James A. Moynihan

Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department.

Objectives: Pediatric patients with cerebrospinal fluid shunts frequently present to the emergency department for evaluation of possible shunt malfunction. Most shunt studies appear in the neurosurgical literature. To our knowledge, none have reviewed presenting signs and symptoms of shunt malfunction in patients who present to the pediatric emergency department. The study objective was to evaluate the medical record of children with cerebrospinal fluid shunts who presented to a pediatric emergency department to determine if any signs and/or symptoms were predictive of shunt malfunction. Methods: A retrospective chart review was conducted on 352 pediatric patients aged 0 to 18 years, who presented to the pediatric emergency department between January 1, 1998, and December 31, 2002, with signs and/or symptoms that prompted an evaluation for possible shunt malfunction. Results: Univariate analysis of all signs and symptoms revealed lethargy (odds ratio, 1.99; 95% confidence interval, 1.15-3.42; P = 0.02) and shunt site swelling (odds ratio, 2.56, 95% confidence interval, 1.08-6.07, P = 0.03) to be significantly predictive of shunt malfunction. Logistic regression analysis continued to show significance for lethargy (odds ratio, 2.20; bias-corrected 95% confidence interval, 1.11-3.63) and shunt site swelling (odds ratio, 3.10; bias-corrected 95% confidence interval, 1.38-9.05), but found no other study variable to be significant. Bootstrap resampling validated the importance of the significant variables identified in the regression analysis. Conclusions: In this study, lethargy and shunt site swelling were predictive of shunt malfunction. Other signs and symptoms studied did not reach statistical significance; however, one must maintain a high index of suspicion when evaluating children with an intracranial shunt because the presentation of malfunction is widely varied. A missed diagnosis can result in permanent neurological sequelae or even death.

Cardiac troponin I as a predictor of respiratory failure in children hospitalized with respiratory syncytial virus (RSV) infections: A pilot study

This pilot study was performed to assess the use of cardiac troponin I to predict respiratory failure in children admitted to the hospital with respiratory syncytial virus (RSV) infections. We enrolled a prospective convenience sample of children under 5 years of age who were admitted to our university-based, tertiary care childrens hospital from December 1, 2000, to February 1, 2002, with RSV infections. A cardiac troponin I was drawn at admission. We assessed the test characteristics for positive cardiac troponin I (defined as >0.3 ng/mL, the manufacturers upper limit of normal) in correctly identifying children who had respiratory failure as evidenced by the need for endotracheal intubation. Twenty-five children from 9 days to 38 months of age were included. Ten children had a positive cardiac troponin I and 3 of these children had respiratory failure. A positive cardiac troponin I demonstrated a sensitivity of 100%, specificity 68%, positive predictive value of 30%, negative predictive value of 100%, and accuracy of 72%. The area under the receiver operating characteristic curve was 0.939 (95% confidence interval, 0.820-1.0), suggesting a high degree of discriminatory power in selecting children with respiratory failure. A sample size calculation revealed that a follow-up study of 359 patients is needed before the clinical use of cardiac troponin I for this purpose.

Cardiac troponin I as a predictor of mortality for pediatric submersion injuries requiring out-of-hospital cardiopulmonary resuscitation.

Background: It is difficult to predict ultimate survivors to hospital discharge in children who are successfully resuscitated after a cardiorespiratory arrest associated with a submersion injury. Serum measurements of organ injury or dysfunction may serve as a surrogate marker of the degree of hypoxic injury. We designed a prospective study whose purpose was to assess the predictive value for outcome of serum cardiac troponin I measurements after submersion injury and cardiorespiratory arrest. Methods: This is a prospective, observational study of children admitted to a postintensive care unit after experiencing an out-of-hospital cardiorespiratory arrest associated with a submersion event. Cardiac troponin I measurements were examined upon admission to the postoperative intensive care unit after successful emergency department resuscitation. Results: Nine patients were admitted, and 2 patients (22%) survived to hospital discharge. The area under the receiver operating characteristic curve is 0.786 (95% confidence interval, 0.481-1.0). This suggests that cardiac troponin I has a moderate degree of discriminatory power in selecting children who did not survive to hospital discharge.

Blunt pediatric head trauma requiring neurosurgical intervention: how subtle can it be?

Recent literature on pediatric head injuries has suggested that important intracranial injuries might present to the ED without typical signs or symptoms. The objective of our study was to review our institutional experience with head-injured infants and young children to assess the subtlety of the ED presentation. We performed a retrospective medical record review of head-injured children </=10 years of age who underwent neurosurgical procedures from January 1, 1985, through November 28, 2001. We identified 110 children who met our inclusion criteria. All of the children had at least 2 signs or symptoms indicative of head injury. No single sign or symptom was present in all cases. Altered mental status was identified 85% of the time and was the most common sign or symptom. Eighteen children presented with a Glasgow Coma Scale score of 15 or the absence of abnormal mental status documented, but all of these children had other indications for head computed tomographic scanning. Emergency physicians should feel confident that standard history and physical examination skills are adequate to identify head-injured children who require neurosurgical procedures.

Investigation of afebrile neonates with a history of fever.

OBJECTIVE Our objective was to describe clinically significant infections in a cohort of afebrile neonates who underwent an emergency department (ED) septic workup because of the history of a measured fever at home. METHODS Retrospective medical record review of all infants (3/4)28 days of age who presented to our tertiary care pediatric ED between Jan. 1, 1999, and Aug. 22, 2002, underwent lumbar puncture in the ED, had a reported temperature at home of >or=38 degrees C, and an ED triage temperature of <38 degrees C. Laboratory and radiographic results were tabulated. RESULTS During the study period, 206 neonates underwent lumbar puncture in our ED. Of these, 108 were excluded because their home temperature was not documented, and 71 were excluded because they were still febrile on presentation to the ED. The study group consisted of the remaining 27 subjects, 4 of whom had received acetaminophen prior to ED arrival. Infections were confirmed in 10 (37%) subjects (3 urinary tract infections, 2 aseptic meningitis, 1 enterovirus meningitis, 1 respiratory syncytial virus bronchiolitis, 1 rotavirus enteritis and 2 pneumonias). CONCLUSIONS Clinically important infections are not uncommon among afebrile neonates undergoing ED septic workup because of a measured fever at home. Some diagnostic testing is warranted in this group, although the clinical utility and indications for specific test modalities remain unclear.

The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study

OBJECTIVE There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure. METHODS This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004. RESULTS Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems. CONCLUSIONS This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.