Kathy W. Monroe

Anaphylaxis Management in the Pediatric Emergency Department: Opportunities for Improvement

Purpose: To determine the rate, immediate treatment, and outpatient management for anaphylaxis in patients receiving care in a pediatric emergency department (ED). Methods: This is a retrospective cross-sectional descriptive study of patients (21 years or younger) who received care for anaphylaxis for a 5-year period in the ED of the Childrens Hospital of Alabama in Birmingham, AL, which has an annual census of 55,000. The diagnostic criteria for anaphylaxis were symptoms and/or signs involving 2 or more organ systems (dermatologic, respiratory, gastrointestinal, and cardiovascular), hypotension for age, 1 organ system involvement with admission to the hospital, and/or dermatologic system involvement treated with intramuscular epinephrine. Results: There were 124 patient visits by 103 patients (4.5 events/10,000 ED patient visits) who met the diagnostic criteria for anaphylaxis. This included 114 (92%) patients who had involvement of two or more organ systems. There were 66 (64%) males and 33 (27%) patient visits that resulted in hospitalization. The most common organ system involvement was dermatologic in 121 (98%), followed by respiratory in 101 (81%), gastrointestinal in 33 (27%), and cardiovascular in 11 (9%). Medical interventions include 69 patients treated with intramuscular epinephrine (56%; either in pre-hospital setting and/or during ED visit), 97 patients treated with corticosteroids (79%), 114 patients treated with H1 and/or H2 antihistamine (93%), 15 patients treated with intravenous fluid bolus (12%), and 37 patients treated with albuterol nebulization (30%). Food was the most common inciting allergen (in 45 or 36% of patients). Among the foods that were listed as causing reactions were peanuts, shellfish, milk, ice cream, fruit, nuts, and fried chicken. Compared with ED care-only patients, the hospitalized patients had a significantly greater rate of cardiovascular system involvement and of receiving more ED interventions. Of 91 ED care-only patients, autoinjection epinephrine was prescribed to 63% and referral to an allergist was recommended to 33%. Patients treated with intramuscular epinephrine had a significantly greater rate of hospitalization and of receiving more ED interventions compared with patients who were not treated with epinephrine. There were no patient deaths. Conclusions: This study is the first to describe the management of anaphylaxis in a pediatric ED. The results revealed opportunities for improvement. Although our ED treatment and outpatient management of patients with anaphylaxis did not meet the recommended standards of care with regard to administration of intramuscular epinephrine, prescribing autoinjection epinephrine, or referral to an allergist for all patients who had a diagnosis of anaphylaxis, we do report a higher concordance with published recommendations than those reported in previous studies performed in adults.

Pediatric emergency department nurses' perspectives on fever in children.

BACKGROUND Fever is the most common complaint of children seen in a Pediatric Emergency Department (PED). Since pediatric emergency nurses commonly educate parents on fever management, this study sought to examine their knowledge base regarding fever in children. METHODS Through convenience sampling, pediatric emergency registered nurses working at one of four PEDs were surveyed using a self-administered questionnaire containing 10 open-ended questions pertaining to fever in children. RESULTS Eighty-eight pediatric emergency registered nurses (median experience 8.0 years, range 3 months to 28 years) were surveyed. The median temperature considered by pediatric emergency nurses to be a fever was 38.0 degrees C (100.4 degrees F) with a range of 37.2 degrees C (99.0 degrees F) to 38.9 degrees C (102.0 degrees F), while the median temperature considered to be dangerous to a child was 40.6 degrees C (105.0 degrees F) with a range of 38.0 degrees C (100.4 degrees F) to 41.8 degrees C (107.0 degrees F). Eleven percent was not sure what temperature constituted a fever while 31% was not sure what temperature would be dangerous to a child. Fifty-seven percent considered seizures the primary danger to a febrile child while 29% stated permanent brain injury or death could occur from a high fever. Sixty percent chose acetaminophen as first line treatment while 7% stated alcohol or tepid water baths were also acceptable treatment options. Thirty-eight percent stated that a different medication should be added if a child was still febrile 1 hour after initial treatment while 31% would not use additional medication. Eighteen percent stated it was dangerous for a child to leave the PED if still febrile. CONCLUSION Fever phobia and inconsistent treatment approaches occur among experienced pediatric emergency registered nurses. These phobias and inconsistencies subsequently could be conveyed to parents. In order to assure accurate parental education, PEDs should educate their medical team regarding the management of fever in children.

Acceptability of urine screening for Neisseria gonorrheae and Chlamydia trachomatis in adolescents at an urban emergency department.

Objective The objective of this study was to determine the acceptability of urine screening for Neisseria gonorrhoeae and Chlamydia trachomatis in adolescents in a pediatric emergency department. Study Design We used a prospective enrollment of adolescents aged 14–20 visiting an urban pediatric emergency department. Main Outcome Measures The main outcome measure was acceptance of urine STD screening rates. Results Of 1231 potential participants, 879 (71%) agreed to participate and 352 (29%) declined screening. Participants were similar to those refusing to participate in terms of gender. In multivariate analysis, age, race/ethnicity, and insurance status were associated with variation in sexually transmitted disease (STD) test acceptance, whereas the presence of a parent was not. Despite similar training, 1 of 3 recruiters had significantly lower acceptance rates than her peers. Overall, 10% of patients enrolled were found to have one or both infections. Conclusion Urine screening for STDs can be efficiently conducted in an emergency department setting. This screening appears to be acceptable to most patients.

Effect of ketorolac in pediatric sickle cell vaso-occlusive pain crisis.

BACKGROUND Ketorolac is a parenteral, nonsteroidal analgesic that does not have a narcotics risks of respiratory depression, hypotension, or dependence. Its usefulness in providing pain relief in pediatric patients with acute vaso-occlusive crisis of sickle cell disease has not been studied to date. METHODS Twenty-nine patients with sickle cell disease between the ages of 5 and 18 years who presented to The Childrens Hospital of Alabama emergency department (ED) with 41 distinct episodes of acute vaso-occlusive pain crisis were enrolled prospectively and randomized to receive either 0.9 mg/kg intravenous (IV) ketorolac or placebo in a double-blind fashion. All patients also received IV fluids and an initial 0.1 mg/kg of IV morphine. Subsequent standardized doses of morphine were given every 2 hours over a 6-hour observation period based upon severity of pain as scored by a 10-cm linear visual analog scale (VAS). Vital signs and pain severity were recorded initially and assessed hourly. Disposition was made at the end of the observation period. RESULTS Patients receiving ketorolac and those receiving placebo were of similar age, weight, gender, number of prior ED visits, number of prior hospital admissions, duration of pain prior to presentation, and initial pain score. The total dose of morphine received, reduction in severity of pain as measured by VAS, rate of hospital admission, and rate of return to the ED for discharged patients did not differ significantly between the two groups. CONCLUSION We were unable to demonstrate a synergistic analgesic effect for ketorolac in the treatment of pain from acute vaso-occlusive crisis in pediatric sickle cell disease. Further investigations involving larger samples of sickle cell patients may be needed to further define a role for ketorolac in the acute management of sickle cell vaso-occlusive pain.

Childhood hypoglycemia in an urban emergency department: epidemiology and a diagnostic approach to the problem.

Objective To 1) determine the prevalence of hypoglycemia in childhood in a pediatric emergency department (ED), 2) determine epidemiology of idiopathic ketotic hypoglycemia (IKH), 3) determine diagnostic yield of the workup of hypoglycemia, and 4) review a diagnostic approach to hypoglycemia. Setting Urban pediatric ED of a tertiary level childrens hospital Methods Retrospective review of all medical records with a primary or secondary diagnosis of hypoglycemia (ICD-9 code 251.2) seen at the ED between 1/92 and 8/95. Results Thirty-one patients were identified. Mean blood glucose was 34.2 mg/dl. Prevalence of hypoglycemia among population seeking care in our ED was 6.54/100,000 visits. Eighteen patients were diagnosed with IKH for a prevalence of 3.9/100,000. IKH demographics were: mean age 27.7 months; 12 males, 6 females; 8 white, 9 black, and 1 not available. The weights of five patients were < 25th percentile. Fourteen of the 18 IKH patients had hormone studies done insulin [cost

Effectiveness of fever education in a pediatric emergency department.

40], growth hormone [

Sedation after intubation using etomidate and a long-acting neuromuscular blocker.

69], cortisol [

Most Common Sports-Related Injuries in a Pediatric Emergency Department

54]. All 14 had appropriately suppressed insulin levels (< μU/ml) and high cortisol levels > 22 μg/ml. Thirteen of the 14 had normal or high growth hormone (GH) levels (0.7–6 ng/ml). Four IKH patients had urine drug screens (

Parental preferences for boarding locations when a children's hospital exceeds capacity.

280); all were negative. Although no IKH patient was febrile, six had sepsis workups (

Protocol for Reducing Time to Antibiotics in Pediatric Patients Presenting to an Emergency Department With Fever and Neutropenia: Efficacy and Barriers.

380); all were negative. Urine ketones were positive in 15 of the 18 tested (> 3+ in eight patients). Mean anion gap was 20 (range: 16–30). Eight of the 18 IKH patients were discharged from the ED after return to normal status. Conclusions IKH is the most common cause of hypoglycemia in children beyond the infancy period. In its typical presentation (previously healthy one- to five-year-old, with normal growth and development, who presents with a first episode of symptomatic fasting hypoglycemia and appropriate degree of ketonuria, without hepatomegaly, and with resolution of symptoms on administration of glucose), an extensive and overzealous workup for endocrinopathy or inborn error of metabolism is not necessary.