John M. Loiselle

Forensic Evidence Findings in Prepubertal Victims of Sexual Assault

Objective. The American Academy of Pediatrics recommends forensic evidence collection when sexual abuse has occurred within 72 hours, or when there is bleeding or acute injury. It is not known whether these recommendations are appropriate for prepubertal children, because few data exist regarding the utility of forensic evidence collection in cases of child sexual assault. This study describes the epidemiology of forensic evidence findings in prepubertal victims of sexual assault. Methods. The medical records of 273 children <10 years old who were evaluated in hospital emergency departments in Philadelphia, Pennsylvania, and had forensic evidence processed by the Philadelphia Police Criminalistics Laboratory were retrospectively reviewed for history, physical examination findings, forensic evidence collection, and forensic results. Results. Some form of forensic evidence was identified in 24.9% of children, all of whom were examined within 44 hours of their assault. Over 90% of children with positive forensic evidence findings were seen within 24 hours of their assault. The majority of forensic evidence (64%) was found on clothing and linens, yet only 35% of children had clothing collected for analysis. After 24 hours, all evidence, with the exception of 1 pubic hair, was recovered from clothing or linens. No swabs taken from the childs body were positive for blood after 13 hours or sperm/semen after 9 hours. A minority of children (23%) had genital injuries. Genital injury and a history of ejaculation provided by the child were associated with an increased likelihood of identifying forensic evidence, but several children had forensic evidence found that was unanticipated by the childs history. Conclusions. The general guidelines for forensic evidence collection in cases of acute sexual assault are not well-suited for prepubertal victims. The decision to collect evidence is best made by the timing of the examination. Swabbing the childs body for evidence is unnecessary after 24 hours. Clothing and linens yield the majority of evidence and should be pursued vigorously for analysis.

Nebulized dexamethasone versus oral prednisone in the emergency treatment of asthmatic children

STUDY OBJECTIVE To compare nebulized dexamethasone with oral prednisone in the treatment of children with asthma. DESIGN A randomized, double-blind, double-placebo study. SETTING An urban pediatric emergency department. PARTICIPANTS Patients aged 1 to 17 years with acute asthma. INTERVENTIONS Patients with moderate asthma exacerbation received frequent aerosolized albuterol and either 1.5 mg/kg of nebulized dexamethasone or 2 mg/kg of oral prednisone. RESULTS A total of 111 children was evaluated; 21% of those treated with dexamethasone required hospitalization, compared with 31% of those treated with prednisone (P = .26). A significantly greater proportion of dexamethasone-treated children were discharged home within 2 hours (23% versus 7%, P = .02). In the dexamethasone group, 8% who received the drug by mouthpiece were hospitalized compared with 33% who received it by face mask (P = .06). Fewer children treated with dexamethasone vomited (0% versus 15%, P = .001) and fewer relapsed within 48 hours of ED discharge (0% versus 16%, P = .008). CONCLUSION Nebulized dexamethasone was as effective as oral prednisone in the ED treatment of moderately ill children with acute asthma and was associated with more rapid clinical improvement, more reliable drug delivery, and fewer relapses.

Cardiotoxic effects of astemizole overdose in children

Astemizole, a nonsedating antihistamine, caused a prolonged corrected QT interval, ventricular dysrhythmias, and atrioventricular heart block after overdose in five children. Cardiotoxic effects lasted an average of 2 1/2 days. Children poisoned with astemizole need emergent medical evaluation, a 12-lead electrocardiogram with calculation of the corrected QT interval, and continuous cardiac monitoring for 24 hours.

Substance abuse in adolescent trauma.

STUDY OBJECTIVE To determine if there is a significant prevalence of drug or alcohol use among adolescents evaluated for significant acute trauma. DESIGN A prospective, age-matched controlled study over a 20-month period. SETTING Urban pediatric emergency department in a Level I pediatric trauma center. PARTICIPANTS Patients between 13 and 19 years of age requiring admission to the trauma service following evaluation in a pediatric ED and an age-matched control group of asthmatic patients. RESULTS A total of 134 patients (mean age, 14.8 years) were admitted for trauma-related injuries, and 22 of 65 (34%) were positive for alcohol or drugs of abuse. The mean age of patients with a positive toxicology screen was 15.4 years. Most commonly detected drugs were alcohol (eight), benzodiazepines (eight), cocaine (five), and cannabinoids (four). The number of positive screens in the trauma group (22 of 65) was significantly higher than controls (one of 49) (P < .001). This remained statistically significant even when those trauma patients not screened were assumed to have a negative toxicology screen (22 of 134 versus one of 49) (P < .01). There was also a significantly higher number of positive toxicology screens among adolescents with an intentional versus unintentional mechanism of injury (21 of 71 versus one of 63) (P < .001). CONCLUSION A significant number of adolescents admitted to the hospital for trauma-related injuries have a toxicology screen positive for alcohol or drugs of abuse. A toxicology screen should be a standard laboratory test in adolescents involved in significant trauma, especially if the mechanism was intentional.

Emergency Severity Index version 4: a valid and reliable tool in pediatric emergency department triage.

Objectives The Emergency Severity Index version 4 (ESI v.4) is the most recently implemented 5-level triage system. The validity and reliability of this triage tool in the pediatric population have not been extensively established. The goals of this study were to assess the validity of ESI v.4 in predicting hospital admission, emergency department (ED) length of stay (LOS), and number of resources utilized, as well as its reliability in a prospective cohort of pediatric patients. Methods The first arm of the study was a retrospective chart review of 780 pediatric patients presenting to a pediatric ED to determine the validity of ESI v.4. Abstracted data included acuity level assigned by the triage nurse using ESI v.4 algorithm, disposition (admission vs discharge), LOS, and number of resources utilized in the ED. To analyze the validity of ESI v.4, patients were divided into 2 groups for comparison: higher-acuity patients (ESI levels 1, 2, and 3) and lower-acuity patients (ESI levels 4 and 5). Pearson &khgr;2 analysis was performed for categorical variables. For continuous variables, we conducted a comparison of means based on parametric distribution of variables. The second arm was a prospective cohort study to determine the interrater reliability of ESI v.4 among and between pediatric triage (PT) nurses and pediatric emergency medicine (PEM) physicians. Three raters (2 PT nurses and 1 PEM physician) independently assigned triage scores to 100 patients; k and interclass correlation coefficient were calculated among PT nurses and between the primary PT nurses and physicians. Results In the validity arm, the distribution of ESI score levels among the 780 cases are as follows: ESI 1: 2 (0.25%); ESI 2: 73 (9.4%); ESI 3: 289 (37%); ESI 4: 251 (32%); and ESI 5: 165 (21%). Hospital admission rates by ESI level were 1: 100%, 2: 42%, 3: 14.9%, 4: 1.2%, and 5: 0.6%. The admission rate of the higher-acuity group (76/364, 21%) was significantly greater than the lower-acuity group (4/415, 0.96%), P < 0.001. The mean ED LOS (in minutes) for the higher-acuity group was 257 (SD, 132) versus 143 (SD, 81) in the lower-acuity group, P < 0.001. The higher-acuity group also had significantly greater use of resources than the lower-acuity group, P < 0.001. The percentage of low-acuity patients receiving no resources was 54%, compared with only 26% in the higher-acuity group. Conversely, a greater percentage of higher-acuity patients utilized 2 or more resources than the lower-acuity cohorts, 43% vs 12%, respectively, P < 0.001. In the prospective reliability arm of the study, 15 PT nurses and 8 PEM attending physicians participated in the study; k among nurses was 0.92 and between the primary triage nurses and physicians was 0.78, P < 0.001. The intraclass correlation coefficient was 0.96 for PT nurses and 0.91 between the primary triage nurse and physicians, P < 0.001. Conclusions Emergency Severity Index v.4 is a valid predictor of hospital admission, ED LOS, and resource utilization in the pediatric ED population. It is a reliable pediatric triage instrument with high agreement among PT nurses and between PT nurses and PEM physicians.

The Emergency Severity Index Version 4: reliability in pediatric patients.

Objectives: The Emergency Severity Index version 4 (ESI v.4) is a triage system, which demonstrates reliability in adult populations, however, it has not been extensively studied in pediatrics. The goal of this study was to measure interrater reliability and agreement rates within and between a group of pediatric emergency medicine physicians and pediatric triage (PT) nurses using ESI v.4 in a pediatric population. Methods: Pediatric emergency medicine physicians and PT nurses completed ESI v.4 training and a survey of 20 pediatric case scenarios, requiring them to assign a triage category to each case. Cases and standardized responses were adapted from the ESI v.4 training materials. Unweighted and weighted &kgr; was measured, and agreement rates for each group were compared with the standard response. Results: Sixteen physicians and 17 nurses completed the study. The group had a mean of 10.2 (±7.7) years experience in pediatrics. Nurses had a mean of 7.6 (±8.7) years experience in triage. Unweighted &kgr; for physicians and nurses was 0.68 and 0.67, respectively. Weighted &kgr; for physicians and nurses was 0.92 and 0.93, respectively. The agreement rate among physicians and nurses with the standardized responses to case scenarios was 83%. Conclusions: ESI v.4 is a reliable tool for triage assessments in pediatric patients when used by experienced pediatric emergency medicine physicians and PT nurses. It is a triage system with high agreement between physicians and nurses.

Inpatient reports of suspected child abuse or neglect (SCAN) : A question of missed opportunities in the acute care setting

OBJECTIVE To determine reasons inpatient reports of suspected child abuse or neglect (SCAN) were not initiated at the time of evaluation in the acute care setting. DESIGN Retrospective case series. SETTING Urban childrens hospital. PATIENTS Forty-four children with reports of SCAN filed as hospital inpatients between January 1 and December 31, 1993. INTERVENTIONS None. RESULTS Prior to admission, the 44 patients were evaluated in the following settings: pediatric emergency department (PED) (50%), general emergency department (GED) (30%), PED and GED (9%), and outpatient clinic (11%). Inpatient reports were more often for suspicion of neglect than for physical abuse, when compared to reports made in the ambulatory setting (P<0.001). In 23% of cases, the injury or illness necessitating admission was not related to the SCAN. Mean delay in filing a SCAN report following admission was 2.7 days (range 0-20 days). In 45% of cases, it was determined that inadequate information was available at the time of the acute visit to file a SCAN report. Compared with admissions from a PED, a higher percent of admissions from a GED had inpatient reports without additional findings after the acute care evaluation (P<0.05). Seventy-five percent of patients in whom no additional information was obtained during the admission required admission to an intensive care unit (ICU) setting. Forty-eight percent (21 of 44) of inpatient SCAN reports were determined substantiated following Child Protective Services (CPS) investigation. Forty-two percent (10 of 24) of those cases in which no additional information was uncovered following admission were determined substantiated. CONCLUSIONS Inpatient reports are often the result of additional findings obtained after admission. A higher percentage of admissions from a GED than from a PED had inpatient reports of SCAN without additional findings. Patients who have an inpatient report filed for SCAN are often of high medical acuity, less likely to have physical findings, and may present with injuries or illnesses unrelated to the SCAN.

Consistency Between Emergency Department and Orthopedic Physicians in the Diagnosis and Treatment of Distal Fibular Salter Harris I Fractures

Objective: The objective was to determine diagnostic and management differences between emergency physicians (EPs) and orthopedic physicians (OPs) for patients with distal fibular physis pain without radiographic fracture. Methods: Records from patients with emergency department ankle radiographs between January 2006 and March 2008 were reviewed. Inclusion criteria included trauma, fibular physis pain, normal radiographs, and orthopedic follow-up. Results: Of 1343 patients, 247 met criteria. Emergency physician diagnoses included Salter Harris (SH) I fracture 198 (80%), sprain 5 (2%), other fracture 24 (10%), or other injury 20 (8%). Orthopedic physician diagnoses included SH I fracture 136 (55%), sprain 48 (19%), other fracture 56 (23%), or other injury 7 (3%). Emergency physicians were more likely to diagnose SH I fracture (P = 0.01). Thirty-six patients diagnosed with SH I fracture by EPs were diagnosed by OPs with different fractures, whereas 40 had sprains and 5 had other injuries. A total of 173 (70%) patients were diagnosed with fractures by both EPs and OPs. On the basis of orthopedists diagnosis, EPs did not diagnose 19 (8%) fractures (P = 0.8). EP treatment included splint 157 (64%), boot 82 (33%), air cast 3 (1%), or cast 5 (2%). Orthopedic physicians treatment included splint 2 (1%), boot 46 (19%), air cast 11 (4%), cast 167 (67%), or none 21 (9%). Conclusions: Although EPs diagnosed SH I fracture more frequently than OPs, few fractures were missed. Most patients required ongoing immobilization by OPs regardless of final diagnosis. Suspected SH I fractures should be immobilized and referred for orthopedic evaluation.