Madhumita Sinha

Weighing the pediatric patient during trauma resuscitation and its concordance with estimated weight using Broselow Luten Emergency Tape.

Objective Obtaining an accurate weight is crucial during pediatric trauma/medical resuscitation. Currently, length-based weight estimations are used. Study objective was to assess feasibility of obtaining actual weights of children during trauma resuscitation and study its concordance with length-based estimated weight using the Broselow Pediatric Emergency Tape. Methods Pediatric trauma patients 0 to 14 years old presenting to a tertiary care pediatric trauma center between November 2008 and October 2009 were enrolled prospectively. Length-based weight estimation was done on patient arrival using the Broselow tape; in addition, an actual patient weight was recorded using the trauma stretcher integrated weighing scale. Results Two hundred thirty-one patients were eligible and enrolled. Weights were recorded in 145 children (63.2%). In 27 patients (18.6%) whose body length exceeded Broselow tape range, weight was measured using stretcher scale only. The remaining 118 patients (mean age, 5.0 [SE ± 0.3] years; 67% male) were used for correlation analysis. There was good correlation (Pearson correlation coefficient, r = 0.86) between estimated weight and measured weight. However, Bland-Altman analysis showed mean bias +2.6 kg (95% confidence interval [CI], 1.6–3.6 kg); lower/upper limits of agreement were −8.3 kg (CI, −10.0 to −6.6 kg) and 13.5 kg (CI, 11.7–15.2 kg). Conclusions It is possible to obtain an actual patient weight during pediatric trauma resuscitation. Length-based estimated weight using Broselow tape underestimated weight by 2.6 kg; the mean error was greatest in the highest weight category.

Use of a silver-containing hydrofiber dressing for filling abscess cavity following incision and drainage in the emergency department: a randomized controlled trial.

OBJECTIVE: The objective of this study was to investigate whether the use of a silver-containing hydrofiber dressing to pack abscess cavity after incision and drainage (I & D) leads to faster wound healing and less pain. METHODS: Patients 18 years or older visiting the emergency department with cutaneous abscesses, requiring I & D, were randomly assigned to the intervention (Aquacel Ag; ConvaTec, Skillman, New Jersey) or standard care (iodoform) group between April 2008 and May 2009. Patients were followed up 48 to 72 hours and 10 to 14 days after the initial visit. Primary outcomes were the proportion of patients with greater than 30% reduction in surface area of abscess or cellulitis at first follow-up. RESULTS: Ninety-two patients were enrolled prospectively and randomly assigned to the Aquacel Ag or the iodoform groups; mean age was 38.0 (SD, 12.0) years; 49 patients were in the Aquacel Ag and 43 were in iodoform groups, respectively. There were no differences in demographic and clinical characteristics between groups. Logistic regression analysis showed that the intervention (Aquacel Ag) was independently associated with greater than 30% reduction in surface area of abscess (P = .002) but not in cellulitis at first follow-up. There was also significant decrease in pain intensity perceived by patients in the Aquacel Ag group based on the mean change in Facial Pain Scale scores between the initial visit and first follow-up. CONCLUSION: In patients with cutaneous abscesses, use of an antimicrobial hydrofiber ribbon dressing for packing was associated with faster wound healing and reduction in perceived pain in comparison with use of iodoform dressing.

Serum procalcitonin concentration in the evaluation of febrile infants 2 to 60 days of age.

Objective Febrile infants younger than 60 days are at risk for serious bacterial infections (SBIs) and often undergo extensive laboratory investigation and hospitalization. We aim to determine the diagnostic value of serum procalcitonin (PCT) concentration for identification of febrile infants at low risk for SBI in comparison to the Rochester Criteria (RC). Methods Infants 2 to 60 days of age with rectal temperature 38°C were enrolled between May 2004 and March 2007. Blood was obtained from each, and PCT was assessed using BRAHMS PCT LIA method. Information for identification of low-risk infants using RC was obtained. Negative predictive value, sensitivity, specificity, and likelihood ratio of PCT were compared with the RC. In univariate analysis, the components of RC and PCT were considered. Variables holding a significant association with the absence of SBI were included in a backward stepwise logistic regression model with SBI as the dependent variable, creating new low risk criteria. Results One hundred fifty-five patients were enrolled. Thirteen (8.4%) had an SBI. Procalcitonin concentration at a cutoff value of 0.26 ng/mL is similar in sensitivity (92%) and better in specificity (64%) than RC. A combination of urine white blood cell and PCT was the best model in the regression analysis. Conclusions Procalcitonin concentration is a serological marker for identification of or exclusion of SBI in infants aged 2 to 60 days. The predictive value of PCT in combination with urinary white blood cell count may be clinically useful. A validation study is indicated.

Antibiotic dosing for acute otitis media in children: a weighty issue.

Background: The American Academy of Pediatrics 2004 guidelines on diagnosis and management of acute otitis media (OM) recommends use of high-dose amoxicillin for the treatment of acute uncomplicated OM. With rising childhood obesity, recommended amoxicillin dose of 80 to 90 mg/kg per day often exceed standard adult dose of 1500 mg/d. Objective: To study prescribing patterns of primary care physicians for amoxicillin in the treatment of OM. To assess opinions of American Academy of Pediatrics subcommittee members who participated in guideline formulation. Methods: This study had 2 parts. Part 1: Retrospective review of medical records of children visiting the hospital between April and June 2008 and with a diagnosis of OM and were prescribed amoxicillin. Part 2: Web-based survey of 14 members of the OM guidelines subcommittee. Results: Part 1: Three hundred fifty-nine children were eligible, with a mean (SD) age of 3.2 (4.0) years and 185 (51.5%) of whom were males. Children weighing 20 kg or less received higher mean daily dose of amoxicillin (74.2 vs 40.4 mg/kg per day, P < 0.00). Part 2: Nine (64.3%) subcommittee members responded to the survey. Most (77.8%) affirmed that the impact of obesity on high-dose amoxicillin recommendation was not discussed during guideline formulation. If a patients estimated amoxicillin dose exceeded the standard adult dose (1500 mg/d), 66.7% members would prescribe the standard adult dose whereas 33.3% would prescribe the recommended dose of 80 to 90 mg/kg per day. Conclusions: Primary care physicians prescribe a significantly lower-than-recommended amoxicillin dose in older children and those in the higher weight category. The opinion among subcommittee members regarding maximum dose specification of amoxicillin is varied.

Predictors of serious bacterial infections in pediatric burn patients with fever.

To determine predictors of serious bacterial infections in pediatric burn patients with fever (core temp ≥38.5°C), the authors conducted a retrospective review of medical records of pediatric (0–18 years) patients admitted to the Arizona Burn Center between 2008 and 2011 with greater than 5% TBSA and inpatient hospitalization for ≥72 hours. The study group comprised patients with a febrile episode during their inpatient stay. Serious bacterial infection (the primary outcome variable) was defined as: bacteremia, urinary tract infection, meningitis (blood, urine, or cerebrospinal fluid culture positive for a pathogen respectively), pneumonia, line, and wound infection. A generalized estimating equation analysis was done to predict the presence or absence of serious bacterial infection. Of 1082 pediatric burn patients hospitalized during the study period, 353 met the study eligibility criteria. A total of 108 patients (30.6%) had at least one fever episode (fever group). No difference in demographic characteristics was noted between the fever and no-fever groups; significant differences were observed for: third-degree TBSA, second-degree TBSA, total operating room visits, length of stay, Injury Severity Score, and death. A total of 47.2% of the patients had one or more episodes of fever with serious bacterial infection. In a generalized estimating equation predictive model, presence of a central line, second-, and third-degree TBSA were predictive of serious bacterial infection in burn patients with fever. In this study, individual clinical variables such as tachypnea and tachycardia were not predictive of serious bacterial infections, but the presence of a central line, and larger TBSA were significant predictors of serious bacterial infections. Younger age (P =.08) and ventilator support (P =.057) also approached significance as predictors of serious bacterial infections.

Clinical Outcomes of Pediatric Patients With Acute Abdominal Pain and Incidental Findings of Free Intraperitoneal Fluid on Diagnostic Imaging

The presence of free intraperitoneal fluid on diagnostic imaging (sonography or computed tomography [CT]) may indicate an acute inflammatory process in children with abdominal pain in a nontraumatic setting. Although clinical outcomes of pediatric trauma patients with free fluid on diagnostic examinations without evidence of solid‐organ injury have been studied, similar studies in the absence of trauma are rare. Our objective was to study clinical outcomes of children with acute abdominal pain of nontraumatic etiology and free intraperitoneal fluid on diagnostic imaging (abdominal/pelvic sonography, CT, or both).

Assessing physician-parent communication during emergency medical procedures in children: an observational study in a low-literacy Latino patient population.

Objective Effective physician-patient communication is critical to the clinical decision-making process. We studied parental recall of information provided during an informed consent discussion process before performance of emergency medical procedures in a pediatric emergency department of an inner-city hospital with a large bilingual population. Methods Fifty-five parent/child dyads undergoing emergency medical procedures were surveyed prospectively in English/Spanish postprocedure for recall of informed consent information. Exact logistic regression was used to predict the ability to name a risk, benefit, and alternative to the procedure based on a parents language, education, and acculturation. Results Among English-speaking parents, there tended to be higher proportions that could name a risk, benefit, or alternative. Our regression models showed overall that the parents with more than a high school education tended to have nearly 5 times higher odds of being able to name a risk. Conclusions A gap in communication may exist between physicians and patients (or parents of patients) during the consent-taking process, and this gap may be impacted by socio-demographic factors such as language and education level.

Growth Tracking in Severely Obese or Underweight Children

This study examines the utility of various growth charts, including a new modified CDC BMI z score chart, in tracking children with normal and problematic growth. OBJECTIVES: To illustrate the difficulties in optimal growth monitoring of children with severe obesity or underweight by using the Centers for Disease Control and Prevention (CDC) 2000 age- and sex-specific BMI percentile growth charts. We also aimed to examine the utility of a new modified CDC BMI z score chart to monitor growth in children with normal and extreme BMI percentiles by using real-life clinical scenarios. METHODS: Modified BMI z score charts were created by using the 2000 CDC algorithm. Three cases of children with extreme BMI values and abnormal growth patterns were plotted by using the standard CDC 2000 clinical growth chart, the modified BMI z score chart, and the CDC BMI percentile chart, modified to include the percentage of the 95th percentile (%BMIp95) curves. RESULTS: Children with severe obesity could not be plotted on the standard CDC BMI percentile chart because their BMI points lay above the chart cutoff. Children with a low BMI (<3%) were also difficult to track on the standard BMI percentile chart. The addition of the %BMIp95 scale to the standard BMI percentile chart allowed tracking of severely obese children; however, it did not address severely underweight children and required a change of units within the chart when transitioning from normal to obese BMIs. The modified BMI z score chart allowed uniform tracking. CONCLUSIONS: The modified CDC z score chart is suitable for growth tracking of children with normal and extreme growth patterns; the measures correlate well with the %BMIp95, and the chart can be incorporated easily into existing electronic health record systems for clinical use.

Cost Minimization Analysis of Different Strategies of Management of Clinically Significant Scorpion Envenomation Among Pediatric Patients.

Objective Scorpion antivenom was recently approved for use in patients with clinically significant scorpion envenomation in the United States; no formal economic analysis on its impact on cost of management has been performed. Methods Three different strategies of management of scorpion envenomation with systemic neurotoxic symptoms in children were compared for cost minimization from a societal perspective. In strategy I, patients were managed with supportive care only without antivenom. In strategy II, an aggressive strategy of full-dose antivenom (initial dose of 3 vials with the use of additional vials administered 1 vial at a time) was considered. In strategy III, a single-vial serial antivenom dosing strategy titrated to clinical response was considered. Clinical probabilities for the different strategies were obtained from retrospective review of medical records of patients with scorpion envenomation over a 10-year period at our institution. Baseline cost values were obtained from patient reimbursement data from our institution. Results In baseline analysis, strategy I of supportive care only with no antivenom was least costly at US

Social Media Use Among Adolescent Patients Visiting an Inner City Pediatric Emergency Department

3466.50/patient. Strategy III of single-vial serial dosing was intermediate but less expensive than strategy II of full-dose antivenom, with an incremental cost of US