Michael K. Kim

A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain

STUDY OBJECTIVE We compare the treatment of pain in children with arm fractures by ibuprofen 10 mg/kg versus acetaminophen with codeine 1 mg/kg/dose (codeine component). METHODS This was a randomized, double-blind, clinical trial of children during the first 3 days after discharge from the emergency department (ED). The primary outcome was failure of the oral study medication, defined as use of the rescue medication. Pain medication use, pain scores, functional outcomes, adverse effects, and satisfaction were also assessed. RESULTS Three hundred thirty-six children were randomized to treatment, 169 to ibuprofen and 167 to acetaminophen with codeine; 244 patients were analyzed. Both groups used a median of 4 doses (interquartile range 2, 6.5). The proportion of treatment failures for ibuprofen (20.3%) was lower than for acetaminophen with codeine (31.0%), though not statistically significant (difference=10.7%; 95% confidence interval -0.2 to 21.6). The proportion of children who had any function (play, sleep, eating, school) affected by pain when pain was analyzed by day after injury was significantly lower for the ibuprofen group. Significantly more children receiving acetaminophen with codeine reported adverse effects and did not want to use it for future fractures. CONCLUSION Ibuprofen was at least as effective as acetaminophen with codeine for outpatient analgesia for children with arm fractures. There was no significant difference in analgesic failure or pain scores, but children receiving ibuprofen had better functional outcomes. Children receiving ibuprofen had significantly fewer adverse effects, and both children and parents were more satisfied with ibuprofen. Ibuprofen is preferable to acetaminophen with codeine for outpatient treatment of children with uncomplicated arm fractures.

A randomized clinical trial of dermal anesthesia by iontophoresis for peripheral intravenous catheter placement in children.

STUDY OBJECTIVE To assess the efficacy of dermal anesthesia by lidocaine iontophoresis in children undergoing peripheral intravenous (PIV) catheter placement in the emergency department. METHODS A double-blind, randomized, clinical trial was conducted at a tertiary childrens hospital ED. Alert children 7 years or older requiring nonemergency PIV were eligible. Patients in the lidocaine group received 1 mL of 2% lidocaine with 1:100,000 epinephrine over a potential PIV site by iontophoresis. The control group received 1 mL of.9% saline solution with 1:100,000 epinephrine. After PIV placement, patients ranked the procedural pain using a visual analog scale. Complications were noted by visual inspection or telephone follow-up. RESULTS During a 6-month period, 22 patients were assigned to the lidocaine group and 25 to the control group. There was no significant difference in age, sex, or ethnic background between the 2 study groups, and mean application time was 12.0 minutes. The median pain score was.5 in the lidocaine group compared with 4 in the control group (P =.0002; 95% confidence interval [CI] 1 to 5). No significant immediate or delayed complications were observed. CONCLUSION Lidocaine iontophoresis provides effective dermal anesthesia for children older than 7 years of undergoing nonemergency PIV placement in the ED.

Evidence-based approach to the diagnosis of appendicitis in children.

Importance of the Problem Appendicitis is the most common condition requiring emergency abdominal operation in childhood. It is diagnosed in 1% to 8% of children presenting to the emergency department for the evaluation of abdominal pain. The incidence increases with increasing age, from a rate of 1 to 2/ 10,000 children between birth and 4 years, to a rate of 19 to 28/10,000 children younger than 14 years annually. It most frequently presents in the second decade of life, with a lifetime risk of 8.6% in males and 6.7% in females. The incidence of appendiceal perforation is highest in infancy, ranging from 70% to 95%. The risk of perforation in 1to 4-year-old children is 70% to 90%, compared with 10% to 20% in adolescents. Complications from appendiceal perforation include major abscess, phlegmon, enterocutaneous fistula, peritonitis, and partial bowel obstruction. Therefore, prompt and accurate diagnosis of acute appendicitis is crucial. Currently, the diagnosis of appendicitis uses clinical findings, laboratory testing, and imaging studies. To maximize benefit and minimize costs and risks, decisions for diagnostic testing should use an evidence-based approach.

The anesthetic effectiveness of lidocaine-adrenaline-tetracaine gel on finger lacerations

Objectives: To determine the effectiveness of lidocaine-adrenaline-tetracaine (LAT) in providing adequate anesthesia for the repair of finger lacerations and to monitor the risk of digital ischemia following application of LAT gel to finger lacerations. Methods: A prospective case series. Children aged 5 to 18 years with a simple finger laceration-requiring repair were eligible for enrollment. The primary outcome measure was LAT success/failure. Failure was defined as any sharp sensation reported by the patient either before or during suturing. Enrolled patients had LAT gel applied to their laceration for 45 minutes, followed by an examination for signs of digital ischemia and standard laceration repair. Infiltration anesthesia (local subcutaneous injection/digital block) was provided for all LAT failures. Patients were followed up by phone within 3 to 5 days from discharge. Results: Sixty-seven patients were analyzed in the study. The mean age was 11.9 years. Forty-four (65.7%) of 67 patients were male and 46 (68.7%) were white. Locations of the lacerations were equally distributed on the dorsal and ventral surfaces. The overall LAT success rate was 53.7% (95% confidence interval [CI], 41.1% to 66.0%; 36/67). The success rate for dorsal surface lacerations was 68.6% (95% CI, 50.7% to 83.1%; 24/35) versus 37.5% (95% CI, 21.1% to 56.3%; 12/32) for ventral surface lacerations. The difference in success rates between dorsal and ventral surface lacerations was significant (Δ 31.1% [95% CI, 8.3% to 53.8%]). There were no differences in success rates for age, sex, or race. No signs of digital ischemia were noted in any of the 67 cases (0% [95% CI, 0.0% to 5.4%]). Conclusions: LAT gel appears to be a safe and effective means of providing anesthesia for the repair of simple finger lacerations in children. It was most effective on the dorsal surface of the finger.

Chest Radiography in the Initial Episode of Bronchospasm in Children: Can Clinical Variables Predict Pathologic Findings?

STUDY OBJECTIVE To determine whether historical or clinical variables can accurately discriminate among children, experiencing a first episode of bronchospasm, with chest radiography findings that are normal, consistent with reactive airway disease (RAD), or pathologic. METHODS We assembled a prospective case series of patients in our tertiary, academic, pediatric emergency department. All patients aged newborn to 18 years presenting to the ED with their initial episode of wheezing were enrolled. RESULTS Six hundred thirty-three patients presented to the ED during the study period. Pathologic radiographic findings were identified in 39 (6.2%). Radiographs revealing normal findings and evidence of RAD were noted in 25.4% and 68%, respectively. No single variable accurately predicted all pathologic radiographs. Discriminant function analysis identified nine variables, which we combined into a model. The model failed to accurately discriminate among patients with radiographs revealing evidence of a pathologic condition, normal chest findings, and RAD. CONCLUSION No clinical variables, isolated or combined into a model, accurately identify patients with pathologic radiography findings. Continued use of chest radiography as a diagnostic intervention in the initial episode of childhood bronchospasm is recommended.

Vomiting of liquid corticosteroids in children with asthma.

Background: Oral corticosteroids are an essential part of the management of children with acute asthma exacerbations. Vomiting is a frequently cited problem attributed to oral corticosteroids. A new formulation of prednisolone, Orapred, claims to have improved palatability that may decrease the incidence of vomiting. Objective: To compare the incidence of vomiting and taste between patients who are given the generic preparation of prednisolone with those given Orapred. Design/Methods: A randomized, double blind clinical trial was conducted at a tertiary care children s hospital emergency department. Children age 2 to 10 years presenting with acute asthma exacerbation were eligible. Patients with allergy to prednisolone, corticosteroid use within 2 weeks, history of vomiting in the last 24 hours, requirement for vascular access, and preference for other forms of corticosteroid were excluded. Enrolled patients were randomized and given either generic prednisolone (15 mg/5 ml) or Orapred (15 mg/5 ml). In children 6 years or older, a taste score was obtained using a 5 point hedonic face scale (1 = bad to 5 = great). After the administration, patients were observed for 30 minutes for vomiting. The Mann-Whitney U test was used to compare the median taste score between the two study groups. Relative risk (RR) of vomiting was calculated. Other confidence intervals were calculated when appropriate. Results: During the study period, 211 eligible children were enrolled, of whom 23 were excluded. Of the remaining 188 subjects, 96 received generic prednisolone and 92 received Orapred. All baseline characteristics were similar in both groups. In the generic prednisolone group, 17 (17.7%) children vomited compared with 5 (5.4%) in the Orapred group (RR = 3.26, 95% CI, 1.25, 8.47). Taste scores were obtained from 18 children in the generic prednisolone group and from 19 children in the Orapred group. The median taste score was 2 for the generic prednisolone group and 4 for the Orapred group (&Dgr; = -2.0, 95% CI, -3.0, -1.0) (P = 0.0001). Conclusions: In our study population, Orapred was associated with a significant less incidence of vomiting and better taste score compared to the generic prednisolone.