents recommended transport by ambulance, 64% to the nearest facility and 36% directly to a tertiary care center. Regarding interhospital transfers, 49% recommended intubation prior to transport in all cases, whereas 49% considered it on an individual basis. The majority of respondents preferred nasal intubation. To prevent dislocation of the endotracheal tube, 79.1% recommended taping it to the face only (as opposed to around the skull), 70.7% administered paralytic agents, but only 35.2% used additional mechanical restraints. Thirty-seven percent reported complications during transport. When groups with and without transport teams were compared, significantly fewer groups with teams reported complications. Reports of accidental extubation did not differ significantly between those groups that recommended the use of paralytic agents and those that did not, or between those that used mechanical restraints and those that did not. In summary, there was no universally accepted protocol for transporting a patient with epiglottitis. Our data did suggest, however, that using a trained transport team may reduce the risk of complications.

The child with multiple injuries: resuscitation priorities

The child with multiple injuries frequently presents with airway compromise, hypovolemia, and central nervous system injury. These often result in shock, a state characterized by inadequate delivery of oxygen to tissues. Signs of shock are more subtle in children. Recognition of shock is importait because it is the final common pathway leading to death. Treatment begins with establishing a patent airway, and attaining adequate oxygenation and ventilation. Aggressive resuscitation, with large fluid boluses, is imperative. Once the child is hemodynamically stable, the CT scan aids in the diagnosis and management of head, chest, and abdominal trauma. Non-operative treatment of splenic and hepatic injuries is increasingly favored with excellent outcome. To ensure a smooth and complete evaluation of the injured child, a predetermined protocol and an interdisciplinary approach are essential.