Jeffrey R. Avner

Outpatient management without antibiotics of fever in selected infants

Background In many academic centers it is standard practice to hospitalize all febrile infants younger than two months of age, whereas in community settings such infants are often cared for as outpatients. Methods We conducted a controlled study of 747 consecutive infants 29 through 56 days of age who had temperatures of at least 38.2 °C. After a complete history taking, physical examination, and sepsis workup, the 460 infants with laboratory or clinical findings suggestive of serious bacterial illness were hospitalized and treated with antibiotics. The screening criteria for serious bacterial illness included a white-cell count of at least 15,000 per cubic millimeter, a spun urine specimen that had 10 or more white cells per high-power field or that was positive on bright-field microscopy, cerebrospinal fluid with a white-cell count of 8 or more per cubic millimeter or a positive Grams stain, or a chest film showing an infiltrate. The 287 infants who had unremarkable examinations and normal laboratory r...

A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children.

To evaluate the relative utility of clinical and laboratory parameters of dehydration in children for predicting the magnitude of percent loss of body weight (PLBW), we studied 97 children who required intravenous fluids for acute dehydration. After a complete history and physical examination, the managing physician made a clinical estimation of dehydration for each child, based on a standard clinical scale. Serum electrolytes were obtained in all children prior to intravenous hydration therapy. PLBW was calculated after recovery from acute dehydration by comparing the weight on presentation to the emergency department with the weight measured at a follow- up visit when the child was judged well. Children were classified according to PLBW into three groups which reflect the categories in a standard clinical scale: mild=PLBW ≤ 5 (n=50), moderate=PLBW 6-10 (n=30), and severe=PLBW > 10 (n=17). The physicians clinical estimate of dehydration compared to PLBW had a sensitivity of 74% (95% confidence interval (CI): 60-85) for mild dehydration, 33% (95% CI: 17-53) for moderate dehydration, and 70% (95% CI: 44-89) for severe dehydration. There was a significant difference in the mean serum bicarbonate concentrations (HCO3) between the PLBW groups (P < 0.01). The sensitivity of the HCO3 < 17 mEq/L in predicting PLBW was 77% (95% CI: 58-90) for PLBW 6-10, and 94% (95% CI: 71-100) for PLBW > 10. The combination of the clinical scale and the serum bicarbonate identified all 17 children with PLBW > 10 and 90% (27 of 30) children with PLBW 6-10. Our data suggest that physicians should not rely solely on clinical assessment to rule out severe dehydration in children, and that obtaining a serum bicarbonate may improve the accuracy of predicting serious dehydration.

The Preparedness of Schools to Respond to Emergencies in Children: A National Survey of School Nurses

Objectives. Because children spend a significant proportion of their day in school, pediatric emergencies such as the exacerbation of medical conditions, behavioral crises, and accidental/intentional injuries are likely to occur. Recently, both the American Academy of Pediatrics and the American Heart Association have published guidelines stressing the need for school leaders to establish emergency-response plans to deal with life-threatening medical emergencies in children. The goals include developing an efficient and effective campus-wide communication system for each school with local emergency medical services (EMS); establishing and practicing a medical emergency-response plan (MERP) involving school nurses, physicians, athletic trainers, and the EMS system; identifying students at risk for life-threatening emergencies and ensuring the presence of individual emergency care plans; training staff and students in first aid and cardiopulmonary resuscitation (CPR); equipping the school for potential life-threatening emergencies; and implementing lay rescuer automated external defibrillator (AED) programs. The objective of this study was to use published guidelines by the American Academy of Pediatrics and the American Heart Association to examine the preparedness of schools to respond to pediatric emergencies, including those involving children with special care needs, and potential mass disasters. Methods. A 2-part questionnaire was mailed to 1000 randomly selected members of the National Association of School Nurses. The first part included 20 questions focusing on: (1) the clinical background of the school nurse (highest level of education, years practicing as a school health provider, CPR training); (2) demographic features of the school (student attendance, grades represented, inner-city or rural/suburban setting, private or public funding, presence of children with special needs); (3) self-reported frequency of medical and psychiatric emergencies (most common reported school emergencies encountered over the past school year, weekly number of visits to school nurses, annual number of “life-threatening” emergencies requiring activation of EMS); and (4) the preparedness of schools to manage life-threatening emergencies (presence of an MERP, presence of emergency care plans for asthmatics, diabetics, and children with special needs, presence of a school nurse during all school hours, CPR training of staff and students, availability of athletic trainers during all athletic events, presence of an MERP for potential mass disasters). The second part included 10 clinical scenarios measuring the availability of emergency equipment and the confidence level of the school nurse to manage potential life-threatening emergencies. Results. Of the 675 questionnaires returned, 573 were eligible for analysis. A majority of responses were from registered nurses who have been practicing for >5 years in a rural or suburban setting. The most common reported school emergencies were extremity sprains and shortness of breath. Sixty-eight percent (391 of 573 [95% confidence interval (CI): 64–72%]) of school nurses have managed a life-threatening emergency requiring EMS activation during the past school year. Eighty-six percent (95% CI: 84–90%) of schools have an MERP, although 35% (95% CI: 31–39%) of schools do not practice the plan. Thirteen percent (95% CI: 10–16%) of schools do not identify authorized personnel to make emergency medical decisions. When stratified by mean student attendance, school setting, and funding classification, schools with and without an MERP did not differ significantly. Of the 205 schools that do not have a school nurse present on campus during all school hours, 17% (95% CI: 12–23%) do not have an MERP, 17% (95% CI: 12–23%) do not identify an authorized person to make medical decisions when faced with a life-threatening emergency, and 72% (95% CI: 65–78%) do not have an effective campus-wide communication system. CPR training is offered to 76% (95% CI: 70–81%) of the teachers, 68% (95% CI: 61–74%) of the administrative staff, and 28% (95% CI: 22–35%) of the students. School nurses reported the availability of a bronchodilator meter-dosed inhaler (78% [95% CI: 74–81%]), AED (32% [95% CI: 28–36%]), and epinephrine autoinjector (76% [95% CI: 68–79%]) in their school. When stratified by inner-city and rural/suburban school setting, the availability of emergency equipment did not differ significantly except for the availability of an oxygen source, which was higher in rural/suburban schools (15% vs 5%). School-nurse responders self-reported more confidence in managing respiratory distress, airway obstruction, profuse bleeding/extremity fracture, anaphylaxis, and shock in a diabetic child and comparatively less confidence in managing cardiac arrest, overdose, seizure, heat illness, and head injury. When analyzing schools with at least 1 child with special care needs, 90% (95% CI: 86–93%) have an MERP, 64% (95% CI: 58–69%) have a nurse available during all school hours, and 32% (95% CI: 27–38%) have an efficient and effective campus-wide communication system linked with EMS. There are no identified authorized personnel to make medical decisions when the school nurse is not present on campus in 12% (95% CI: 9–16%) of the schools with children with special care needs. When analyzing the confidence level of school nurses to respond to common potential life-threatening emergencies in children with special care needs, 67% (95% CI: 61–72%) of school nurses felt confident in managing seizures, 88% (95% CI: 84–91%) felt confident in managing respiratory distress, and 83% (95% CI: 78–87%) felt confident in managing airway obstruction. School nurses reported having the following emergency equipment available in the event of an emergency in a child with special care needs: glucose source (94% [95% CI: 91–96%]), bronchodilator (79% [95% CI: 74–83%]), suction (22% [95% CI: 18–27%]), bag-valve-mask device (16% [95% CI: 12–21%]), and oxygen (12% [95% CI: 9–16%]). An MERP designed specifically for potential mass disasters was present in 418 (74%) of 573 schools (95% CI: 70–77%). When stratified by mean student attendance, school setting, and funding classification, schools with and without an MERP for mass disasters did not differ significantly. Conclusions. Although schools are in compliance with many of the recommendations for emergency preparedness, specific areas for improvement include practicing the MERP several times per year, linking all areas of the school directly with EMS, identifying authorized personnel to make emergency medical decisions, and increasing the availability of AED in schools. Efforts should be made to increase the education of school nurses in the assessment and management of life-threatening emergencies for which they have less confidence, particularly cardiac arrest, overdose, seizures, heat illness, and head injury.

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 cluster of children with seizures caused by camphor poisoning.

BACKGROUND. Isolated cases of camphor-induced seizures have been reported in young children after gastrointestinal, dermal, and inhalation exposure. In 1982, after a series of unintentional ingestions of camphor products, the US Food and Drug Administration restricted the camphor content to <11% in some products intended for medicinal use. Camphor products intended for use as pesticides must be registered with the US Environmental Protection Agency. Still, many imported camphor-containing products fail to meet Food and Drug Administration and Environmental Protection Agency requirements for labeling and content. OBJECTIVE. To describe a cluster of cases of camphor-associated seizure activity resulting from the availability of imported camphor products in certain ethnic populations that use it as a natural remedy. METHODS. We present 3 cases of seizures associated with imported, illegally sold camphor in young children who presented to a large, urban childrens hospital in Bronx, New York, during a 2-week period. RESULTS. The childrens ages ranged from 15 to 36 months. Two children ingested camphor, and 1 child was exposed through repetitive rubbing of camphor on her skin. All 3 patients required pharmacologic intervention to terminate the seizures. One patient required bag-valve-mask ventilation for transient respiratory depression. All 3 patients had leukocytosis, and 2 patients had hyperglycemia. Exposure occurred as a result of using camphor for spiritual purposes, cold remedy, or pest control. After identification of these cases, the New York City Department of Health released a public health warning to keep camphor products away from children. Similar warnings were issued later by other state health departments. CONCLUSIONS. These cases highlight the toxicity associated with camphor usage in the community and that inappropriate use of illegally sold camphor products is an important public health issue. Camphor may be a common, yet unrecognized, source of seizures in children in certain ethnic populations that use it as a natural remedy. Efforts are needed to educate the communities about the hazards of using camphor products and to limit the illegal availability of these products.

Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children

Objectives Previous studies demonstrated that the collapsibility index (percent decrease in inferior vena cava [IVC] diameter with inspiration) of 50% or greater and an IVC/aorta ratio of 0.8 or less correlated with a low intravascular volume. Our study sought to determine if bedside ultrasound (BUS) measurements of the IVC diameter correlate with central venous pressure (CVP) measurements as an indicator of intravascular volume status in acutely ill children. Methods A convenience sample of children younger than 21 years who were admitted to the pediatric critical care unit and required CVP monitoring had BUS measurements of both IVC and aortic diameters with simultaneous CVP measurement. The collapsibility index (sagittal view) and IVC/aorta ratio (transverse view) were calculated from these measurements. A CVP of 8 mm Hg or less was considered as a marker for decreased intravascular volume. Results Of the 51 participants, 21 (43%) had a CVP of 8 mm Hg or less. Eight (16%) of 51 children had a collapsibility index 50% or greater, and 8 (18%) of 43 had an IVC/aorta ratio of 0.8 or less. The sensitivity of a collapsibility index 0.5 or greater to predict a CVP of 8 mm Hg or less was 14%, the specificity was 83%, the positive predictive value was 38%, and the negative predictive value was 57%. Neither collapsibility index (r = −0.23, P = 0.11) nor IVC/aorta (r = −0.19, P = 0.22) correlated with CVP in assessing intravascular volume in our study population. Conclusions Based on these data, the IVC and aortic measurements by BUS are not reliable indicators of intravascular volume (as determined by CVP) in acutely ill children.

Altered Mental Status

Abstract Altered mental status is a sign of serious neurologic or systemic disease. The physician must rapidly assess the depth of coma and risk of intracranial hypertension, then determine the etiology and prescribe appropriate management. This is no small task, considering the variety and multitude of illnesses that may present with altered mental status. The etiologies can be broken down into structural and medical causes. The structural causes more frequently affect the brainstem centers adjacent to the ascending reticular activating system that are responsible for pupillary response and oculocephalic reflexes. Medical causes generally spare these structures. Management of structural lesions requires prompt diagnosis and neurosurgical input. Medical etiologies are protean and treatment is often supportive.

Follow-up of patients with occult bacteremia in pediatric emergency departments

Blood cultures are frequently obtained in pediatric emergency departments (EDs) from febrile young children at risk for bacteremia and subsequent development of serious bacterial infections. This study of 105 children with occult bacteremia treated in two large urban pediatric EDs describes the follow-up of these patients and the impact that positive blood culture results have on the detection of serious illness. Seventy-seven percent of patients had a follow-up visit in the ED, 8% had follow-up by telephone alone, and 15% were not contacted. Of the patients who returned to the ED, 49% did so because they were notified of the positive blood culture result. The mean time interval for these patients from registration at the initial visit to report of positive blood culture result was 30.0 hours and, from registration at the initial visit to follow-up visit, was 42.7 hours. Thirty-seven percent of those who returned did so because a follow-up visit was scheduled at the initial encounter, and 13% returned because of persistent illness. Ten children (9.6%), five of whom had been notified of the positive blood culture, returned with serious illnesses. Patients whose diagnosis of serious illness was facilitated by blood culture results had shorter delay in identifying cultures as positive than did patients notified of positive results who did not develop serious illness (16.2 vs 31.6 hours; P < 0.05). The delay in follow-up of children with occult bacteremia limits the usefulness of blood cultures in the early detection of serious illness. In our study, most of the delay was attributable to the time it took for cultures to be identified as positive. Techniques that speed the identification of positive blood cultures will be beneficial to outpatients with bacteremia. Although patients usually return promptly after being contacted, many patients with occult bacteremia were not reached. EDs must ensure that children at risk for the complications of bacteremia have prompt follow-up.