Hnin Khine

Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients

Objective: To determine if there are actual differences between pediatric emergency medicine (PEM) physicians and general emergency medicine (GEM) physicians in the management of pain in pediatric patients with fractured extremities. Method: Retrospective chart review of children seen with a forearm or lower extremity fracture over a 2-year period at 3 emergency departments (1 staffed by PEM physicians and 2 staffed by GEM physicians). A severe fracture was defined as a closed fracture with the presence of angulation or displacement. Procedural sedation was defined as the administration of medicine (sedative, analgesic, or dissociative anesthetic) at the time of reduction and/or immobilization of a fracture. Results: Of the 718 charts reviewed, PEM physicians managed 428 patients, and GEM physicians managed 290 patients. There were no significant differences between the patients managed by PEM physicians and GEM physicians with regard to age, sex, site of fracture, and proportion of severe fractures. There were no differences in the administration of analgesic-related medicines between PEM physicians and GEM physicians in the management of all fractures [40% (95% CI 35-45%) vs. 43% (95% CI 37-49%)] or severe fractures [58% (95% CI 51-64%) vs. 66% (95% CI 58-73%)]. In the management of all fractures, procedural sedation was used by PEM physicians in 100 [23% (95% CI 19-27%)] patients and by GEM physicians in 52 [18% (95% CI 14-23%)] patients. When procedural sedation was used, PEM physicians were more likely to use a sedative agent than GEM physicians [94% (95% CI 88-97%) vs. 46% (95% CI 33-59%)], fentanyl as opposed to morphine or meperidine [62% (95% CI 52-71%) vs. 19% (95% CI 33-59%)] and a combination of sedative and analgesic [90% (95% CI 83-94%) vs. 44% (95% CI 31-57%)]. For all fractures, GEM physicians documented recommending pain medications on discharge more often than PEM physicians [66% (95% CI 60-71%) vs. 45% (95% CI 40-50%)], and they prescribed significantly more prescription analgesics than PEM physicians [13% (95% CI 10-17%) vs. 2% (95% CI 1-4%)]. Conclusions: In our study, most children with an extremity fracture and greater than one-third of children with a severe fracture did not receive pain medications in the emergency department. Overall, both PEM physicians and GEM physicians have similar practices of analgesic administration for fracture reduction, with a notable exception in the types of agents used during procedural sedation. GEM physicians documented discharge pain medications and prescribed prescription analgesics more often than PEM physicians.

Accuracy of point-of-care ultrasound for diagnosis of skull fractures in children.

OBJECTIVE: To determine the test performance characteristics for point-of-care ultrasound performed by clinicians compared with computed tomography (CT) diagnosis of skull fractures. METHODS: We conducted a prospective study in a convenience sample of patients ≤21 years of age who presented to the emergency department with head injuries or suspected skull fractures that required CT scan evaluation. After a 1-hour, focused ultrasound training session, clinicians performed ultrasound examinations to evaluate patients for skull fractures. CT scan interpretations by attending radiologists were the reference standard for this study. Point-of-care ultrasound scans were reviewed by an experienced sonologist to evaluate interobserver agreement. RESULTS: Point-of-care ultrasound was performed by 17 clinicians in 69 subjects with suspected skull fractures. The patients’ mean age was 6.4 years (SD: 6.2 years), and 65% of patients were male. The prevalence of fracture was 12% (n = 8). Point-of-care ultrasound for skull fracture had a sensitivity of 88% (95% confidence interval [CI]: 53%–98%), a specificity of 97% (95% CI: 89%–99%), a positive likelihood ratio of 27 (95% CI: 7–107), and a negative likelihood ratio of 0.13 (95% CI: 0.02–0.81). The only false-negative ultrasound scan was due to a skull fracture not directly under a scalp hematoma, but rather adjacent to it. The κ for interobserver agreement was 0.86 (95% CI: 0.67–1.0). CONCLUSIONS: Clinicians with focused ultrasound training were able to diagnose skull fractures in children with high specificity.

Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children

STUDY OBJECTIVE We determine the test performance characteristics for point-of-care ultrasonography performed by pediatric emergency physicians compared with radiographic diagnosis of elbow fractures and compare interobserver agreement between enrolling physicians and an experienced pediatric emergency medicine sonologist. METHODS This was a prospective study of children aged up to 21 years and presenting to the emergency department (ED) with elbow injuries requiring radiographs. Before obtaining radiographs, pediatric emergency physicians performed focused elbow ultrasonography. An ultrasonographic result positive for fracture at the elbow was defined as the pediatric emergency physicians determination of an elevated posterior fat pad or lipohemarthrosis of the posterior fat pad. All patients received an elbow radiograph in the ED and clinical follow-up. The criterion standard for fracture was fracture on initial or follow-up radiographs. RESULTS One hundred thirty patients with a mean age of 7.5 years were enrolled by 26 sonologists. Forty-three (33%) patients had a radiograph result positive for fracture. A positive elbow ultrasonographic result had a sensitivity of 98% (95% confidence interval [CI] 88% to 100%), specificity of 70% (95% CI 60% to 79%), positive likelihood ratio of 3.3 (95% CI 2.4 to 4.5), and negative likelihood ratio of 0.03 (95% CI 0.01 to 0.23) for fracture. The interobserver agreement (κ) was 0.77. The use of elbow ultrasonography would reduce radiographs in 48% of patients but would miss 1 fracture. CONCLUSION Point-of-care ultrasonography is highly sensitive for elbow fractures, and a negative ultrasonographic result may reduce the need for radiographs in children with elbow injuries. Elbow ultrasonography may be useful in settings in which radiography is not readily accessible or is time consuming to obtain.

A simple intervention for improving telephone contact of patients discharged from the emergency department

Objective To determine if emergency department (ED) follow-up contact rates can be improved by confirming a best contact telephone number with the patient prior to discharge. Design/Setting Prospective comparison of intervention and control groups taken from convenience samples of ED patients from Childrens Hospital of Pittsburgh (CHP) and Childrens Hospital of Wisconsin (CHW). Participants One hundred eighty-eight (188) patients (138 from CHP and 50 from CHW) who had x-rays and laboratory studies done in the ED were interviewed by the investigators prior to discharge (intervention group) and 305 control patients (256 from CHP, 49 from CHW) identified from ED log books. Intervention Prior to discharging the patient from the ED, the investigators verified and/or corrected the best contact number for a follow-up phone call with each intervention patient. Within 24 hours of each visit, a follow-up call was made to each intervention and control patient during one of three time intervals spaced between 8 AM and 10 PM. Results A total of 29 patients, or 15.4%, of the intervention group, gave a telephone number that differed from the one listed in the patients medical record. Of the CHP group, 93.5% (129/138) of intervention patients and 78.5% (201/256) of control patients were successfully contacted (P < 0.001). Of the CHW group, 96% (48/50) of intervention patients, and 94% (46/49) of control patients were successfully contacted (P = NS). Successful contact of control patients was greater in CHW than CHP (46/49 vs 201/256, P = 0.02). Conclusions A significant proportion of telephone numbers listed in the ED medical records are incorrect, but the frequency of inaccuracy may be institution-dependent. Confirming the patients “best contact” number can significantly increase the successful contact of ED patients.

Applicability of Ottawa knee rule for knee injury in children

Objective Previous studies have shown that the application of the Ottawa knee rule (OKR) reduces the need for radiographs in adults with acute knee injuries. Our objectives were to describe the epidemiology and incidence of knee injuries in children with acute knee trauma and to validate the OKR in a pediatric population. Design A prospective, consecutive study. Settings Two urban pediatric emergency departments. Methods All children 18 years of age and under who presented with acute traumatic knee injury of less than 1 week’s duration, excluding patients with a normal knee examination, superficial skin injuries, prior history of knee injury, underlying bone disease, serious injuries involving two or more organ systems, or altered mental status were enrolled. Physicians assessed each patient for 22 standardized clinical findings prior to radiography. The OKR was applied to each patient by the investigating physician. Results All 234 patients eligible for the study had radiographs of the affected knee. The median age was 13 years with a range of 2 to 18 years. Using the OKR criteria for obtaining knee radiographs, 12 of 13 patients with fractures were identified (sensitivity 92%; 95% CI= 64–99). The missed case was an 8-year-old male who had sustained a nondisplaced fracture of the proximal tibia after a fall. If the OKR were applied to the pediatric population, it would have reduced the need for radiography in 46% of children. Conclusions In the pediatric population studied, the OKR did not identify all patients with knee fractures. Future studies may consider modifying the OKR to accommodate the differences between pediatric and adult patients to improve the sensitivity of the rule while maintaining its specificity, before it can be applied routinely in clinical practice.

Intranasal fentanyl for initial treatment of vaso-occlusive crisis in sickle cell disease

Analgesia administration for children with vaso‐occlusive crises is often delayed in the emergency department. Intranasal fentanyl (INF) has been shown to be safe and effective in providing rapid analgesia for other painful conditions. Our objective was to determine if children with a vaso‐occlusive crisis (VOC) who received initial treatment with INF compared to placebo achieved a greater decrease in pain score after 20 min.

Perception and Attitude of Providers Toward Pain and Anxiety Associated With Pediatric Vaccine Injection

Despite the many options available for control of the pain and anxiety during vaccine injections, they are not often used. A total of 70 primary care providers (PCPs) were asked to rate their perception of pain and anxiety associated with vaccine injection in an average 4- to 6-year-old using a visual analog scale—0 (no pain/anxiety) to 10 (very severe pain/anxiety)—as well as perceived barriers. The mean PCPs’ perception of pain associated with vaccine injection was 5.7 (95% confidence interval [CI] = 5.3-6.1), and perceived anxiety was 7.7 (95% CI = 7.2-8.1). Trainees recorded higher perceived anxiety than attending physicians (8.0 vs 6.9; P = .03)]. Of the respondents, 63 (90%) felt that pain and anxiety control is achievable in their office setting. Nevertheless, only 8 (11%) PCPs had ordered any pain and anxiety control measures during vaccine injection. There is a gap between the PCPs’ perception of pain and anxiety and practice of pain and anxiety control measures during vaccine injection.

Seat belt use by children brought to an inner-city hospital

OBJECTIVE To characterize restraint use among children brought to an inner-city hospital by private car or taxicab. DESIGN Cross-sectional survey and direct observation of a convenience sample. SETTING Main entrance and clinic entrance of a large urban public hospital. PARTICIPANTS Direct observation was made on 352 children brought by 257 vehicles. One hundred seventy-seven parents or caretakers responded to questionnaires for 240 children. INTERVENTION None. MEASURES AND MAIN RESULTS Of the 352 children who were directly observed, 256 (73%) arrived by taxicabs and 96 (27%) by private cars. Thirty-three of 352 (9%) children were observed to be appropriately restrained. Children brought by taxicabs were significantly less likely to be restrained than children brought by private cars (1% vs 31%, P < 0.001). Caretakers reported that seat belts were available in 46 of 54 (85%) private cars, compared to 38 of 88 (43%) taxicabs (P < 0.01). Twenty percent of caretakers who came by taxicabs did not check for seat belts. CONCLUSION Taxicabs, which are exempt from the New York States mandatory seat belt law, are a common mode of transportation for children in the inner city. While the overall use of child restraints in the study sample is low, it is particularly low for children in taxicabs. The low rate may be related to both the decreased availability of seat belts and the lack of the mandatory seat belt law for taxicabs. Strategies should be sought to improve child restraint availability in taxicabs and mandate seat belt use.

Fever and Rash: A Changing Landscape in the 21st Century

Although “fever and rash” is a common complaint in the pediatric emergency department, most causes are benign. Of the more severe causes, several have been greatly reduced by vaccination programs. In addition, new vaccines such as those for invasive meningococcal disease hold promise for an even brighter future. Although meningococcemia remains an important concern when evaluating a child with fever and a rash, the resurgence of measles, the emergence of invasive group A streptococcal disease and antibiotic-resistant Staphylococcus aureus, as well as the fear of agents of bioterrorism (anthrax, smallpox) have changed the landscape of fever and rash in the 21st century. The purpose of this article is not to offer a comprehensive differential of febrile exanthema, but rather to highlight some new concerns related to the evaluation of fever and rash in todays emergency department.

Pediatric neurologic potpourri: cases to remember

Abstract Neurological emergencies are many and varied. While some emergencies occur commonly, others are seen more infrequently and can create diagnostic dilemmas. The four cases presented in this paper are intended to expose the reader to uncommon yet consequential cases that can pass through the emergency department. In each case we identify key concerns and offer up-to-date information on the patient management.