James G. Linakis

Emergency Department Visits for Concussion in Young Child Athletes

OBJECTIVES: The objective of this study was to characterize emergency department (ED) visits for pediatric sport-related concussion (SRC) in pre–high school– versus high school–aged athletes. METHODS: A stratified probability sample of US hospitals that provide emergency services in the National Electronic Injury Surveillance System (1997–2007) and All Injury Program (2001–2005) was used. Concussion-related ED visits were analyzed for 8- to 13- and 14- to 19-year-old patients. Population data were obtained from the US Census Bureau; sport participation data were obtained from National Sporting Goods Association. RESULTS: From 2001 to 2005, US children who were aged 8 to 19 years had an estimated 502 000 ED visits for concussion. The 8- to 13-year-old group accounted for ∼35% of these visits. Approximately half of all ED visits for concussion were SRC. The 8- to 13-year-old group sustained 40% of these, which represents 58% of all concussions in this group. Approximately 25% of all SRC visits in the 8- to 13-year-old group occurred during organized team sport (OTS). During the study period, ∼4 in 1000 children aged 8 to 13 years and 6 in 1000 children aged 14 to 19 years had an ED visit for SRC, and 1 in 1000 children aged 8 to 13 years and 3 in 1000 children aged 14 to 19 years had an ED visit for concussion sustained during OTS. From 1997 to 2007, although participation had declined, ED visits for concussions in OTS in 8- to 13-year-old children had doubled and had increased by >200% in the 14- to 19-year-old group. CONCLUSIONS: The number of SRCs in young athletes is noteworthy. Additional research is required.

Effects of concentration of ethanol injected intraperitoneally on taste aversion, body temperature, and activity.

Levels of ethanol-induced conditioned taste aversion and hypothermia were found to be directly related to the concentration of fixed amounts of ethanol injected i.p. in a range of doses (1.0–1.8 g/kg) and concentrations (8–32% v/v) commonly used in behavioral studies. No effect of ethanol concentration on locomotor activity was obtained. The results of blood-ethanol determinations indicate that a given dose of ethanol is absorbed more rapidly, and thus reaches greater peak levels, when injected in a higher concentration. Thus ethanol dosage might be better manipulated by varying the volume of a single concentration rather than by altering concentration. In this way, dose-response data will not be obscured by concentration-induced differences in absorption.

Treatment of pediatric migraine headaches: A randomized, double-blind trial of prochlorperazine versus ketorolac

STUDY OBJECTIVE We compare the effectiveness of intravenous ketorolac and intravenous prochlorperazine in the treatment of pediatric migraine headaches. METHODS We performed a prospective, randomized, double-blind clinical trial in 2 pediatric emergency departments (EDs) within childrens hospitals. Children aged 5 to 18 years presenting to the ED with migraine headaches were eligible for the study. Contraindications to either medication or the inability to complete the pain score resulted in exclusion. Children were randomized to receive intravenous ketorolac (0.5 mg/kg; maximum 30 mg) or intravenous prochlorperazine (0.15 mg/kg; maximum 10 mg). All children also received a normal saline solution bolus. Successful treatment was defined as a 50% or greater reduction in the Nine Faces Pain Scale score at 60 minutes. If a less than 50% improvement occurred by 60 minutes, the child received the other medication. Forty-eight-hour follow-up telephone calls were made to each family to assess recurrence and late side effects. RESULTS Sixty-two children were enrolled: 33 initially received prochlorperazine, and 29 initially received ketorolac. By 60 minutes, 16 (55.2%) of 29 of those who received ketorolac and 28 (84.8%) of 33 of those who received prochlorperazine were successfully treated (difference=30%; 95% confidence interval [CI] 8% to 52%). Fifty-six (93.3%) of the 60 children who completed the study were successfully treated by the studys conclusion. Approximately 30% of each group had a recurrence of some headache symptoms. Only 2 children reported side effects, both mild and self-limited. CONCLUSION In children, intravenous prochlorperazine is superior to intravenous ketorolac in the acute treatment of migraine headaches.

Differential effects of selective dopamine, norepinephrine or catecholamine depletion on activity and learning in the developing rat

The present experiment investigated the behavioral changes which occurred following neonatal depletion of central catecholamine systems in the rat. The behavioral effects which resulted from selective dopamine (DA) depletion were compared with those resulting from selective norepinephrine (NE) depletion as well as depletion of both catecholamines (CA). Neonatal 6-hydroxydopamine (6-OHDA) was administered intracisternally at 5 days of age following pretreatment with desmethylimipramine in order to selectively deplete DA. NE levels were reduced by intraperitoneal injections of 6-OHDA at 1 and 2 days of age. Depletion of both catecholamines was effected by combining the procedures used for selective depletion of both DA and NE. Activity was time sampled during an hour at 3 preweanling ages. Avoidance and escape learning were measured in a T maze when pups were 20 days of age and in a Shuttlebox apparatus on day 28. Results revealed that DA and CA depleted animals were hyperactive in comparison to controls and displayed severe learning impairments in both T maze and Shuttlebox performance. In contrast, NE depleted animals showed activity levels which were similar to controls but were significantly impaired on both learning paradigms. These results suggest that selective lesions of DA and NE in infancy lead to a constellation of behaviors which are distinctly unique. The implications of these findings is discussed in terms of clinical research into the Attentional Deficit Disorder of childhood.

Poisoning deaths not reported to the regional poison control center

STUDY OBJECTIVES This study was designed to characterize poisoning deaths in Rhode Island and to determine the incidence of poisoning deaths that are not reported to the regional poison center. DESIGN The records of the state medical examiner were reviewed retrospectively for all toxin-related deaths from January 1986 through December 1989, and those deaths were compared with deaths recorded by the poison center during the same period. PARTICIPANTS All patients whose deaths were due to a toxic substance and were recorded by either the state medical examiners office or the regional poison center during the four-year study period. INTERVENTIONS Age, sex, location of death, cause of death (both primary and secondary toxins were noted), manner of death (accidental, suicide, undetermined), and the circumstances surrounding the death were recorded for each victim. Medical examiner and poison center cases were matched and compared using a computerized data base program. RESULTS During the study period, 369 deaths reported to the medical examiner were attributed to poisoning, while 45 poisoning deaths were recorded by the poison center. Of the deaths reported to the medical examiner, the most common reasons for lack of reporting to the poison center were that death occurred at a residence or patients were dead on arrival at the hospital and a toxin was not suspected until an autopsy was performed. Seventy-nine other poisoning victims arrived at the hospital alive with a suspected toxic exposure and hypothetically could have been reported to the poison center but were not. CONCLUSION The medical examiners office represents a significant source of statistics regarding poisoning deaths, the majority of toxic deaths not reported to the poison center are dead on arrival, and using deaths as the dependent measure, the poison center may be underutilized in severe poisoning cases.

Use of Urinary Gram Stain for Detection of Urinary Tract Infection in Infants

STUDY OBJECTIVE To determine whether Gram stain of urine is more sensitive than urinalysis in detecting urinary tract infection in infants. DESIGN Prospective series. SETTING Urban teaching hospital emergency department. PARTICIPANTS Two hundred seven infants 6 months old or less, from whom a catheterized or suprapubically aspirated urine specimen was obtained for culture. INTERVENTIONS Urinary Gram stain, culture, and urinalysis were performed. With culture results as the validating standard, the Gram stain sensitivity, specificity, and predictive values were compared with urinalysis, including leukocyte esterase, nitrite, pyuria, and bacteriuria. RESULTS The prevalence of positive cultures was 8.7% (18 of 207). Gram stain had higher sensitivity than overall urinalysis (94% versus 67%, P < .05), higher specificity (92% versus 79%, P < .05), and higher positive predictive value (53% versus 23%, P < .05). CONCLUSION Urinary Gram stain appears to be more reliable than urinalysis in detecting urinary tract infection in young infants.

Increasing Computed Tomography Use for Patients With Appendicitis and Discrepancies in Pain Management Between Adults and Children: An Analysis of the NHAMCS

STUDY OBJECTIVE Using a national sample of emergency department (ED) visits, we aim to describe use of CBC, computed tomography (CT), and pain medication among ED visits in which appendicitis was diagnosed. We describe use trends over time and identify use differences between adults and children. METHODS The ED component of the National Hospital Ambulatory Medical Care Survey was analyzed for 1992 through 2006, comprising a sample of 447,011 visits (representing an estimated total of approximately 1.5 billion visits), from which a sample of 1,088 patients (representing an estimated 3.7 million patients) received a diagnosis of appendicitis. The frequency of CBC and CT use and frequency of pain medication administration were determined. Survey-adjusted regression analyses were used to determine the probability of a patient receiving CBC, CT, or pain medication. Use was compared between adults and children. RESULTS During the course of the study, from 1996 to 2006, the percentage of patients with appendicitis who received a CT scan increased from 6.3% (95% confidence interval [CI] 0% to 15.3%) to 69% (95% CI 55.5% to 81.7%) for adults and from 0% to 59.8% (95% CI 31.6% to 87.9%) for children. CBC use for adults increased from 77.2% (95% CI 62.9% to 91.5%) to 92.8% (95% CI 85.8% to 99.7%) and decreased from 89.1% (95% CI 74.9% to 100.0%) to 68.4% (95% CI 41.9% to 94.9%) for children. The use of pain medications increased from 24.8% (95% CI 11.3% to 38.4%) to 69.9% (95% CI 56.7% to 83.1%) for adults and from 27.2% (95% CI 5.7% to 48.8%) to 42.8% (95% CI 18.1% to 67.5%) for children. The proportion of children who received parenteral narcotics (13.7% [95% CI 9.3% to 18.0%]) was less than that of adults (23% [95% CI 18.9% to 27.1%]). CONCLUSION CT use has increased for patients with appendicitis over time, and CBC use remains high. There has been an increase in analgesic administration, but more than half of all patients with appendicitis had not received pain medication over the course of the entire study period. Children received fewer parenteral narcotics than adults and appeared to be preferentially treated with nonparenteral nonnarcotic analgesics.

Bispectral analysis during pediatric procedural sedation.

Objective: Bispectral analysis (BIS) is a technology using EEG information from a forehead electrode to calculate an index (0-100; 0 = coma, 90-100 = awake). Our objective was to determine the degree of agreement between sedation scales and BIS values in pediatric patients undergoing sedation. Methods: Patients ages 2 to 17 years, undergoing procedural sedation, were enrolled. Sedation was performed in the customary manner with the addition of BIS monitoring and assessment of a clinical sedation scale: the Observers Assessment of Alertness/Sedation (OAA/S), every 5 minutes during the sedation procedure. Clinical scales were performed by an investigator blinded to the BIS index. The association between a clinical scale and BIS scores was analyzed using longitudinal regression analysis. Results: We enrolled 47 subjects; 55% were sedated with ketamine and midazolam and the remaining 45% received methohexital, propofol or midazolam and a narcotic. The results of the regression analysis demonstrated a highly significant association between the OAA/S score and BIS value (β = 5.0, 95% CI 4.3 to 5.7, P < 0.0001). Patients were divided into 2 groups, those sedated with ketamine and those sedated with nonketamine medications. The association between OAA/S score and BIS value was not statistically significant for the ketamine population (β = 0.809, 95% CI −0.1 to 1.7, P = 0.09), but remained significant for the nonketamine subjects (β = 8.6, 95% CI 7.7 to 9.4, P < 0.0001). Conclusions: The OAA/S sedation scale predicts the BIS value for pediatric patients undergoing procedural sedation when sedated with certain medications, excluding ketamine.

Length of Stay of Pediatric Mental Health Emergency Department Visits in the United States

OBJECTIVE To compare pediatric mental health emergency department visits to other pediatric emergency department visits, focusing on length of stay. METHOD We analyzed data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of US emergency department visits from 2001 to 2008, for patients aged ≤18 years (n = 73,015). Visits with a principal diagnosis of a mental disorder (n = 1,476) were compared to visits (n = 71,539) with regard to patient and hospital characteristics, treatment, and length of stay. Predictors of prolonged mental health visits were identified. RESULTS Mental health visits were more likely than other visits to arrive by ambulance (21.8% versus 6.3%, p < .001), to be triaged to rapid evaluation (27.9% versus 14.9%, p < .001), and to be admitted (16.4% versus 7.6%, p < .001) or transferred (15.7% versus 1.5%, p < .001). The median length of stay for mental health visits (169 minutes) significantly exceeded that of other visits (108 minutes). The odds of extended stay beyond 4 hours for mental health visits was almost twice that for other visits (adjusted odds ratio 1.9, 95% CI = 1.5-2.4) and was not explained by observed differences in evaluation, treatment, or disposition. Among mental health visits, advancing calendar year of study, intentional self-injury, age 6-13 years, Northeastern, Southern, and metropolitan hospital location, use of laboratory studies, and patient transfer all predicted extended stays. CONCLUSIONS Compared with other pediatric emergency visits, mental health visits are longer, are more frequently triaged to urgent evaluation, and more likely to result in patient admission or transfer, thereby placing distinctive burdens on US emergency departments.

Energy drink and other substance use among adolescent and young adult emergency department patients.

Objective This study aimed to understand current patterns of energy drink use and compare the extent of usage of energy drinks and other commonly used and misused substances between adolescent (13–17-years-old) and young adult (18–25-years-old) emergency department (ED) patients. Methods During a 6-week period between June and August 2010, all patients presenting to an adult or pediatric ED were asked to complete a computer-based, anonymous questionnaire regarding use of energy drinks and other substances. Wilcoxon rank-sum, 2-sample tests of binomial proportions, Pearson &khgr;2 testing, and regression models were used to compare energy drink and substance use by age groups. Results Past 30-day energy drink use was greater for young adults (57.9%) than adolescents (34.9%) (P < 0.03). Adolescents typically consumed a mean of 1.5 and young adults a mean of 2.6 energy drinks per day when using energy drinks and drank at most a mean of 2.4 and 2.6 drinks per day, respectively. Among adolescents, energy drink usage was more common than alcohol, “street” or illicit drugs, and tobacco usage, but less common than caffeine product usage. For young adults, energy drink usage was more common than “street” or illicit drugs, but less common than caffeine use, and similar to tobacco and alcohol usage. Young adult energy drink users were more likely than young adult non–energy drink users also to use tobacco and caffeine. Conclusions Energy drink use is common among ED patients. Given the high prevalence of energy drink use observed, emergency physicians should consider the involvement of energy drinks in the presentations of young people.