Jane F. Knapp

Nitrous oxide analgesia in a pediatric emergency department

Nitrous oxide (N2O) has been shown to be an effective analgesic in adult medical outpatients, yet no prospective studies of its use in the pediatric medical outpatient exist. Thirty-four children requiring laceration repair were randomly assigned to one of two treatment groups: 30% N2O/70% O2 or a placebo, 100% O2. Pain behavior, using the observer-scored Childrens Hospital of Eastern Ontario Pain Scale, was assessed by double-blind techniques, before and during the laceration repair. Less pain behavior was seen in children less than 8 years old who received the N2O mixture than in those receiving the placebo. In patients 8 or more years old who received N2O, there was a significant improvement in the second evaluation as compared with those receiving only O2 during the procedure (P less than .05). There also was a smaller increase in pain behavior, from the first to the second evaluation, in those receiving N2O (P less than .05). No side effects were encountered. The authors conclude that continuous N2O inhalation is an effective and painless analgesic in children for outpatient procedures. More effective analgesia will likely occur with 40% to 50% N2O, although these concentrations remain to be studied in pediatric outpatients.

TAC use and absorption of cocaine in a pediatric emergency department.

The topical anesthetic TAC (tetracaine 0.5%, adrenaline 0.05%, cocaine 11.8%) has been reported to be effective in pain control for local procedures. However, it has the potential for cocaine toxicity by absorption through an open wound. A study was undertaken to assess the systemic absorption of cocaine and its metabolites when TAC is used as a local anesthetic. Fifty-one children, 1 to 14 years of age, were enrolled in the study. Plasma for cocaine and/or its metabolite levels was available from 46 children and obtained 20 to 40 minutes after the topical anesthetic was applied. No plasma sample had detectable parent cocaine levels; however, 26 (56.5%) had cocaine metabolite levels. Ecgonine methylester levels were detected in plasma from six children and ranged from 59 to 985 ng/mL. Benzoylecgonine levels were detected in none of 19 specimens not preserved with sodium fluoride, and in 23 of 27 specimens to which sodium fluoride had been added. Benzoylecgonine levels ranged from 40 to more than 600 ng/mL. No clinical sign of cocaine toxicity was observed in any child.

Quality of Care for Common Pediatric Respiratory Illnesses in United States Emergency Departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey Data

OBJECTIVE. The goal was to measure US emergency department performance in the pediatric care of asthma, bronchiolitis, and croup, by using systematically developed quality indicators. METHODS. Data on visits to emergency departments by children 1 to 19 years of age with moderate/severe asthma, 3 months to 2 years of age with bronchiolitis, and 3 months to 3 years of age with croup from the 2005 National Hospital Ambulatory Medical Care Survey, with a nationally representative sample of US patients, were analyzed. We used national rates of use of corticosteroids, antibiotics, and radiographs as our main outcome measures. RESULTS. Physicians prescribed corticosteroids in 69% of the estimated 405 000 annual visits for moderate/severe asthma and in 31% of the estimated 317 000 annual croup visits. Children with bronchiolitis received antibiotics in 53% of the estimated 228 000 annual visits. Physicians obtained radiographs in 72% of bronchiolitis visits and 32% of croup visits. CONCLUSIONS. Physicians treating children with asthma, bronchiolitis, and croup in US emergency departments are underusing known effective treatments and overusing ineffective or unproven therapies and diagnostic tests.

Death of a child in the emergency department

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

Benchmarks for the Emergency Department Care of Children With Asthma, Bronchiolitis, and Croup

Objectives: The objectives of this study were (1) to measure the 2005 performance of freestanding childrens hospital emergency departments (EDs) in the care of children with asthma, bronchiolitis, and croup (ABC) using 5 clinical quality indicators and (2) to construct achievable benchmarks for 7 clinical quality indicators of ED care for children with ABC for 2005. Methods: This was a retrospective review using the Pediatric Health Information System database containing information on 1,468,607 (2005) discharges. Performance on 5 established clinical quality indicators for ABC was determined in patients younger than 19 years at 27 hospital EDs in the United States. Benchmarks were computed for 7 clinical quality indicators. Results: Corticosteroids were administered in 65.8% (95% confidence interval [CI], 65.2%-66.2%) of visits for moderate to severe asthma and in 82.5% (95% CI, 82.0%-83.0%) of visits for croup. Physicians ordered an x-ray in 28.6% (95% CI, 28.1%-29.0%) of asthma visits, 37.3% (95% CI, 36.7%-37.9%) of bronchiolitis visits, and in 9.1% (95% CI, 8.7%-9.5%) of croup visits. Benchmarks for corticosteroid administration were 79% and 92% for asthma and croup, respectively; benchmarks for ordering x-rays were 17% for both asthma and bronchiolitis and 2% for croup. Additional benchmarks for antibiotic administration in the ED for asthma and bronchiolitis were 1% and 2%, respectively. Conclusions: Variation exists among freestanding childrens hospitals in the ED care for ABC, but the performance is better than previously reported national averages. We report achievable benchmarks for ED care based on objective clinical quality indicators.

Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

OBJECTIVES: The objectives were (1) to determine trends in radiograph use in emergency department (ED) care of children with asthma, bronchiolitis, and croup; and (2) to examine the association of patient and hospital factors with variation in radiograph use. METHODS: A retrospective, cross-sectional study of National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 on radiograph use at ED visits in children aged 2 to 18 years with asthma, aged 3 months to 1 year with bronchiolitis, and aged 3 months to 6 years with croup. Odds ratios (ORs) were calculated and adjusted for all factors studied. RESULTS: The use of radiographs for asthma increased significantly over time (OR: 1.06; 95% confidence interval [CI]: 1.03–1.09; P < .001 for trend) but were unchanged for bronchiolitis and croup. Pediatric-focused EDs had lower use for asthma (OR: 0.44; 95% CI: 0.29–0.68), bronchiolitis (OR: 0.37; 95% CI: 0.23–0.59), and croup (OR: 0.34; 95% CI: 0.17–0.68). Compared with the Northeast region, the Midwest and South had statistically higher use of radiographs for all 3 conditions. The Western region had higher use only for asthma (OR: 1.67; 95% CI: 1.07–2.60), and bronchiolitis (OR: 2.94; 95% CI: 1.48–5.87). No associations were seen for metropolitan statistical area or hospital ownership status. CONCLUSIONS: The ED use of radiographs for children with asthma increased significantly from 1995 to 2009. Reversing this trend could result in substantial cost savings and reduced radiation. Pediatric-focused EDs used significantly fewer radiographs for asthma, bronchiolitis, and croup. The translation of practices from pediatric-focused EDs to all EDs could improve performance.

Chloroquine poisoning in a child

Chloroquine poisoning in children, although infrequent, is extremely dangerous because of the narrow margin between therapeutic and toxic doses. Children clinically present with apnea, seizures, and cardiac arrhythmias. We present the case of a 12-month-old infant, the second-youngest patient reported in the US literature to die from chloroquine poisoning. A serum level of 4.4 mg/L (13.64 mumol/L) was obtained after the infant ingested only one tablet (300 mg). This establishes a new minimal lethal dose/blood level for children. Although some pediatric and adult pharmacokinetic and clinical similarities exist, the outcome is different. Pediatric mortality is 80%, whereas adult mortality is only 10%. Pediatric ingestion cases are primarily unintentional, and most adult cases are suicide attempts. Current treatment in adults includes a protocol of diazepam and epinephrine. Further studies involving children and these medications and other modalities are needed to improve survival.

The summer penile syndrome : Seasonal acute hypersensitivity reaction caused by chigger bites on the penis

Objective To describe the seasonal acute hypersensitivity reaction of the penis due to chigger bites, known as the summer penile syndrome. Design A consecutive series of patients. Setting The emergency department of an urban academic childrens hospital in the midwestern United States. Participants Male pediatric patients with an acute hypersensitivity reaction of the penis. Results Ninety-four patients were treated for summer penile syndrome during the four-month period from June through September. Patients ranged in age from seven months to 11 years (mean = 5.1, SD = 2.5). Twenty-one percent of patients had also experienced a similar prior episode of penile swelling. Symptoms included pruritus in 84% of cases, dysuria in 33%, and decreased strength of urine stream in 8% of patients. Eighty-four percent of patients had recent exposure to the woods, park, lawn, or poison ivy. In addition to edema, findings on physical examination included a papule or bite puncture mark in 50% of patients, erythema in 32%, and excoriation in 6% of patients. Fifty-six percent of patients had bites on other areas of the body. The emergency physician attributed the penile edema to an insect or chigger bite in 98% of cases. Treatment consisted of an oral antihistamine and cold compresses in most cases. The reported duration of penile swelling ranged from one to 18 days with a mean of 4.1 days (SD = 3.5), and the reported duration of pruritus ranged from 0 to 14 days with a mean of 3.0 days (SD = 2.6). Conclusion This study provides an understanding of the summer penile syndrome for pediatric care providers. To our knowledge, this study is the first to describe this seasonal syndrome in the medical literature.

Evaluation of a curriculum for intimate partner violence screening in a pediatric emergency department.

OBJECTIVE. We sought to describe the assessment of course participant changes in attitudes, self-efficacy, and behaviors after completion of the Its Time to Ask training curriculum for screening for intimate partner violence (IPV) in a pediatric emergency department (PED). METHODS. A 22-item Likert scale questionnaire was administered at baseline (before training), after training, and at 6-month follow-up to PED employee participants in a 2-hour IPV education program. Mean participant responses were compared between baseline/posttraining and baseline/6-month follow-up. Participants also completed a course-satisfaction survey. RESULTS. A total of 79 PED staff completed the baseline questionnaire before the training. Eighty-seven participants completed the posttraining questionnaire, and 48 completed the 6-month follow-up questionnaire. Participants had consistent, positive changes in attitudes after training that persisted at the 6-month follow-up for 5 items on the questionnaire. Attitudes that did not change showed baseline means already in disagreement with questionnaire statements. Participants reported significant, positive changes for all 7 self-efficacy statements at 1 or both of the posttraining evaluations. The only changes in behavior were observed at 6 months. The majority of participants were satisfied with the training and would recommend it to colleagues. CONCLUSIONS. Significant, self-reported changes in attitudes, self-efficacy, and behaviors/clinical practice regarding screening for IPV in a PED can be achieved through participation in a brief training curriculum.

Injuries associated with downhill sledding

During the winter season of 1985 to 1986, 30 children presented to the emergency department with injuries related to downhill sledding. All of the patients were seen and treated during December 1985, which was an unusually cold and snowy month. The age range of the patients was six to 16 years. Six patients required admission, and all were related to head and/or abdominal trauma. The special characteristics of the sled, the environment, and the rider work in concert to produce injuries. The injury is most likely to occur under cold, icy conditions. After analysis of this series of patients, it is concluded that downhill sledding injuries can be minimized. The factors that make this activity dangerous are defined, and safety precautions are suggested.