Jennifer A. Oman

Performance of a Decision Rule to Predict Need for Computed Tomography Among Children With Blunt Head Trauma

OBJECTIVE. To assess the ability of the NEXUS II head trauma decision instrument to identify patients with clinically important intracranial injury (ICI) from among children with blunt head trauma. METHODS. An analysis was conducted of the pediatric cohort involved in the derivation set of National Emergency X-Radiography Utilization Study II (NEXUS II), a prospective, observational, multicenter study of all patients who had blunt head trauma and underwent cranial computed tomography (CT) imaging at 1 of 21 emergency departments. We determined the test performance characteristics of the 8-variable NEXUS II decision instrument, derived from the entire NEXUS II cohort, in the pediatric cohort (0–18 years of age), as well as in the very young children (<3 years). Clinically important ICI was defined as ICI that required neurosurgical intervention (craniotomy, intracranial pressure monitoring, or mechanical ventilation) or was likely to be associated with significant long-term neurologic impairment. RESULTS. NEXUS II enrolled 1666 children, 138 (8.3%) of whom had clinically important ICI. The decision instrument correctly identified 136 of the 138 cases and classified 230 as low risk. A total of 309 children were younger than 3 years, among whom 25 had ICI. The decision instrument identified all 25 cases of clinically important ICI in this subgroup. CONCLUSIONS. The decision instrument derived in the large NEXUS II cohort performed with similarly high sensitivity among the subgroup of children who were included in this study. Clinically important ICI were rare in children who did not exhibit at least 1 of the NEXUS II risk criteria.

The worsening of ED on-call coverage in California: 6-year trend

To reassess problems with on-call physician coverage in California, we repeated our anonymous 2000 survey of the California chapter of the American College of Emergency Physicians. Physicians responded from 77.4% of California emergency departments (EDs), 51.0% of ED directors, and 34% of those surveyed. Of 21 specialties, on-call availability worsened since 2000 for 9, was unchanged for 11, and improved for 1. Of ED directors, 54% report medical staff rules require on-call duty, down from 72% in 2000. Hospitals have increased specialist on-call payments (from 21% to 35%, with 75% paying at least one specialty). Most emergency physicians (80.3%) report insurance status negatively affects on-call physician responsiveness, up from 42% in 2000. Emergency departments with predominantely minority or uninsured patients had fewer specialists and more trouble accessing them. Insurance status has a major negative effect on ED consultation and follow-up care. The on-call situation in California has worsened substantially in 6 years.

Stevens-Johnson Syndrome after Mycoplasma pneumoniae Infection

An 11-year-old boy presented to the Emergency Department complaining of a rash over his extremities and cold sores on the lips and inside the mouth. His mother stated that about 10 days prior, the patient developed a cough and mild nasal congestion. He was given a “cough medicine” from Mexico with no improvement of symptoms. He subsequently developed a fever as high as 38.4°C (101°F), which resolved after a couple of days and did not return. The patient went on to develop swollen eyelids, eye discharge, and swollen and hemorrhagic lips that crusted with black eschars (Figure 1). The patient’s buccal mucosa and gingivae were swollen and erythematous, and later became covered with whitish plaques. He had no history of cold sores or herpetic-type lesions. After the development of eye and oral symptoms, a rash erupted on the palms, soles of the feet, back, and scattered throughout the extremities (Figures 2, 3, 4). His mother described the skin lesions as appearing as pink, fluid-filled blisters initially, then progressively became darker and flatter. The patient reported that the oral lesions and skin rash were painful, and he could not tolerate oral intake. During this period, the patient was seen by multiple physicians and given prescriptions for nystatin, acyclovir, ampicillin, gentamicin eye drops, and naprosyn. He also received an intramuscular antibiotic shot of unknown type. However, both the patient and

Prospective correlation of arterial vs venous blood gas measurements in trauma patients.

OBJECTIVE The objective of this study is to assess if venous blood gas (VBG) results (pH and base excess [BE]) are numerically similar to arterial blood gas (ABG) in acutely ill trauma patients. METHODS We prospectively correlated paired ABG and VBG results (pH and BE) in adult trauma patients when ABG was clinically indicated. A priori consensus threshold of clinical equivalence was set at ± less than 0.05 pH units and ± less than 2 BE units. We hypothesized that ABG results could be predicted by VBG results using a regression equation, derived from 173 patients, and validated on 173 separate patients. RESULTS We analyzed 346 patients and found mean arterial pH of 7.39 and mean venous pH of 7.35 in the derivation set. Seventy-two percent of the paired sample pH values fell within the predefined consensus equivalence threshold of ± less than 0.05 pH units, whereas the 95% limits of agreement (LOAs) were twice as wide, at -0.10 to 0.11 pH units. Mean arterial BE was -2.2 and venous BE was -1.9. Eighty percent of the paired BE values fell within the predefined ± less than 2 BE units, whereas the 95% LOA were again more than twice as wide, at -4.4 to 3.9 BE units. Correlations between ABG and VBG were strong, at r(2) = 0.70 for pH and 0.75 for BE. CONCLUSION Although VBG results do correlate well with ABG results, only 72% to 80% of paired samples are clinically equivalent, and the 95% LOAs are unacceptably wide. Therefore, ABG samples should be obtained in acutely ill trauma patients if accurate acid-base status is required.