Karen A. Santucci

Utility of bedside bladder ultrasound before urethral catheterization in young children.

Background. Urethral catheterization is the method of choice for obtaining samples for urine culture and urine analysis in infants. Before the procedure, there is little certainty of the presence or amount of urine in the bladder. Consequently, this relatively invasive and uncomfortable procedure often needs to be repeated. The newly available technology of portable ultrasound may be useful in reducing the number of unsuccessful procedures. Objective. To investigate the utility of bedside ultrasound of the bladder performed by pediatric emergency medicine physicians before catheterization in reducing the number of unsuccessful attempts. Methods. A prospective, 2-phase study was performed in the setting of an urban pediatric emergency department from August 2003 to February 2004. Children who were between the ages of 0 and 24 months were enrolled. During the observation phase, the amount of urine obtained during the first catheterization was recorded for each patient. During the intervention period, a rapid bedside ultrasound of the bladder was performed by a pediatric emergency medicine physician immediately before urethral catheterization. When a sufficient amount of urine was seen, catheterization was conducted as usual. Otherwise, catheterization was deferred and repeated ultrasound was performed at 30-minute intervals until sufficient urine was identified. The amount of urine obtained was recorded. Results. During the observation phase, 136 infants underwent urethral catheterization. Overall, the rate of success during the first attempt, defined as obtaining >2 mL of urine, sufficient for culture and other routine studies, was 72% (95% confidence interval: 66%–78%). A total of 112 subjects were enrolled during the intervention phase. Sufficient urine was identified on the first ultrasound in 76% (n = 85) of the patients. Among these, 98% (n = 83) underwent successful urethral catheterization during the first attempt. Among those in whom insufficient urine was identified initially (n = 27; 24%), subsequent ultrasound revealed sufficient amount in all patients within 90 minutes. Among these, 93% (n = 25) underwent successful urethral catheterization during the first attempt. Overall rate of success of initial urethral catheterization during the intervention phase was 96% (95% confidence interval: 93%–99%). Compared with the success rate during the observation phase, the differences were statistically significant. The results were consistent after being adjusted for gender. Conclusion. A rapid bedside ultrasound of the bladder performed by pediatric emergency physicians led to an increased success rate of urethral catheterization in children who were younger than 2 years. We were able to avoid repeated invasive testing with a simple noninvasive procedure.

Use of Bedside Ultrasound to Assess Degree of Dehydration in Children With Gastroenteritis

OBJECTIVES Prospectively identifying children with significant dehydration from gastroenteritis is difficult in acute care settings. Previous work by our group has shown that bedside ultrasound (US) measurement of the inferior vena cava (IVC) and the aorta (Ao) diameter ratio is correlated with intravascular volume. This study was designed to validate the use of this method in the prospective identification of children with dehydration by investigating whether the IVC/Ao ratio correlated with dehydration in children with acute gastroenteritis. Another objective was to investigate the interrater reliability of the IVC/Ao measurements. METHODS A prospective observational study was carried out in a pediatric emergency department (PED) between November 2007 and June 2009. Children with acute gastroenteritis were enrolled as subjects. A pair of investigators obtained transverse images of the IVC and Ao using bedside US. The ratio of IVC and Ao diameters (IVC/Ao) was calculated. Subjects were asked to return after resolution of symptoms. The difference between the convalescent weight and ill weight was used to calculate the degree of dehydration. Greater than or equal to 5% difference was judged to be significant. Linear regression was performed with dehydration as the dependent variable and the IVC/Ao as the independent variable. Pearsons correlation coefficient was calculated to assess the degree of agreement between observers. RESULTS A total of 112 subjects were enrolled. Seventy-one subjects (63%) completed follow-up. Twenty-eight subjects (39%) had significant dehydration. The linear regression model resulted in an R² value of 0.21 (p < 0.001) and a slope (B) of 0.11 (95% confidence interval [CI] = 0.08 to 0.14). An IVC/Ao cutoff of 0.8 produced a sensitivity of 86% and a specificity of 56% for the diagnosis of significant dehydration. Forty-eight paired measurements of IVC/Ao ratios were made. The Pearson correlation coefficient was 0.76. CONCLUSIONS   In this pilot study the ratio of IVC to Ao diameters, as measured by bedside US, was a marginally accurate measurement of acute weight loss in children with dehydration from gastroenteritis. The technique demonstrated good interrater reliability.

Positioning for Lumbar Puncture in Children Evaluated by Bedside Ultrasound

BACKGROUND: Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure. OBJECTIVE: To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound. METHODS: A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences. RESULTS: There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space (P < .05). Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions (P < .05). Flexion of the neck, did not significantly change the interspinous space (P = .998). CONCLUSIONS: The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.

Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine.

Objectives: Hypopneic hypoventilation, a decrease in tidal volume without a change in respiratory rate, is not easily detected by standard monitoring practices during sedation but can be detected by capnography. Our goal was to determine the frequency of hypopneic hypoventilation and its association with hypoxia in children undergoing sedation with ketamine. Methods: Children who received intravenous ketamine with or without midazolam for sedation in a pediatric emergency department were prospectively enrolled. Heart rate, respiratory rate, pulse oximetry, and end-tidal carbon dioxide (ETCO2) levels were recorded every 30 seconds. Results: Fifty-eight subjects were included in this study. Fifty percent of subjects had recorded ETCO2 values less than 30 mm Hg without a rise in respiratory rate. Twenty-eight percent of subjects experienced a decrease in pulse oximetry less than 95%. Patients who experienced a persistent decrease in ETCO2 at least 30 seconds in length were much more likely to have a persistent decrease in pulse oximetry than those with normal or transient decreases in ETCO2 (relative risk, 6.6; 95% confidence interval, 1.4-30.5). Decreases in ETcO2 occurred on an average of 3.7 minutes before decreases in pulse oximetry. Conclusions: Hypopneic hypoventilation as detected by capnography is common in children undergoing sedation with ketamine with or without midazolam. Hypoxia is frequently preceded by low ETCO2 levels. Further studies are needed to determine if the addition of routine monitoring with capnography can reduce the frequency of hypoxia in children undergoing sedation.

Acute isoniazid exposures and antidote availability.

BACKGROUND Over the past 10 years the reported incidence of acute isoniazid (INH)-related poisonings has increased, with 507 cases reported in 1996. Parenteral pyridoxine is the antidote for INH-induced seizures, but 5-g aliquot recommended to treat an ingestion of unknown quantity of INH is not always readily available to emergency physicians. OBJECTIVE To determine the hospital availability of pyridoxine. METHODS One hundred thirty questionnaires were distributed nationwide to the pharmacies and emergency departments (ED) of hospitals containing pediatric emergency medicine (PEM) fellowships and/or emergency medicine (EM) residencies. Questions were posed regarding the availability, quantity, location, and deemed importance of pyridoxine at each institution. RESULTS Responses were received from 81% of the hospitals with fellowships and 80% of the hospitals with residencies. Half of the former and one third of the latter reported not having the recommended 5-g aliquot available. Eighty percent of the hospitals with PEM programs and 71% with EM residencies with an adequate stock store it in the hospitals pharmacy, as opposed to in the ED. Thirty-four states were represented, 18 of which have experienced an increase in tuberculosis (TB) from 1993 to 1994; 6/18 (33%) of those did not have the pyridoxine available, and 7/18 (39%) did not deem it necessary. CONCLUSIONS Our results imply that between one third and one half of the respondents would be ill-equipped to treat acute INH neurotoxicity. Establishing regional distribution centers may alleviate this deficiency, specifically in urban areas with a high incidence or a positive percent increase in TB.

Pediatric Fatality Following Ingestion of Dinitrophenol: Postmortem Identification of a “Dietary Supplement”

Dinitrophenol, a chemical currently used as an insecticide, is known to uncouple mitochondrial oxidative phosphorylation. A component of explosives, it has also been used in the past as a food coloring and clothing dye. In the 1930s, physicians prescribed it for weight loss, but this practice was discontinued when reports of cataracts, deaths, and other adverse outcomes came to light. We describe in our report the overdose and fatality of a teenager who purchased the product as a weight loss dietary supplement by mail order. We also describe a laboratory method that allowed postmortem determination of the dinitrophenol concentration in the victims serum. Her death, despite prompt medical treatment, underscores the danger of dinitrophenol. The easy accessibility and apparent resurgent interest in dinitrophenol as a weight loss agent is extremely timely and troubling.

A randomized trial to assess the efficacy of point-of-care testing in decreasing length of stay in a pediatric emergency department.

Objectives: To compare the effect of point-of-care (POC) testing versus traditional laboratory methods on length of stay in a pediatric emergency department (ED). Methods: This study was a prospective, randomized, controlled trial of patients solely requiring blood work that a POC device was capable of performing. Two hundred twenty-five patients presenting to a tertiary hospital ED in an urban setting enrolled after informed consent. Of all patients studied, 114 were randomized to the POC group, 111 to routine laboratory analysis. Exact times of critical phases of management and patient flow were recorded by dedicated research assistants. Medical management decisions were made at the discretion of the supervising physicians. Results: Similar waiting periods were noted in both groups for time spent in the waiting room, time waiting for first physician contact, and time waiting for blood draw. Significantly less time was required for results to become available to physicians when POC testing was used (65.0 minutes; P < 0.001). Significant decrease in overall length of stay was also noted, with patients randomized to the POC group spending an average of 38.5 minutes (P < 0.001) less time in the ED. Conclusions: Point-of-care testing can significantly decrease the length of stay in select pediatric patients in an ED setting. Point-of-care devices may prove to facilitate patient flow during busiest periods of service demand.

In situ pediatric trauma simulation: assessing the impact and feasibility of an interdisciplinary pediatric in situ trauma care quality improvement simulation program.

Objective This study aimed to evaluate the feasibility and measure the impact of an in situ interdisciplinary pediatric trauma quality improvement simulation program. Methods Twenty-two monthly simulations were conducted in a tertiary care pediatric emergency department with the aim of improving the quality of pediatric trauma (February 2010 to November 2012). Each session included 20 minutes of simulated patient care, followed by 30 minutes of debriefing that focused on teamwork, communication, and the identification of gaps in care. A single rater scored the performance of the team in real time using a validated assessment instrument for 6 subcomponents of care (teamwork, airway, intubation, breathing, circulation, and disability). Participants completed a survey and written feedback forms. Results A trend analysis of the 22 simulations found statistically significant positive trends for overall performance, teamwork, and intubation subcomponents; the strength of the upward trend was the strongest for the teamwork (&tgr; = 0.512), followed by overall performance (&tgr; = 0.488) and intubation (&tgr; = 0.433). Two hundred fifty-one of 398 participants completed the participant feedback form (response rate, 63%), reporting that debriefing was the most valuable aspect of the simulation. Conclusions An in situ interdisciplinary pediatric trauma simulation quality improvement program resulted in improved validated trauma simulation assessment scores for overall performance, teamwork, and intubation. Participants reported high levels of satisfaction with the program, and debriefing was reported as the most valuable component of the program.

A Randomized Controlled Trial of Capnography in the Correction of Simulated Endotracheal Tube Dislodgement

OBJECTIVES Unrecognized dislodgement of an endotracheal tube (ETT) during the transport of an intubated patient can have life-threatening consequences. Standard methods to monitor these patients, such as pulse oximetry and physical examination, are both subject to inaccuracies with patient movement and ambient noise. Capnography provides a continuous and objective measure of ventilation that can alert a provider immediately to an airway problem. The objective of this study was to determine through simulation if capnography decreases time to correction of dislodged ETTs during the transport of intubated patients, in comparison to standard monitoring. METHODS Paramedics and paramedic students were randomized as to whether or not they had capnography available to them in addition to standard monitoring during a simulated scenario. In the scenario, subjects monitored an intubated baby who subsequently experiences a dislodgement of the ETT during interfacility transport. Time to correction of the ETT dislodgement was the primary outcome. The secondary outcome was correction of dislodgement prior to decline in pulse oximetry. RESULTS Fifty-three subjects were enrolled in the study, with complete data on 50 subjects. Median time to correction of ETT dislodgement was 2.02 minutes (95% confidence interval [CI] = 1.22 to 4.12 minutes) for the capnography group versus 4.00 minutes (95% CI = 3.35 to 5.50 minutes) in the standard monitoring group (p = 0.05). Forty-eight percent of subjects using capnography corrected the ETT dislodgement prior to decline in pulse oximetry compared with 12% of controls (p = 0.01). There were no differences in time to correction of dislodgement based on years of experience, perceived comfort, reported adequacy of teaching, or past use of capnography. CONCLUSIONS The addition of capnography to standard monitoring significantly improves recognition of ETT dislodgement and reduces the time to correction of dislodged ETTs by prehospital providers in a simulated pediatric transport setting.

Advances in clinical forensic medicine.

Clinical forensic medicine is the branch of medicine that deals specifically with cases involving both legal and medical aspects of patient care. A forensic evaluation refers to the detection, collection, and preservation of evidence. Pattern injury recognition, interpretation of injuries, documentation of testimonial and injuries (including photography), reporting requirements, and regulations are all vital components of a forensic evaluation, but are rarely the topic of discussion in training hospitals. Medical professionals working in prehospital care and acute care settings are likely to encounter perplexing forensic issues related to child abuse, sexual assault, or unexpected childhood death in their practice. This article focuses on the most recent insights related to sexual assault and forensic evidence as it relates to successful prosecution, shaken baby syndrome, and pediatric nonaccidental thermal injury. Also reviewed are the most current publications related to clinical forensic medicine for the year 2002, incorporating practical clinical tips from the most informative articles from the past decade.