Michael P. Poirier

Fever Phobia: A Survey of Caregivers of Children Seen in a Pediatric Emergency Department

Background. Fever continues to be the most common complaint of children seen in a Pediatric Emergency Department (PED). Previous studies have assessed the prevalence of fever phobia in various populations. This study aims to document the incidence of fever phobia in a PED. Methods.Through convenience sampling, caregivers of children seen in a PED were surveyed using a research-assistant-administered questionnaire. The survey contained 28 questions pertaining to caregivers’ perceptions, attitudes, and behaviors regarding fever in children. Results . In all, 230 caregivers were surveyed. The median temperature considered to be a fever was 37.8°C (100.0°F), with a range of 36.1°C (97°F) to 40.6°C (105°F), whereas the median temperature considered to result in harmful consequences was 40.6°C (105°F), with a range of 37.8°C (100°F) to 43.3°C (110°F). The median temperature at which antipyretics would be administered was 37.8°C (100°F), with a range of 36.1°C (97°F) to 39.4°C (103°F). More than one third of caregivers reported that they would administer antipyretics inappropriately. The median temperature at which a child would be taken to the PED was 39.4°C (103°F), with a range of 36.7°C (98°F) to 40.8°C (105.4°F). There was also a relationship between level of education and level of fever concern. Conclusion. Fever phobia and inappropriate treatment for febrile children is present among caregivers of patients seen in a PED. Level of education may be a factor in fever knowledge and practices. Overly zealous, potentially harmful home practices and unnecessary PED visits for the assessment and treatment of fever in children is widespread among caregivers surveyed in the PED.

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.

Concussions: assessment, management, and recommendations for return to activity

Abstract Concussions in children and adolescents are a common presenting complaint seen in all emergency departments. Concussions range from a brief period of neural dysfunction to a prolonged period of unconsciousness with retrograde amnesia. It is imperative that the emergency physician be familiar with the appropriate assessment of the child or adolescent who has sustained a concussion, methods for grading their severity, current acute management, and recommendations for returning to activity.

Sports-related concussions.

Concussion is the most common head injury occurring in sports participation. Concussions range from a brief period of neural dysfunction to a prolonged period of unconsciousness with retrograde amnesia. It is imperative that the pediatric emergency medicine specialist be familiar with the proper initial assessment of the child or adolescent athlete who has sustained a sports-related concussion, the latest grading scales of concussions, and the current recommendations for returning the athlete to competition. A systematic approach to the athlete who has suffered a concussion will minimize the risk of further injury or mortality.

Vocal cord dysfunction presenting as acute asthma in a pediatric patient.

We report a pediatric patient with an acute onset of paradoxical vocal cord movement which presented as his first episode of wheezing. History and physical examination suggested the diagnosis of vocal cord dysfunction, which was confirmed by a flexible fiberoptic nasophayrngoscopic examination. This is the first report of paradoxical vocal cord movement being made on initial presentation of wheezing in the emergency department and supports earlier reports that this diagnosis can be made in the pediatric population. The practicing pediatric emergency physician should consider the diagnosis of paradoxical vocal cord dysfunction in the differential diagnosis of wheezing in the pediatric patient, especially if the patient does not have the typical historical and physical findings associated with reactive airway disease.

Peripherally inserted central venous catheter fracture and embolization to the lung

We report an adolescent patient with a peripherally inserted central venous catheter fracture and subsequent migration of the catheter fragment through the heart and into the lower lobe of the right lung. Physical findings were unremarkable for indications of this pulmonary embolization. With the increasing use of such devices for prolonged venous access, the practicing pediatric emergency physician should be aware of this potential complication.

A Prospective Study of the “Two-Bag System” in Diabetic Ketoacidosis Management

The “two-bag” system, an adaptation of the euglycemic clamp technique, consists of simultaneous administration of 2 intravenous (IV) fluid bags of differing dextrose concentrations. Individualized therapy is dictated by adjustment of the infusion rate of each bag. We sought to assess the benefits of the two-bag system in the initial acute emergency department management of children in diabetic ketoacidosis (DKA). Thirty-three children presenting to an urban pediatric emergency department in DKA were randomized into 2 groups: patients managed with the two-bag system and patients managed with the traditional “one-bag” system. Other aspects of the management were standardized. Outcome measures included rate of decline in serum glucose, rate of bicarbonate correction, time on IV insulin therapy, and response time for IV fluid changes. Study period was defined as time on IV insulin therapy. There were no differences between the 2 groups in demographic parameters, initial baseline metabolic parameters, or total time on IV insulin therapy. There were no differences between the groups in average rates of serum glucose decline: two-bag 33.1 mg/dL/hr (s.e. 5.57, 95% CI 22.2, 44), one-bag 30.2 mg/dL/hr (s.e. 5.72, 95% CI 19, 41.4); average rate of serum bicarbonate correction: two-bag 1.19 mEq/L/hr, one-bag 1.27 mEq/L/hr; or the average number of IV fluid bags used: two-bag 4.1 bags, one-bag 3.2 bags. However, there was a difference between the groups in regard to elapsed total time to make changes in the IV fluids: two-bag 1 minute, one-bag 42 minutes, (p < 0.001). The “two-bag” system enables a faster response time in making IV fluid therapy changes. This efficiency makes this system ideal for use in the emergency department.

Near Strangulation as a Result of Hair Tourniquet Syndrome

Hair tourniquet syndrome has been a recognized clinical entity for many decades. In this syndrome, hair becomes tightly wrapped around an appendage, usually that of an infant. Body parts involved include the finger, toe, penis, clitoris, and uvula. The end result of necrosis is also well documented. In this report, an 11-month-old girl with hair tourniquet syndrome causing signs and symptoms of an acute strangulation is presented.

Prudent Layperson Definition of an Emergent Pediatric Medical Condition

This study was designed to assess how well parents rated pediatric medical conditions based on their perceived degree of urgency so as to determine if the “Prudent Layperson Standard” is reasonable. A self-administered, supervised survey was given to a convenience sample of 340 caregivers in the emergency department of an urban childrens hospital. Respondents were asked to rank the urgency of 15 scenarios. A caregiver response within 1 point of the physician score was considered concordant with medical opinion. A 2-week-old infant with a rectal temperature of 103.7°F was the only emergent scenario underestimated by caregivers. A 11/2-yr-old child with an upper respiratory tract infection, a 7-year-old child with ringworm, an 8-month-old infant with a simple forehead contusion, and a 4-year-old child with conjunctivitis were the non-urgent scenarios overestimated by caregivers. Laypeople are able to identify cases constructed to represent obvious pediatric medical emergencies. Several patient subgroups frequently overestimate medical urgency.

Internal Applicants to Pediatric Emergency Medicine Fellowships and Current Use of the National Resident Matching Program Match: A Survey of Fellowship Directors.

Objectives Applicants to fellowship programs are divided into the following 2 distinct groups: the external versus internal candidate. Internal fellowship candidates did residency at the same institution they are applying to, whereas the external candidate is from another institution. Internal candidates have likely done rotation(s) within the fellowships division and are known to faculty, whereas the external candidates are evaluated by their applications and interviews alone. Acceptance of internal fellowship candidates may be complicated by competing interests of the associated residency program and overlapping faculty who have academic roles in both training programs. The current percentage of pediatric emergency medicine (PEM) fellowships exclusively using the National Resident Matching Program (NRMP) Specialties Matching Service (SMS) for filling fellowship slots is not known. Methods We surveyed all the current US PEM fellowship directors in April/May 2013 using a 15-question anonymous institutional review board–approved survey. This survey was hosted through http://www.surveymonkey.com and was available between April 08, 2013 and May 08, 2013. The unique link sent to each fellowship director recorded completion of the survey but no individual responses. All questions had to be answered for the results to be recorded. Results Fifty-four of 70 fellowship directors responded. Each question was individually evaluated. Fellowship directors had different feelings toward internal candidates. The NRMP-SMS exclusive use was high. Possible confounders using the NRMP match seemed uncommon. Conclusions Twenty-nine percent of current PEM fellows are in training at the same institution where they completed their residency. Both internal and external candidates are valued by PEM fellowship directors. The exclusive use of the NRMP SMS is high and not confounded by internal factors.