Jay Pershad

Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient.

Objective. Echocardiography can be a rapid, noninvasive, objective tool in the assessment of ventricular function and preload during resuscitation of a critically ill or injured child. We sought to determine the accuracy of bedside limited echocardiography by the emergency physician (BLEEP) in estimation of (1) left ventricular function (LVF) and (2) inferior vena cava (IVC) volume, as an indirect measure of preload. Methods. We conducted a prospective observational study of a convenience sample of patients who were admitted to our intensive care unit. All patients underwent BLEEP followed by an independent formal echocardiogram by an experienced pediatric echocardiography provider (PEP). IVC volume was assessed by measurement of the maximal diameter of the IVC. LVF was determined by calculating shortening fraction (SF) using M-mode measurements on the parasternal short-axis view at the level of the papillary muscle. An independent blinded pediatric cardiologist reviewed all images for accuracy and quality. Estimates of SF obtained on the BLEEP examination were compared with those obtained by the PEP. Results. Thirty-one patients were enrolled. The mean age was 5.1 years (range: 23 days–16 years); 48.4% (15 of 31) were girls; 58.1% (18 of 31) were on mechanical ventilatory support at the time of their study. There was good agreement between the emergency physician (EP) and the PEP for estimation of SF (r = 0.78). The mean difference in the estimate of SF between the providers was 4.4% (95% confidence interval: 1.6%–7.2%). This difference in estimate of SF was statistically significant. Similarly, there was good agreement between the EP and the PEP for estimation of IVC volume (r = 0.8). The mean difference in the estimate of IVC diameter by the PEP and the EP was 0.068 mm (95% confidence interval: −0.16 to 0.025 mm). This difference was not statistically significant. Conclusions. Our study suggests that PEP sonographers are capable of obtaining images that permit accurate assessment of LVF and IVC volume. BLEEP can be performed with focused training and oversight by a pediatric cardiologist.

Chloral hydrate: the good and the bad.

Chloral hydrate (CH) is a widely used oral sedative hypnotic drug. Our Regional Poison Control Center frequently receives calls regarding unintentional and intentional chloral hydrate overdose. The chief manifestations of toxicity are due to central nervous system depressant action and its arrhythmogenic potential. After absorption, it is immediately converted to trichloroethanol (TCE), which is the active drug. Levels of TCE at which significant toxicity occurs have been variable. Ingestions of greater than 1.5 to 2.0 g of chloral hydrate have produced symptoms in children and adults. Management includes consideration of gastrointestinal decontamination, supportive care for altered mental status and treatment of arrhythmias. For routine use of chloral hydrate as sedation for pediatric procedures, the American Academy of Pediatrics (AAP) guidelines for sedation in children should be followed to decrease the likelihood of untoward complications.

Comparison of Propofol With Pentobarbital/Midazolam/Fentanyl Sedation for Magnetic Resonance Imaging of the Brain in Children

OBJECTIVE. Propofol and pentobarbital, alone or combined with other agents, are frequently used to induce deep sedation in children for MRI. However, we are unaware of a previous comparison of these 2 agents as part of a randomized, controlled trial. We compared the recovery time of children after deep sedation with single-agent propofol with a pentobarbital-based regimen for MRI and considered additional variables of safety and efficacy. METHODS. This prospective, randomized trial at a tertiary childrens hospital enrolled 60 patients 1 to 17 years old who required intravenous sedation for elective cranial MRI. Patients were assigned randomly to receive a loading dose of propofol followed by continuous intravenous infusion of propofol or to receive sequential doses of midazolam, pentobarbital, and fentanyl until a modified Ramsay score of >4 was attained. A nurse who was blind to group assignment assessed discharge readiness (Aldrete score > 8) and administered a follow-up questionnaire. We compared recovery time, time to induction of sedation, total sedation time, quality of imaging, number of repeat-image sequences, adverse events, caregiver satisfaction, and time to return to presedation functional status. RESULTS. The groups were similar in age, gender, race, American Society of Anesthesiology physical status class, and frequency of cognitive impairment. No sedation failure or significant adverse events were observed. Propofol offered significantly shorter sedation induction time, recovery time, total sedation time, and time to return to baseline functional status. Caregiver satisfaction scores were also significantly higher in the patients in the propofol group. CONCLUSIONS. Propofol permits faster onset and recovery than, and comparable efficacy to, a pentobarbital/midazolam/fentanyl regimen for sedation of children for MRI.

Pediatric elbow trauma.

Acute pediatric elbow trauma is commonly seen in the emergency department (ED). Reports confirm that, compared to other fractures, childrens elbow fractures are commonly misdiagnosed in the ED. In addition, missed orthopedic injuries are one of the leading causes of malpractice claims in emergency medicine. Radiologic diagnosis of these injuries is challenging, as a large portion of the pediatric elbow is composed of radiolucent cartilage. Knowledge of the normal anatomy and ossification centers around the elbow is essential for correct diagnosis. Acute neurovascular injury is frequently associated with these injuries, but is often difficult to assess in an apprehensive child. Immediate orthopedic consultation is indicated for any child with an elbow injury in whom neurologic or vascular compromise is suspected. Consultation should be strongly considered for children with displaced supracondylar fractures and/or significant echymosis and swelling about the cubital fossa.

7% Hypertonic Saline in Acute Bronchiolitis: A Randomized Controlled Trial

BACKGROUND: Research suggests that hypertonic saline (HS) may improve mucous flow in infants with acute bronchiolitis. Data suggest a trend favoring reduced length of hospital stay and improved pulmonary scores with increasing concentration of nebulized solution to 3% and 5% saline as compared with 0.9% saline mixed with epinephrine. To our knowledge, 7% HS has not been previously investigated. METHODS: We conducted a prospective, double-blind, randomized controlled trial in 101 infants presenting with moderate to severe acute bronchiolitis. Subjects received either 7% saline or 0.9% saline, both with epinephrine. Our primary outcome was a change in bronchiolitis severity score (BSS), obtained before and after treatment, and at the time of disposition from the emergency department (ED). Secondary outcomes measured were hospitalization rate, proportion of admitted patients discharged at 23 hours, and ED and inpatient length of stay. RESULTS: At baseline, study groups were similar in demographic and clinical characteristics. The decrease in mean BSS was not statistically significant between groups (2.6 vs 2.4 for HS and control groups, respectively). The difference between the groups in proportion of admitted patients (42% in HS versus 49% in normal saline), ED or inpatient length of stay, and proportion of admitted patients discharged at 23 hours was not statistically significant. CONCLUSIONS: In moderate to severe acute bronchiolitis, inhalation of 7% HS with epinephrine does not appear to confer any clinically significant decrease in BSS when compared with 0.9% saline with epinephrine.

Childhood hypoglycemia in an urban emergency department: epidemiology and a diagnostic approach to the problem.

Objective To 1) determine the prevalence of hypoglycemia in childhood in a pediatric emergency department (ED), 2) determine epidemiology of idiopathic ketotic hypoglycemia (IKH), 3) determine diagnostic yield of the workup of hypoglycemia, and 4) review a diagnostic approach to hypoglycemia. Setting Urban pediatric ED of a tertiary level childrens hospital Methods Retrospective review of all medical records with a primary or secondary diagnosis of hypoglycemia (ICD-9 code 251.2) seen at the ED between 1/92 and 8/95. Results Thirty-one patients were identified. Mean blood glucose was 34.2 mg/dl. Prevalence of hypoglycemia among population seeking care in our ED was 6.54/100,000 visits. Eighteen patients were diagnosed with IKH for a prevalence of 3.9/100,000. IKH demographics were: mean age 27.7 months; 12 males, 6 females; 8 white, 9 black, and 1 not available. The weights of five patients were < 25th percentile. Fourteen of the 18 IKH patients had hormone studies done insulin [cost

Does Lidocaine Gel Alleviate the Pain of Bladder Catheterization in Young Children? A Randomized, Controlled Trial

40], growth hormone [

Successful Implementation of a Radiology Sedation Service Staffed Exclusively by Pediatric Emergency Physicians

69], cortisol [

Axillary block for analgesia during manipulation of forearm fractures in the pediatric emergency department a prospective randomized comparative trial.

54]. All 14 had appropriately suppressed insulin levels (< μU/ml) and high cortisol levels > 22 μg/ml. Thirteen of the 14 had normal or high growth hormone (GH) levels (0.7–6 ng/ml). Four IKH patients had urine drug screens (

Early detection of cardiac disease masquerading as acute bronchospasm: The role of bedside limited echocardiography by the emergency physician.

280); all were negative. Although no IKH patient was febrile, six had sepsis workups (