Michele H. Nichols

Chloral hydrate: the good and the bad.

Chloral hydrate (CH) is a widely used oral sedative hypnotic drug. Our Regional Poison Control Center frequently receives calls regarding unintentional and intentional chloral hydrate overdose. The chief manifestations of toxicity are due to central nervous system depressant action and its arrhythmogenic potential. After absorption, it is immediately converted to trichloroethanol (TCE), which is the active drug. Levels of TCE at which significant toxicity occurs have been variable. Ingestions of greater than 1.5 to 2.0 g of chloral hydrate have produced symptoms in children and adults. Management includes consideration of gastrointestinal decontamination, supportive care for altered mental status and treatment of arrhythmias. For routine use of chloral hydrate as sedation for pediatric procedures, the American Academy of Pediatrics (AAP) guidelines for sedation in children should be followed to decrease the likelihood of untoward complications.

Clonidine Poisoning in Jefferson County, Alabama

STUDY OBJECTIVE To describe the epidemiology of clonidine-related hospitalization in children, to evaluate the efficacy of naloxone, and to review the clinical effects of clonidine toxicity. METHODS This was a retrospective analysis in an urban teaching pediatric emergency department with an annual census of 55,000 involving 80 children younger than 6 years who were admitted for clonidine ingestion during a 6-year period. RESULTS Clonidine commonly belonged to the patients grand-mother (54%). Black children were twice as likely to be hospitalized for clonidine ingestion than white children compared with children hospitalized for any injury. Average time to onset of symptoms was 35 minutes. Decreased level of consciousness was the most common presenting symptom (96%). Mean ED vital signs were systolic blood pressure, 102 mm Hg; pulse, 98; respirations, 25 (six patients intubated); and temperature, 36.6 degrees C, Naloxone was administered to 49% of patients, 84% of whom demonstrated no response. CONCLUSION Clonidine ingestion is endemic in our area. Serious clinical effects mandate that all children with clonidine ingestion be triaged to a health care facility. Naloxone as an antidote for clonidine remains controversial.

Availability and perceived competence of pediatricians to serve as child protection team medical consultants: a survey of practicing pediatricians

Objectives: The effectiveness of multidisciplinary child protection teams has been demonstrated. This study is an attempt to assess the level of this commitment and the perceived competence of primary care pediatricians to provide this service. Methods: A questionnaire survey was mailed to primary care pediatricians practicing in the state of Alabama. Results: Among respondents who did not consider themselves competent to conduct sexual abuse or physical abuse examinations, 27% and 19%, respectively, were called on to conduct such examinations. Approximately half of respondents expressed a willingness to serve as consultants under a time commitment obligation of less than 2 hours per week or 1 day per month, and under a reimbursement provision of

Pediatric emergency medicine fellowship training in the new millennium.

200 per examination or less. Respondents recognized a need for, and expressed a desire for, more training in this area. Conclusions: Primary care pediatricians are willing to serve as multidisciplinary child protection team medical consultants if provided appropriate training and support.

Phenothiazine, Butyrophenone, and Other Psychotropic Medication Poisonings in Children and Adolescents

Objective Fellowship training in pediatric emergency medicine has been available since the early 1980s. Its availability increased rapidly in the late 1980s and early 1990s, but its growth has been much slower in recent years. In this report, we characterize and compare the training programs of today to those that existed 10 years ago. Our study deals with program content and design, focusing on five aspects of fellowship training: demographics, curriculum, clinical emergency department time, research, and benefits. The data gathered in this study are meant to assist programs, both new and old, in enhancing their fellowship training. Methods A 43-question survey was mailed to all known pediatric emergency medicine fellowship program directors in March of 2000. Two additional attempts were made to obtain survey responses. Forty of the 50 program directors responded, for a response rate of 80%. Statistical analysis was performed, and the data were compared with data that were gathered in two previous studies of fellowship training programs conducted in 1988 and 1991. Results Fellowship training in pediatric emergency medicine continues to grow but at a slower pace than previously experienced. The number of training programs has increased by 27% over the past 10 years; however, the number of first-year positions has only increased by 15%. Clinical fellow supervision has increased significantly over the years, likely as a result of changes in reimbursement. In 1990, 75% of fellows worked unsupervised in the emergency department versus 23% of first-year fellows, 56% of second-year fellows, and 74% of third-year fellows in the year 2000. The structure of the fellowship curriculum has become more standardized during the past 10 years, with numerous core rotations required by most programs. The percentage of programs offering protected research time has changed significantly over the years, with the amount of time increasing from 40% in 1988, to 95% in 1990, to 100% in 2000. The amount of clinical time has also increased with the transition to a 3-year program. Conclusions Pediatric emergency medicine continues to expand as a pediatric subspecialty but at a slower rate. During the previous decade, fellowship training has become more structured, with greater emphasis being placed on fellow supervision, standardization of education, and research. These data are meant to assist new as well as established fellowship programs with the development of their training curriculum.

Knowledge and management of sports concussions among coaches and certified athletic trainers in Alabama.

Objective: To describe the presentation, epidemiology, management, and outcome of phenothiazine and butyrophenone ingestions in children requiring hospitalization. Method: Retrospective case series in two pediatric hospitals. Results: Eighty-six cases were identified among 83 patients. The majority (69.7%) of ingestions occurred in children <6 years of age and there was no gender predominance. These ingestions were more common in African Americans (65.1%). They occurred more commonly in the patients (64.0%) or a relatives (22.1%) home and haloperidol and thioridazine accounted for 58.1% of exposures. Depressed levels of consciousness and dystonia were the most common presenting signs, present in 90.7% and 51.2% of patients, respectively. Miosis occurred in only 13.9% of the patients. Fluid boluses were administered to 28.7% of the patients but about a quarter of these had coingested potentially cardiotoxic drugs. In addition, 2 of the 12 (13.9%) patients with abnormal electrocardiograms had also ingested potentially cardiotoxic drugs. Numerous diagnostic tests were performed in these patients including electrolyte panels (80.2%), complete blood counts (69.8%), liver function tests (31.4%), serum osmolality (20.9%), blood cultures (10.5%), lumbar punctures (17.4%), head computed tomographies (15.1%), and electroencephalograms (3.5%). The median length of hospitalization was 1.78 (range 1–9) days and there were no deaths. Patients presenting with dystonias were more likely to have extensive diagnostic testing for neurologic disease than those presenting without dystonias. Conclusion: The presentation of phenothiazine and butyrophenone ingestions in children and adolescents may be nonspecific and confounded by coingestants. Patients with dystonias had more extensive neurologic testing than patients without dystonias, suggesting that physicians may not recognize dystonias as a clinical finding characteristic of phenothiazine or butyrophenone exposure.

Bicycle Injury Documentation Before and After Charting Intervention

Objectives To identify modifiable barriers in resources, knowledge, and management that may improve the care of young athletes with concussions in the state of Alabama. Methods An electronic survey was distributed to 2668 middle and high school coaches of contact sports in Alabama, and a paper survey was completed by 79 certified athletic trainers (ATCs) in 2010. Questions focused on their resource availability, knowledge of concussions based on the 2008 Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport (commonly known as the Zurich consensus statement), and management of concussions. Results A total of 402 (16% response rate) coaches and 55 ATCs (70% response rate) responded to the survey. This study highlights that ATC coverage often is limited to the high school level, football, and competitions. Both coaches and ATCs primarily use physicians to make return-to-play decisions, although coaches (43.7%) usually refer to primary care physicians, whereas ATCs (43.6%) refer to orthopedic or sports medicine physicians. The study also revealed that coaches and ATCs desire education and could expand concussion awareness by providing education to parents and athletes. No overall difference was seen in the knowledge and management of concussions between coaches and ATCs; however, ATCs were more likely to identify symptoms that are positive for concussions (P = 0.04). Both groups had difficulty recognizing subtle symptoms such as trouble sleeping, personality changes, and dizziness; they also were unaware that strenuous mental activities could delay concussion recovery, although ATCs scored significantly better than coaches (P < 0.001). Neither coaches nor ATCs consistently use standardized measures such as the Sports Concussion Assessment Tool 2 (7.5% vs 56.4%) or neuropsychological testing (5.3% vs 14.5%). Conclusions This study describes coaches’ and ATCs’ varying knowledge and management techniques and highlights areas in which targeted interventions and outreach could be useful. These areas include increased ATC availability, coach/ATC concussion education, improved parent/athlete education, increased “return to think” awareness, and more consistent use of Sports Concussion Assessment Tool 2.

Trends in Alabama teen driving death and injury

Background: Previous studies have shown that routinely completed free-text emergency department medical records contain limited information necessary for injury surveillance. We instituted an injury documentation sheet into our emergency department records to evaluate the impact on completeness of bicycle injury documentation rates. Methods: The pretest/posttest study design used E-codes to identify bicycle-related injuries. A standardized data collection tool was utilized to review these charts. Time periods before (January 1 to December 31, 2004) and after (January 1 to June 30, 2005) institution of a standardized documentation sheet were reviewed. Data were entered into the computer program, Epistat, and scores were used for comparison. Results: Initial review (n = 667) revealed mean age of patients 8.6 years, with 46% African American and 67% male. Helmet usage was documented in 49% of the charts (81 were wearing helmets; 245 were not wearing helmets). Mechanism of injury was documented as bicycle alone in 587, bicycle versus car in 13, and bicycle versus stationary object in 64. After implementation of an injury data sheet (n = 205), it was found that the mean age was 9.24 years, with 51% African American and 43% male. Helmet use was documented in 77% of cases (26 wearing helmets; 132 not wearing). Mechanism was documented as bicycle alone in 125, bicycle versus car in 66, and bicycle versus stationary object in 14. Helmet use was much more frequently documented after the initiation of an injury documentation reminder sheet (z = 6.97; P < 0.001; 95% confidence interval, 20.2-35.8). Conclusion: The use of standard injury documentation prompts increased completeness of documentation. With improved documentation, more accurate injury surveillance can be performed.

Emergency department poisoning visits in children younger than 6 years: comparing referrals by a regional poison control center to referrals by other sources.

BACKGROUND Motor vehicle crashes (MVCs) are a leading cause of morbidity and mortality in teens. Alabama has been in the Top 5 states for MVC fatality rate among teens in the United States for several years. Twelve years of teen MVC deaths and injuries were evaluated. Our hypothesis is that the teen driving motor vehicle–related deaths and injuries have decreased related to legislative and community awareness activities. METHODS A retrospective analysis of Alabama teen MVC deaths and injury for the years 2000 to 2011 was conducted. MVC data were obtained from a Fatality Analysis Reporting System data set managed by the Center for Advanced Public Safety at the University of Alabama. A Lowess regression–scattergram analysis was used to identify period specific changes in deaths and injury over time. Statistical analysis was conducted using True Epistat 5.0 software. When the Lowess regression was applied, there was an obvious change in the trend line in 2007. To test that observation, we then compared medians in the pre-2007 and post-2007 periods, which validated our observation. Moreover, it provided a near-even number of observations for comparison. The Spearman rank correlation was used to test for correlation of deaths and injury over time. The Mann-Whitney U-test was used to evaluate median differences in deaths and injury comparing pre-2007 and post-2007 data. RESULTS Alabama teen MVC deaths and injury demonstrated a significant negative correlation over the 12-year period (Rs for deaths and injury, −0.87 [p < 0.001] and −0.92 [p < 0.001], respectively). Lowess regression identified a notable decline in deaths and injury after the year 2006. Median deaths and injury for the pre-2007 period were significantly higher than the post-2007 period, (U = 35.0, p = 0.003). CONCLUSION Alabama teen driver deaths and injury have decreased during the 12-year study period, most notably after 2006. Factors that may have contributed to this trend may include stricter laws for teen drivers (enacted in 2002 and updated in 2010), less teen driving because of a nationwide economic downturn, delayed licensing in teens, steady improvements in overall seat belt use, and heightened public awareness of risky behaviors in teen driving. LEVEL OF EVIDENCE Epidemiologic study, level V.

Assessing the knowledge of all-terrain vehicle safety for children among Alabama pediatricians.

Objective The study purpose was to compare medical appropriateness and costs of regional poison control center (RPCC) versus non-RPCC referrals to children’s hospital emergency department (ED) for acute poison exposure. Methods This is a retrospective cross-sectional study of children (<6 years) during an 8-month period, who presented for poison exposure. Demographic and clinical patient characteristics were abstracted onto a uniform data form. Medical appropriateness was determined by presence of 1 of 4 criteria by 3 independent reviewers blinded to the patients’ race, source of referral, charges, and disposition. Results Determination of medical appropriateness was matched by all 3 reviewers in 187 patients who make up the study population. There were 92 RPCC-referred cases and 95 non-RPCC–referred controls. Groups were comparable by age, sex, toxin, and symptoms. For RPCC referrals, 84 were self-transported, and 8 were transported by emergency medical services. For non-RPCC referrals, 60 were self-referred/transported, 26 were transported by emergency medical services, and 9 were physician referred. Regional poison control center referrals had a 39.1% higher rate of medical appropriateness than did non-RPCC referrals (odds ratio, 13.0; 95% confidence interval, 3.6–36.1). For this sample, mean charges for inappropriate ED poison exposure visits were