Michael A. Gittelman

Management of febrile infants and children by pediatric emergency medicine and emergency medicine : Comparison with practice guidelines

Objectives Management of febrile infants and children remains controversial despite the 1993 publication inPediatrics and Annals of Emergency Medicineof practice guidelines. Our aim was to determine the management of febrile infants and children by pediatric emergency medicine (PEM) fellowship directors and emergency medicine (EM) residency directors and compare their approach with the published practice guidelines. Methods Four case scenarios were sent to 64 PEM directors and 100 EM directors in the United States and Canada, describing four febrile, nontoxic infants and children aged 25 days (case 1), 7 weeks (case 2), 5 months (case 3), and 22 months (case 4). Respondents were asked to select which laboratory tests and radiographs they would obtain and to decide on treatment and disposition for each hypothetical case. Results Ninety-two percent (53/64) of PEM directors and 64% (64/100) of EM directors responded (overall response rate 74%). Compliance with the guidelines (PEM/EM) was 54%/16% for case 1, 31%/6% for case 2, 35%/19% for case 3, and 20%/11% for case 4. Only 11% of PEM and 2% of EM directors followed the guidelines for all four cases. Overall, directors performed fewer laboratory tests, ordered more chest radiographs and treated fewer patients with antibiotics than the expert panel suggested. EM directors ordered more chest radiographs (cases 1–4) and admitted more patients (case 2) than PEM directors. Conclusions There is poor compliance with published practice guidelines in the management of febrile infants and children among PEM and EM directors.

Injury Patterns in Obese Versus Nonobese Children Presenting to a Pediatric Emergency Department

BACKGROUND: Two of the most prevalent problems facing youth in the United States are injury and obesity. Obesity increases the risk of injury, prolongs recovery time, and increases morbidity among injured children. OBJECTIVE: The purpose of this study was to compare characteristics of injuries between obese and nonobese children who presented to a pediatric emergency department. METHODS: Electronic medical records for all patients aged 3 to 14 years who sustained a traumatic injury (International Classification of Diseases, Ninth Revision [ICD-9] codes 800–899) and were seen in our hospital emergency department from January 1, 2005, to March 31, 2008, were obtained. Data collected included age, chief complaint, discharge diagnosis, gender, race, disposition, and weight. Patients with a weight at >95th percentile for age were considered obese. χ2 analysis was used in comparing the groups; odds ratios (ORs) were calculated. RESULTS: During the study period, 24 588 children had ICD-9 codes that met our inclusion criteria. Of these, 1239 had no weights recorded, leaving 23 349 patients in our study population. Of these children, the mean age was 8.2 years (SD: ±3.6 years), 60.7% were white, and 61.7% were male. Obese children represented 16.5% of the study population (n = 3861). Overall, obese and nonobese children had the same percentage of upper extremity injuries. However, obese children were significantly more likely to have lower extremity injuries compared with upper extremity injuries than were nonobese children (OR: 1.71 [95% confidence interval: 1.56–1.87]; P < .001). In addition, obese children had significantly fewer head and face injuries than nonobese children (OR: 0.54 [95% confidence interval: 0.50– 0.58]; P < .001). CONCLUSIONS: Obese children are significantly more likely to sustain lower extremity injuries than upper extremity injuries and less likely to sustain head and face injuries than nonobese children. Strategies for preventing lower extremity injuries among obese youth should be sought.

Common medical terms defined by parents: are we speaking the same language?

Objectives: Physicians often assume that a patient understands frequently utilized medical words and patient management may be based on these assumptions. The objective of this study was to determine the publics definition of regularly used medical terminology. Methods: A cross-sectional convenience survey was conducted for guardians of children presenting to an urban pediatric emergency department. The orally completed, open-ended questionnaire included parental demographic information and their definition of eleven commonly used medical terms. The words chosen represent common chief complaints given in our emergency department. Definitions were grouped, and a concordance rate of 75% was chosen to consider responses similar. Results: One hundred twenty-two guardians completed the survey (89% parents, 88% female, and 55% high school graduates). Caregivers agreed on the definitions of diarrhea, constipation, dehydration, fever, and seizure. However, diarrhea and constipation were mainly defined by either stool consistency or frequency, not both. Dehydration was appropriately defined as lack of body fluids (92%), but many parents had difficulty identifying more than one sign of dehydration. Fever was thought to be an elevated body temperature (76%), yet 69% felt that a temperature less than 100.5°F was considered a fever. Most respondents did not know the definitions of meningitis (70%), lethargy (64%), and virus (40%). Conclusions: Although commonly used in everyday conversation, there seems to be a large disparity between a caregivers perception and the actual definition of medical terms. More precise communication may help both parties to understand the true situation.

Pediatric All-Terrain Vehicle–Related Injuries in Ohio From 1995 to 2001: Using the Injury Severity Score to Determine Whether Helmets Are a Solution

OBJECTIVE. The goal was to identify regions in Ohio with severe pediatric all-terrain vehicle–related injuries and to determine whether helmet usage was associated with lower injury severity scores. METHODS. We performed a retrospective review of data for all patients entered into the registries of Ohio’s major pediatric trauma centers for the period of January 1, 1995, to December 31, 2001. RESULTS. Seven hospitals participated. A total of 285 children were admitted; 2 patients died, and 13 required rehabilitation. The mean age was 11.1 years, with 76.1% of patients being male and 88.1% white. Most patients came from the central and southwestern regions of Ohio. An average of 30 admissions per year occurred from 1995 to 1998, but the number increased to 55 admissions per year from 1999 to 2001. Among the 285 injured children, 869 injuries were sustained; 57% of patients sustained multiple injuries. The most commonly injured body parts were the head (22.3%) and lower extremities (12.6%). The most common injuries sustained were fractures (31.4%) and contusions/abrasions (22.2%). Of patients for whom documentation was available, 72.2% (171 of 237 patients) were not helmeted. There was no significant difference in mean injury severity scores between helmeted and nonhelmeted riders (9.58 vs 9.12). Helmet usage was not associated with a reduction in head/facial injuries. CONCLUSIONS. All-terrain vehicle–related injuries to children nearly doubled between 1995 to 1998 and 1999 to 2001. Fewer than 30% of injured children were wearing helmets at the time of injury. With the injury severity score as an indicator, helmets provided no significant protection for all-terrain vehicle riders in this pediatric population.

No License Required: Severe Pediatric Motorbike-Related Injuries in Ohio

Objective. Motorbikes (MBs), including motorcycles and dirt bikes, are becoming increasingly popular among children and adolescents. MBs are intended for off-road use. Although children who are younger than 16 years cannot be licensed to drive cars, they can drive MBs off-road without licenses. The objective of this study was to determine the epidemiology of severe MB injuries to children who are younger than 16 years in Ohio. Methods. Eight hospitals that admit the majority of pediatric trauma patients in Ohio were approached to participate. Cases were identified using hospital trauma registries and were defined as any hospitalized child who was younger than 16 years and sustained MB injuries between January 1, 1995, and December 31, 2001. Results. Six hospitals participated. A total of 182 children were hospitalized with a mean age of 11.4 years (range: <1–15 years). A total of 89.6% were male, 89.0% were white, 68.7% had commercial medical insurance, and 71.4% were from urban areas. From 1995 to 1997, there were an average of 20 annual admissions; however, from 1998 to 2001, there were an average of 30 per year. Of the 85% of patients with injury events documented, 35.5% were riding in streets and 53.3% were unhelmeted. One patient died; 8 required rehabilitation. The mean injury severity score was 9.9 (median: 9), and mean length of hospitalization was 4.6 days (median: 3). Unhelmeted riders had significantly higher injury severity scores than helmeted ones (11.5 vs 8.4). The difference in mean length of hospitalization of unhelmeted compared with helmeted riders approached statistical significance (6.1 vs 3.7 days). Of the 163 patients with documented diagnoses, there were 510 injuries; 68.7% of patients sustained multiple injuries. Of all injuries, the most commonly injured body parts were lower extremity (23.4%), head (22.2%), abdomen/pelvis (13.4%), upper extremity (12.4%), and face (11.8%). The most common injuries were fractures (37.1%), abrasions/contusions (24.4%), lacerations (13.4%), intracranial injuries (7.5%), and solid abdominal organ injuries (7.5%). Central and Southwest Ohio had higher numbers of hospitalized injuries than other areas. Conclusion. Urban, white boys with commercial medical insurance predominated among children with MB-related injuries in Ohio. Most injured children did not wear a helmet and sustained multiple injuries. Not wearing a helmet resulted in significantly increased injury severity and a trend toward increased lengths of stay in the hospital. MB-related injuries increased by ∼50% during the study period. Children should not operate MBs until they are old enough to obtain a motor vehicle driver’s license, which occurs at a minimum of 16 years of age. High-risk populations need to be targeted to reduce these injuries, and requiring helmet use while operating MBs should be pursued.

Factors that influence concussion knowledge and self-reported attitudes in high school athletes.

BACKGROUND Many organizations and health care providers support educating high school (HS) athletes about concussions to improve their attitudes and behaviors about reporting. The objectives of this study were to determine if previous education, sport played, and individual factors were associated with better knowledge about concussion and to determine if more knowledge was associated with improved self-reported attitudes toward reporting concussions among HS athletes. METHODS We conducted a survey of HS athletes aged 13 years to 18 years from two large, urban HSs. Players were recruited from selected seasonal (fall and winter) as well as men and women’s sports. During preseason, each participant was given a survey asking about his or her previous education, current knowledge, and self-reported attitudes and behaviors about reporting concussions. Bivariate and multivariate linear regression was used to evaluate the association of age, sex, sport, and previous concussion education with knowledge and self-reported attitudes and behaviors about reporting concussions. RESULTS Surveys were completed by 496 athletes. The median age was 15 years, and 384 (77.4%) were male. A total of 212 (42.7%) participated in football, 123 (24.8%) in soccer, 89 (17.9%) in basketball, and 72 (14.5%) in wrestling. One hundred sixteen (23.4%) reported a history of concussion. Improved knowledge regarding concussions was not associated with improved self-reported behaviors (p = 0.63) in bivariate regression models. The multivariate model demonstrated that older age (p = 0.01) and female sex (p = 0.03) were associated with better knowledge. Younger age (p = 0.01), female sex (p = 0.0002), and soccer participation (p = 0.02) were associated with better self-reported behaviors around reporting concussions. CONCLUSION Previous education on concussions was less predictive of knowledge about concussions when controlling for other factors such as sport and sex. Younger age, female sex, and soccer participation were more likely to be associated with better self-reported behaviors. Future studies need to focus on the development of interventions to improve concussion-specific knowledge and behaviors. LEVEL OF EVIDENCE Epidemiologic study, level III.

Risk factors for dating violence among adolescent females presenting to the pediatric emergency department

BACKGROUND Intimate partner violence (IPV) among the adolescent population is an increasing concern. This study was designed to assess the prevalence, associated risk factors, and best ways to identify IPV among teens presenting to a pediatric emergency room. METHODS This prospective, convenience study was conducted in a busy, pediatric emergency department. Young women, aged 15 years to 21 years, presenting with any chief complaint were enrolled. Adolescents completed a verbally assisted survey, and responses were recorded. Surveys consisted of three sections: demographic information, an eight-item date violence screening tool, and a risk factor assessment tool. Teens who screened positive for IPV were offered immediate social services assistance. Analysis was performed to compare youth risk factors between young women who were screened positive and negative for IPV. All eight of the date violence screening questions were reviewed to analyze whether a set of questions were consistently positive in all the teens who were screened. RESULTS A total of 246 of 270 (91%) approached were enrolled. The prevalence of IPV was 36.6%. Many of the risk-taking behaviors assessed correlated with dating violence. The most significant included having tried alcohol (odds ratio [OR], 2.4; confidence interval [CI], 1.3-4.4), having ridden in a car with a partner who was doing drugs (OR, 2.4; CI, 1.1-5.0) or alcohol (OR, 2.5; CI, 1.0-6.3), fighting with peers (OR, 3.5; CI, 1.6-7.8), and history of sexually transmitted disease (OR, 2.2; CI, 1.2-4.2). Four questions were identified that detected 99% of positive screens for adolescent dating violence. CONCLUSIONS IPV among female adolescents presenting to a pediatric emergency department is high. Certain risk-taking behaviors are correlated with adolescent dating violence. Four specific questions, if asked in this setting, can capture teens at risk.

Acute pediatric digoxin ingestion

Although most acute pediatric ingestions of digoxin or other related cardiac glycosides result in minimal or no symptoms, occasionally a child is symptomatic. Gastrointestinal complaints or first-degree AV block are the most common presenting symptoms. Children can generally be given a single dose of activated charcoal, observed, and discharged without any subsequent problems. However, some patients will be toxic and require monitoring, medication, and possibly digoxin-specific antibody fragments. The most important role of the clinician is to recognize the clinical manifestations and institute the appropriate therapy. As in the case presented, the history of an ingestion may not always be obtained initially. Thus, the physician should maintain a high index of suspicion for acute digoxin ingestion and order the appropriate confirmatory tests (eg, a digoxin level, a potassium level, and a 12-lead ECG) when necessary.

Clinical predictors for the selective use of chest radiographs in pediatric blunt trauma evaluations

BACKGROUND Chest radiographs continue to be a routine part of the evaluation of children sustaining blunt trauma. This study sought to determine those clinical markers associated with an abnormal chest radiograph in nonintubated, pediatric, blunt trauma victims. METHODS A retrospective case-control study was performed for severely injured pediatric trauma patients presenting to our emergency department between January 1, 1996, and December 31, 1997. Abnormal chest radiographs were identified through the trauma registry and four controls were matched to each case. Radiographs were reevaluated by our study radiologist. Variables associated with an abnormal chest radiograph were grouped to develop a set of clinical markers that could predict an abnormal chest radiograph with a high degree of sensitivity. RESULTS An initial chest radiograph was obtained in 457 of 587 trauma patients. Thirty study patients with an abnormal radiograph that met inclusion criteria were analyzed with 133 controls. The presence of either an abnormal respiratory rate for age, chest tenderness, or back abrasions had a sensitivity of 1.0 (95% confidence interval, 0.86-1.0) and a specificity of 0.38 (95% confidence interval, 0.30-0.47). CONCLUSION In pediatric trauma patients, the presence of chest tenderness, back abrasions, or an abnormal respiratory rate identified all abnormal chest radiographs.

Falls in children birth to 5 years: different mechanisms lead to different injuries.

BACKGROUND Falls are the most common cause of injury-related hospitalization in children younger than 5 years old. Most anticipatory guidance surrounding falls is around falls from windows or stairs; however, falls from furniture also are important causes of morbidity. The purpose of this study was to compare the number of children injured, ages of injured children, and injuries sustained in falls from furniture and falls from stairs in hospitalized children younger than 5 years. METHODS All records of individuals from 0 year through 4 years, hospitalized at our institution for a fall from furniture or stairs between January 1, 1996, and December 31, 2006, were retrospectively reviewed. A standard data set was abstracted from each chart. Frequencies were used to characterize the study population. &khgr;2 and t tests were used to determine differences between groups. RESULTS A total of 171 patients were hospitalized for falls from stairs and 318 for falls from furniture. There were no differences between the groups with regard to age, sex, race, type of insurance, length of stay, Injury Severity Score, or total cost. The most common pieces of furniture from which children fell were beds (33.0%), couches (18.9%), and chairs (17.9%). Children who fell from stairs were significantly more likely to have injuries to their head (64.3% vs. 38.1%); those that fell from furniture were more likely to sustain arm injuries (33.3% vs. 9.9%). There were significantly more skull fractures in those that fell from stairs (39.8% vs. 20.1%) and humerus fractures in those that fell from furniture (30.8% vs. 9.4%) (p < 0.001). Falls from furniture increased during the study period, while falls from stairs fell; the difference was not statistically significant, however. CONCLUSION Falls from furniture and stairs are important causes of morbidity in children. More children were hospitalized for falls from furniture than from stairs. Falls down stairs are decreasing while falls off furniture are increasing. More anticipatory guidance should be developed and given to families regarding falls from furniture to help prevent these injuries. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.