Norman M. Rosenberg

Intramuscular versus oral antibiotic therapy for the prevention of meningitis and other bacterial sequelae in young, febrile children at risk for occult bacteremia

Because studies of the treatment of children with occult bacteremia have yielded conflicting results, we compared ceftriaxone with amoxicillin for therapy. Inclusion criteria were age 3 to 36 months, temperature > or = 39 degrees C, an acute febrile illness with no focal findings or with otitis media (6/10 centers), and culture of blood. Subjects were randomly assigned to receive either ceftriaxone, 50 mg/kg intramuscularly, or amoxicillin, 20 mg/kg/dose orally for six doses. Of 6733 patients enrolled, 195 had bacteremia and 192 were evaluable: 164 Streptococcus pneumoniae, 9 Haemophilus influenzae type b, 7 Salmonella, 2 Neisseria meningitidis, and 10 other. After treatment, three patients receiving amoxicillin had the same organism isolated from their blood (two H. influenzae type b, one Salmonella) and two from the spinal fluid (two H. influenzae type b), compared with none given ceftriaxone. Probable or definite infections occurred in three children treated with ceftriaxone and six given amoxicillin (adjusted odds ratio 0.43, 95% confidence interval 0.08 to 1.82, p = 0.31). The five children with definite bacterial infections (three meningitis, one pneumonia, one sepsis) received amoxicillin (adjusted odds ratio 0.00, 95% confidence interval 0.00 to 0.52, p = 0.02). Fever persisted less often with ceftriaxone (adjusted odds ratio 0.52, 95% confidence interval 0.28 to 0.94, p = 0.04). Although the difference in total infections was not significant, ceftriaxone eradicated bacteremia, prevented significantly more definite focal bacterial complications, and was associated with less persistent fever.

Frequency of suspected abuse/neglect in burn patients

This study was conducted to determine the frequency of suspected abuse/neglect in pediatric patients with burns presenting to an emergency department. Criteria were established for the suspicion of abuse/neglect. During a 12-month period, 431 patients were evaluated. Eighty-four (19.5%) were suspected of being abused or neglected. The frequency of suspected abuse/neglect in single-parent families was 22%, compared to 10% for married couples (P = 0.027). There was no significant difference in the rate of suspected abuse/neglect in patients seen fewer than or more than 24 hours after the injury occurred. Seventy-five children (17%) had more than two burn sites, with 24 (32%) appearing to be a result of abuse/neglect (P = 0.01). One hundred twenty-eight patients (30%) were admitted to the hospital, with 34% suspected of being abused/neglected, compared to 13% who were treated on an ambulatory basis (P = 0.00005). Fifty-eight (69%) of the suspected abused/neglected patients were diagnosed based on the history and/or physical examination. The medical records of 31% revealed previous abuse/neglect, ingestion, failure to thrive, or old burns. We conclude that abuse or neglect is a significant factor in pediatric burn patients and that the childs previous medical record must be reviewed. Other associated factors include a single parent family or the child with greater than two burn sites. The actual incidence of abuse/neglect could not be determined, owing to laws regarding confidentiality.

Trauma in infants less than three months of age

We evaluated the characteristics of traumatic injury and risk for subsequent trauma in infants less than three months of age (n = 111). Medical records were reviewed at presentation and one year later. Injury was due to abuse/neglect in 28%, whereas 72% were accidentally injured. Falls were the most common mechanism of accidental injury (67%). The percentage of infants with skull fractures was greater in the abuse/neglect group than in the accidental group (7/31 vs 7/80; P lt; 0.05) with a tendency toward more diastatic and multiple skull fractures (6/7 vs 2/7) as well as intracranial hemorrhages (3/7 vs 0/7). More infants in the abuse/neglect group suffered extremity fractures (4/31 vs 2/80; P lt; 0.05). Hospitalization was more frequent (12/31 vs 8/80; P lt; 0.001), as was social or protective service intervention (25/31 vs 17/80; P lt; 0.001), in the abuse/neglect group. The two groups showed no difference in the number of previous emergency department (ED) visits; however, the use of the ED declined significantly in the abuse/neglect group following the trauma (0.81 ± 1.2 vs 1.5 ± 2.1 visits; P lt; 0.05). The abuse/neglect group tended to have a greater number of subsequent traumatic injuries than those accidentally injured. Abuse/neglect should be considered in any seriously injured infant less than three months of age because of the likelihood of subsequent trauma.

A fatal case of colic.

The potential causes of excessive, prolonged crying in early infancy represent a broad range of conditions. The underlying etiology causing an acute episode of crying may not be recognized in a single emergency department encounter. An adverse outcome may result when an infant with unexplained crying is discharged with a diagnosis of colic.

Pediatric cardiopulmonary arrest in the emergency department

A prospective observation of cardiopulmonary resuscitation was made at an active municipal pediatric emergency department. Pediatric cardiorespiratory arrest, documented in only 26 patients over a 12-month period, was unusual. Fifteen were less than 1 year old, and four children survived to discharge. Asystole was present in 24 of 26 patients with cardiac arrest. Congenital abnormalities were present in 23% of patients; however, these accounted for 50% of the survivors. The overall survival rate was 15.4%. Suggestions for termination of resuscitation are given.

Use of Emergency Medical Service transport system in medical patients up to 36 months of age.

Objectives To determine the frequency of inappropriate transport by Emergency Medical Service (EMS). Design A retrospective study. Subjects Patients up to 36 months of age with medical complaints transported by EMS to an urban pediatric emergency department (ED). Interventions None. Measurements Arbitrary criteria for appropriate use of EMS transport system were developed. The age, triage status, number of previous uses of EMS, health insurance status, time of calls, chief complaint, and clinical management of patients in the ED were determined. The frequency of inappropriate use of EMS was determined and also the percentage of patients up to 36 months of age who used EMS transport system on more than one occasion. Results Charts of 341 patients were reviewed of which 126 patients (37%) could have been transported by nonemergent vehicles according to our arbitrary criteria. In addition 97 (28%) of these patients had used the EMS transport system on at least one other occasion. Conclusions EMS is utilized for inappropriate transportation in approximately 37% of our pediatric patients less than 36 months of age with medical complaints. In addition, 28% of these same patients utilized the EMS system on more than one occasion. It would appear that education of care providers in the appropriate use of EMS and use of alternate means of transportation would make the system more efficient and productive.

Seizures associated with meningitis

The records of 187 patients with bacterial meningitis were reviewed. Seizures were a presenting manifestation in 25 (13%). Seven (28%) of the patients with a presenting seizure had been taking antibiotics prior to the diagnosis. Four of seven pretreated patients did not have additional signs or symptoms with the seizure, while all 18 patients without treatment had additional findings (P<0.01). Patients developing seizures while hospitalized had a poorer outcome than those without seizures. Patients with bacterial meningitis may present with only a seizure if they have been taking oral antibiotics; therefore, all patients taking antibiotics who develop a seizure require a lumbar puncture to exclude meningitis.

Incidence of infection in pediatric patients with laceration

Lacerations are common in emergency departments. A review of pediatric patients was carried out to determine the infection rate. During a three-month period, from August to October, 415 patients were prospectively evaluated to determine the occurrence of infections in sutured lacerations. Sixty-nine patients (16%) were lost to follow-up. Seven patients (2%) developed infections. The infection rate in the lower extremities was 8.5% (P < 0.0001). Six lacerations (5.3%) greater than 3 cm in size became infected, compared to one (0.4%) that was smaller than 3 cm (P < 0.0001). Falls accounted for 61 % of the injuries. The infection rate in children is less than that in adults. However, large lacerations in the lower extremities are at greater risk.

Use of topical lidocaine in pediatric laceration repair : A review of topical anesthetics

Objective: To determine whether application of topical aqueous lidocaine to a laceration attenuates the pain from the subsequent lidocaine injection in children. Design: Prospective, double-blind study. Setting: A large, urban, tertiary care childrens hospital emergency department. Patients: A convenience sample of 100 children, five to 16 years of age, presenting with simple lacerations over a six-month period. Interventions: An unlabelled 3-ml solution of either 1% lidocaine or placebo (saline) was used to soak a Telfa® pad (Kendall, Mansfield, MA) and then placed onto the laceration for 10 minutes. The wound was then injected with 1% lidocaine, irrigated, and sutured per standard emergency department protocol. Independent pain response was elicited from the patient and parent four times: before any intervention, after the soak, after the injection, and at the end of the procedure. Blood pressure and heart rates were recorded at the same intervals. Results: Four patients were excluded. Of the 96 remaining patients, 46 received the placebo and 50 received lidocaine. Age, sex, race, and laceration length and location were similar between groups. Physiologic parameters did not differ between groups. For all four pain ratings, the independent variables of age, sex, race, and laceration length or location did not differ between groups. Topical lidocaine was ineffective in relieving pain from the injection. When groups were combined, a significant negative correlation was noted for age versus injection pain (P = .035), with older children reporting less pain from injection than younger children. Conclusion: For children, soaking a simple laceration with 1% lidocaine does not decrease pain from the subsequent lidocaine injection.

Occult cocaine and opiate exposure in children and associated physical findings

We determined the prevalence of cocaine and opiate exposure and the association of exposure with objective physical findings in children presenting to an urban pediatric emergency department. The study included 942 children between one and 60 months of age who required urinalysis for investigation of their chief complaint. Anonymously and without informed consent, urine was screened for benzoylecgonine (BE) and opiates, using an enzyme multiplied immunoassay technique (EMIT) with sensitivity of 50 ng/ml. EMIT-positive samples were rescreened using a fluorescence polarization immunoassay (FPIA). Specimens positive by both EMIT and FPIA were confirmed by gas chromatography/mass spectrometry (GC/MS) if sufficient quantity of urine was available. BE was identified in 41 (4.4%) and opiates in 46 (4.9%) patients by both EMIT and FPIA. The presence of BE or opiate was confirmed by GC/MS in all 34 cases where sufficient urine was available. The age- and sex-adjusted systolic and diastolic blood pressure percentiles were greater, and head circumference and weight percentiles were lower in BE-positive patients compared to those with negative drug screens. There were no associations between opiate exposure and any of these variables. We conclude that occult postnatal cocaine exposure is associated with measurable physical and physiologic differences.