Joan Bothner

A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitis.

OBJECTIVE. Hypoxia is a common reason for hospital admission in infants and children with acute bronchiolitis. No study has evaluated discharge from the emergency department (ED) on home oxygen. This study evaluated the feasibility and safety of ED discharge on home oxygen in the treatment of acute bronchiolitis. METHODS. This was a prospective, randomized trial of infants and children with acute bronchiolitis and hypoxia (room-air saturations of ≤87%) aged 2 to 24 months presenting to an urban, academic, tertiary care childrens hospital ED from December 1998 to April 2001. Subjects received inpatient admission or home oxygen after an 8-hour observation period in the ED. We measured the failure to meet discharge criteria during the observation period, return for hospital admission, and incidence of serious complications. RESULTS. Ninety-two patients were enrolled. Fifty three (58%) were randomly assigned to home and 39 (42%) to inpatient admission. There were no differences between the groups in age, initial room-air saturation, and respiratory distress severity score. Of 53 patients, 37 (70%) randomly assigned to home oxygen completed the observation period and were discharged from the hospital. The remaining 16 patients were excluded from the study (6), resolved their oxygen requirement (5), or failed to meet the discharge criteria and were admitted (5). One discharged patient (2.7%) returned to the hospital and was admitted for a cyanotic spell at home after the 24-hour follow-up appointment. The patient had an uncomplicated hospital course with a length of stay of 45 hours. The remaining 36 patients (97%) were treated successfully as outpatients with home oxygen. Satisfaction with home oxygen was high from the caregiver and the primary care provider. CONCLUSIONS. Discharge from the ED on home oxygen after a period of observation is an option for patients with acute bronchiolitis. Secondary to the low incidence of complications, the safety of this practice will require a larger study.

Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids

Background. The serum electrolyte panel (SEP) is a frequently ordered laboratory test, but it has unproven usefulness in the treatment of dehydrated pediatric patients. Our study purpose was to evaluate the usefulness of routinely ordering a SEP in the treatment of dehydrated pediatric patients receiving intravenous fluids (IVFs). Methods. Children 2 months to 9 years of age who were receiving IVFs because of dehydration were prospectively studied in a pediatric emergency department (PED). Historical data, physical examination findings, degree of dehydration, and SEP results were recorded. After patient evaluation, attending physicians documented whether they would have ordered a SEP. Outcome measurements included changes in clinical management on the basis of SEP results, as well as correlations of dispositions and unscheduled return visits (URVs) with SEP results. Results. A total of 182 patients were enrolled in the study. One hundred eleven patients had mild dehydration, 55 moderate dehydration, and 16 severe dehydration. Eighty-eight patients (48%; 95% confidence interval: 41–56%) had ≥1 abnormal SEP value. Clinically relevant findings included bicarbonate levels of <16 mmol/L for 28% of patients, hypoglycemia for 9.9%, hypokalemia for 6.0%, and hypernatremia for 3.0%. The attending physicians predicted that a SEP would be clinically important for 34% of all patients. There was a 58% sensitivity in detecting which children would have clinically significant SEP results. Overall, SEP results changed clinical management in 10.4% of cases. One hundred sixty-five (91%) of the patients were discharged from the PED (including 48 who were initially observed), of whom 7 (3.8%) had URVs to the PED within 72 hours and were given additional IVFs. Seventeen patients were admitted (median: 2.6 days), 2 of whom had URVs after hospital discharge for additional IVFs. Conclusions. On the basis of initial presentation, attending physicians were poor at predicting which children would have clinically significant SEP results. Low bicarbonate values were correlated with observation unit use but not with hospitalization or URVs. The observation unit provided effective care for a subset of dehydrated patients, avoiding the need for hospitalization. Obtaining a SEP can provide useful information for the treatment of some children receiving IVFs because of dehydration.

Delivery of albuterol in a pediatric emergency department.

Study objective To determine if albuterol delivery by the combination of a metered-dose inhaler (MDI) with a spacer is equal in effectiveness to nebulization in a pediatric emergency department setting. Design Prospective series. Setting Urban childrens hospital emergency department. Participants Patients ≥six years of age with the diagnosis of acute asthma exacerbation. Exclusion criteria consisted of impending respiratory failure and corticosteroid administration within the preceding seven days. Interventions Patients were randomized into either the nebulizer treatment group or one of two MDI-spacer treatment groups (two spacers were evaluated). Each patient received three albuterol treatments administered evenly over one hour. The dose ratio for albuterol by nebulizer versus MDI-spacer was 6.9:1. Outcome was assessed by comparing the pre- and posttreatment percent predicted respiratory rate and percent predicted peak expiratory flow rate (PEFR) for each patient. Results Sixty patients were enrolled in the study. All three treatment groups showed significant improvement following albuterol therapy in both percent predicted respiratory rate and percent predicted PEFR. When comparing the three groups against each other in regard to outcome, no significant differences were found in improvement of percent predicted respiratory rate (P = 0.3258) or percent predicted PEFR (P = 0.9362). Conclusion In a pediatric emergency department setting, aerosolized albuterol delivered by MDI-spacer was equal in effectiveness to nebulization in the acute asthma management of children ≥six years of age.

History and radiographic findings associated with clinically suspected radial head subluxations

Objectives To determine: 1) physician practices regarding the use of radiographs for radial head subluxations (RHS), 2) the prevalence of missed fractures in children with a clinical diagnosis of RHS, 3) the relative risk of a fracture with a nonclassic history for mechanism of injury for RHS, and 4) radiographic findings associated with RHS that are difficult to reduce. Methods This study began with a physician survey that addressed the integration of radiographs into the management of RHS. We subsequently conducted a prospective randomized trial with a consecutive sampling of children less than 6 years of age who presented to one of 2 urban pediatric emergency departments and 2 suburban pediatric urgent care centers with a clinical diagnosis of RHS. After informed consent was obtained, reduction was undertaken with a maximum of four attempts (two by hyperpronation and two by supination/flexion), 15 minutes apart. Failure to reduce the RHS resulted in the procurement of a radiograph of the elbow. At the conclusion of the study, all radiographs were evaluated by a radiologist blinded to the diagnosis. Patients receiving radiographs were contacted 2 weeks after discharge for verification of the diagnosis. Results Eighty-four percent of 224 physicians returned completed surveys. Fifty-six percent reported using radiographs for failed reduction attempts. In the second phase of the study, 136 patients were enrolled prospectively: 127 were reduced successfully and 9 patients failed attempts at reduction. Of the nine patients receiving radiographs: four had fractures (prevalence of 2.9% with 95% confidence interval (CI) = 0.8–7.4), two had no radiographic findings and normal function on follow up, and three had isolated posterior fat pads on radiograph and normal function on follow-up. The relative risk of a fracture in children with a nonclassic history defined as any mechanism other than “pull” was 1.200 (95% CI = 0.441–3.264); the relative risk was 1.886 (95% CI = 0.680–5.231) when defining a nonclassic history as any mechanism other than “pull” or “fall.” Conclusions 1) Physicians tend to order radiographs for elbow injuries they initially perceive to be radial head subluxations when attempts at reduction fail. 2) In our study, fractures in children who presented with the classic flexed elbow/pronated wrist position were rare. 3) The relative risk of a fracture in children with a nonclassic history for mechanism of injury was not significant. 4) An isolated finding of a posterior fat pad in a child with RHS that is difficult to reduce was not associated with a fracture in our small sample of children with radiographic findings.

Deficits in EMTALA knowledge among pediatric physicians

Objective: All US hospitals that participate in Medicare and Medicaid are regulated by the Emergency Medical Treatment and Active Labor Act (EMTALA). The law was enacted to prevent hospitals from turning away patients with emergency medical conditions. The law imposes specific obligations on hospitals and their physicians, and provides severe penalties for violations. The objective of this study was to evaluate hospital-based pediatric physicians knowledge of these obligations and potential liabilities. Methods: A questionnaire was submitted to the active medical staff and pediatric subspecialty residents at a tertiary care pediatric hospital. The questionnaire collected demographic information and posed 12 questions, based on well-established EMTALA principles, which addressed specific EMTALA obligations and liabilities. Results: The questionnaire was returned by 123 of 332 (37%) potential participants. Twenty-four percent (n = 30) had never heard of EMTALA, 24% (n = 30) had only heard of the law, and 51% (n = 63) considered themselves generally familiar with EMTALA. No respondent correctly answered all 12 questions, and 13% (n = 16) answered all 12 questions incorrectly. The median score was 42%, with a range of 0% to 83% correct. Only 20% (n = 25) reported that they had ever received any EMTALA education. Prior EMTALA education was associated with a higher score (P = 0.001). Eighty percent (n = 98) expressed interest in attending a formal EMTALA education program. Conclusions: Physicians at this pediatric hospital were strikingly unaware of their EMTALA obligations and potential liabilities. A specific educational program regarding EMTALA should be provided to hospital-based pediatric physicians to improve compliance with the law and reduce potential liabilities.

Medical director dilemmas.

You have an attending physician who is very methodical in the care that he renders. He is compulsive and thorough, yet he sees patients much more slowly than the rest of your group. When asked about improving his productivity, the attending states that he feels compelled to take his time and repeat most of the history and physical examination, as the residency supervision guidelines dictate that he does that. The hospital is concerned because wait times and left-without-being-seen rates during this physician’s shift are always significantly higher than when other attendings work. The emergency department (ED) hospital administrator runs a laboratory query and notes that the average laboratory charge per patient seen is also

Do the Cerebrospinal Fluid (CSF) Glucose (GL) and Protein (PR) Values Aid Physicians (MDs) in Disposition or Treatment Decisions in the Emergency Department (ED)? 374

23 higher for this particular individual than for any other physician in your group. How do you handle the situation?

Utility of Serum Electrolytes in the Management of Dehydration 391

Do the Cerebrospinal Fluid (CSF) Glucose (GL) and Protein (PR) Values Aid Physicians (MDs) in Disposition or Treatment Decisions in the Emergency Department (ED)? 374

Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency department trial

Background: The serum electrolyte panel (SEP) is a frequently ordered laboratory test and of unproved utility in the management of dehydrated pediatric patients. Many clinicians believe that the bicarbonate level may be predictive of patient outcome. Our purpose is to study the incidence of SEP abnormalities and assess their role in management.Methods: Children between the ages of 2 months and 18.8 years receiving intravenous fluids for dehydration were prospectively studied. Historical data, physical examination findings, degree of dehydration and SEP were obtained. Attending physicians documented prior to knowing laboratory results whether they would have ordered a SEP. Outcome measures included changes of management based on SEP, disposition, and return visits within 48 hours. Results: 206 patients were entered with a median age of 19.2 months. 123 patients presented with mild (≤5%), 81 with moderate (6-10%) and 2 with severe dehydration (>10%). The incidence of SEP abnormalities was 46% for one or more abnormal values. 29% had BUN levels > 17mg/dl, 26% had bicarbonate levels 150mmol/L. Considering the 54 patients with bicarbonates <16mmol/L; 27 were discharged home, 22 were placed into observation and 5 were admitted. At 95% significance, bicarbonate was lower in those placed into the observation unit versus those discharged home. There was no correlation between low bicarbonate and admission rates or return visits. The attending thought a SEP was needed in 33% of the cases. Knowing the SEP did not change management in 91%. In 17 patients the SEP changed management; 5 with low glucose values received glucose sooner, 5 with low bicarbonate levels were observed longer, 3 with reassuring values were sent home sooner, and 2 with low potassium levels received potassium. There were 10 return visits requiring IV fluids within 48 hours, 8 (2 with bicarbonates <16) were admitted. Conclusion: Although there were a large number of SEP abnormalities, there was minimal effect on clinical management or patient outcome. Low bicarbonate levels were predictive of observation unit placement but not for need of hospitalization or patient return visits.