Miguel Glatstein

Incidence of Traumatic Lumbar Puncture: Experience of a Large, Tertiary Care Pediatric Hospital

The objective of this study was to establish the incidence of traumatic or unsuccessful lumbar punctures (LPs) in the authors’ institution. This is a prospective study. Traumatic LP was defined as >400 red blood cells (RBCs) and unsuccessful LP as failure to obtain cerebrospinal fluid (CSF) after the first LP attempt. A total of 127 CSF were recorded over 1 year. The incidence of a traumatic LP was 27/103 (26.2%) using the sitting position and 3/24 (12.5%) in infants and children using the lying position. In total, 33 (26%) CSF samples had 0 RBCs. The incidence of traumatic LP was 24% when the procedure involved one LP and 50% when more than one attempt was required. RBC count was significantly lower in cases requiring only one attempt (P = .0074). Incidence of traumatic LP was independent of physicians’ experience, sedation use or time of procedure, suggesting an intrinsic factor as the cause of traumatic LPs.

The Effect of a Medical Clown on Pain During Intravenous Access in the Pediatric Emergency Department A Randomized Prospective Pilot Study

Background. We report the effect of the presence of a medical clown during insertion of an intravenous catheter during their emergency department visit. Methods. Prospectively randomized to either the presence or absence of a male medical clown during the procedure. Pain was assessed using the Faces Pain Scale–Revised in children 4 to 7 years old, and visual analog scales in children 8 years and older. Parental situational anxiety was recorded using the State-Trait Anxiety Inventory after the procedure. Results. The presence of a medical clown during a painful procedure in the pediatric emergency department tended to improve pain scores in children younger than 7 years. Parental situational anxiety was significantly reduced in parents of children older than 8 years (P = .02). Conclusion. Therapeutic clowns are useful for diminishing pain and anxiety during painful procedures being performed on children in the emergency department.

Accidental methadone ingestion in an infant: case report and review of the literature.

INTRODUCTION We discuss accidental methadone intoxication in an 11-month-old female infant, review the literature, and stress the potential for child abuse among methadone-maintained caregivers. CASE An 11-month-old female infant presented with lethargy. Vital signs were normal, and pupils were constricted. Sepsis workup revealed no evidence of bacterial infection. High venous pCO2 suggested respiratory acidosis. Urine toxicology revealed high concentrations of methadone and its metabolites, and the diagnosis of methadone intoxication was confirmed when 0.1 mg/kg intravenous naloxone normalized the childs behavior. Social service agency inquiries found that the childs grandfather had been prescribed methadone for acquired morphine addiction. He carried 5-mg methadone tablets in his pocket and had recently babysat the infant. The patient was subsequently discharged home with pediatric and community services follow-up. DISCUSSION Methadone intoxication should be considered in children presenting with lethargy, miosis, and respiratory depression. Seventy-two percent of reported methadone poisoning patients are symptomatic, and unintentional poisoning is a real danger to children because small amounts can be fatal. There are also several case reports where the cause of intoxication was homicide by the parents. Initial management consists of establishing an airway, and naloxone may be indicated, before urine toxicology results are obtained, to help establish the diagnosis. However, if 2 doses do not reverse the childs symptoms, the diagnosis should be questioned. When repeated bolus doses of naloxone are indicated, a continuous infusion may be preferable.

The role of physical examination in establishing the diagnosis of pneumonia.

Background Community-acquired pneumonia (CAP) is an important cause of acute respiratory disease in ambulatory care settings. The objective of this study was to assess the accuracy of medical history and physical examination in diagnosing CAP. Methods Pediatric residents prospectively completed a questionnaire documenting patients’ medical history and physical examination whenever a chest radiograph was ordered on patients 1 month to 16 years of age. Chest radiographs were read by a pediatric radiologist. Results Of 525 children participating in the study, 181 (34%) demonstrated findings of pneumonia. Thirty-four (19%) had no symptoms other than fever, and 51 (28%) had normal lung auscultation. Pediatric residents had the same interpretation in 85% of cases in which radiographic CAP was diagnosed by the radiologist, and in 76% of cases in which radiographic pneumonia was excluded by the radiologist. Conclusions Results demonstrate the significant added value of chest radiography as an ancillary test for diagnosis of pneumonia in the emergency department setting.

Late presentation of massive pleural effusion from intrathoracic migration of a ventriculoperitoneal shunt catheter: case report and review of the literature.

We report an unusual case of ventriculoperitoneal (VP) shunt intrathoracic migration, associated with massive symptomatic hydrothorax. The VP shunt was inserted 10 years before presentation, after hemorrhagic hydrocephalus caused by prenatal intraventricular hemorrhage. The pleural fluid was drained via tube thoracostomy and the shunt was externalized, with full resolution of symptoms and signs. The patient was subsequently managed with shunt revision with drainage into the abdominal cavity. We review the 10 pediatric cases of cerebrospinal fluid hydrothorax reported in the literature and discuss the mechanism of shunt tip migration. Pleural effusion secondary to VP shunt insertion is a rare and potentially life-threatening occurrence, and it should be suspected in any patient with a VP shunt and respiratory distress.

Ascorbic acid for the treatment of methemoglobinemia: the experience of a large tertiary care pediatric hospital.

The purpose of reporting this series of patients is to illustrate the role of ascorbic acid in the treatment of severe acquired methemoglobinemia (metHb), especially when methylene blue is not available. Medical records of affected patients were reviewed to collect history of exposures, food ingestion, physical examination, pulse oximetry, blood gas, and co-oximetry results, and outcomes. Five cases of acquired metHb are presented here, all of whom received treatment with ascorbic acid and fully recovered after 24 hours of treatment. Our series emphasizes that ascorbic acid is an effective alternative in the management of acquired metHb if methylene blue is unavailable and suggests that ascorbic acid infusion may be indicated in patients with glucose-6-phosphatase dehydrogenase deficiency.

Timing and Utility of Ultrasound in Diarrhea-Associated Hemolytic Uremic Syndrome: 7-Year Experience of a Large Tertiary Care Hospital

The authors reviewed the clinical, laboratory, and imaging data from cases of diarrhea-associated hemolytic uremic syndrome (HUS D+), diagnosed at our institution, from 2001 to 2008. The timing and utility of ultrasonographic features of HUS D+ were analyzed. The aim of the study was to determine factors that could aid in the early diagnosis of this disease. A total of 13 children with HUS D+ were identified out of 23 patients with HUS diagnosed during this time period. Evidence of Escherichia coli 0157:H7 was found in 9 cases (70%). Ultrasound studies were ordered in 10 patients (71%), all of which showed renal sonographic findings compatible with HUS. Ultrasound was performed at a mean of 13 days after onset of the diarrhea. Of note, 2 patients whose ultrasounds were performed at the beginning of their diarrheal illness manifested ultrasonographic features suggestive of HUS when there was only a mild increase in serum creatinine and no decrease in hemoglobin or platelets, suggesting that ultrasonography can identify renal involvement early in the course of the disease before other systemic signs appear. Early renal ultrasound may be a useful adjunct in the initial evaluation in children with bloody diarrhea. Evidence of increased renal echogenicity in a patient with bloody diarrhea could aid in early recognition of HUS when other diagnoses such as intussusceptions are being entertained, potentially allowing early intervention.

Propofol for pediatric colonoscopy: the experience of a large, tertiary care pediatric hospital.

Successful colonoscopy includes full visualization of the terminal ileum, especially in inflammatory bowel disease when ileal biopsy is essential. In children, higher levels of anxiety and lack of cooperation often necessitate a deeper level of sedation. The aim of this study was to evaluate the effectiveness of propofol compared with midazolam and fentanyl for colonoscopy, and in accomplishing ileal and cecal intubation in particular. This was a retrospective cohort study comparing the rates of successful colonoscopy in patients receiving propofol with those receiving midazolam/fentanyl. Complete, successful, colonoscopy to the terminal ileum was achieved in 78% of propofol patients compared with 66% of the midazolam/fentanyl group (P = 0.004). Endoscopy reaching the cecum, but not the terminal ileum, was achieved in 78% of propofol patients and 66% of midazolam/fentanyl patients. The use of propofol was associated with a statistically significant increase in the rate of successful colonoscopy reaching the terminal ileum.

Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury.

Abstract A retrospective review of all patients admitted between February 2004 and December 2009, with a diagnosis of burns associated with electrocution, was conducted at The Hospital for Sick Children, Toronto, Ontario, Canada. Data regarding type of electrocution and associated burns were collected. Of the 36 patients identified, 31 (86%) were shocked by electrical current, and 5 (14%) by lightning. Most burns associated with current were first degree (58%). The upper limbs, most frequently the wrist and arm (n = 23), were injured in 26 patients, and the lower limb in 2 patients, whereas 3 patients suffered multiple sites of injury. Twenty-eight patients were treated conservatively with dressings and minor surgical interventions such as debridement and primary repair. The remainder required excision and/or grafting. Fasciotomy and/or escharotomy were performed in 2 patients, and no one required amputation. Burns associated with electrical injuries remain a worldwide problem, responsible for considerable morbidity and mortality. They can usually be prevented through simple safety measures. An effective prevention program would help address this problem.

An Unusual Cause of Small Bowel Obstruction in a Child: Ingested Rhubarb

Small bowel obstruction is rarely caused by bezoars concretions formed from undigested foreign material in the gastrointestinal tract. An important cause of bezoars is phytobezoars, formed from vegetables or fruits. A four-year-old boy presented to our emergency department with symptoms of acute intestinal obstruction. Upright plain abdominal radiography revealed multiple air fluid levels. Ultrasound showed no abnormalities, and because of worsening symptoms computed tomography of abdomen was performed. It showed intraluminal obstruction of the terminal ileum. Exploratory laparotomy revealed a phytobezoar consisting of undigested rhubarb. The mass was milked through the large bowel and out the anus. Although rare in humans, bezoars are a well-documented cause of small bowel obstruction and should be considered when intraluminal bowel obstruction occurs. Bezoars causing small bowel obstruction may require surgical treatment.