Peter W. Glaeser

Five-year experience in prehospital intraosseous infusions in children and adults.

STUDY OBJECTIVEnTo evaluate the ability of emergency medical technician-paramedic (EMT-P) units to become and remain proficient in the performance of the intraosseous infusion procedure.nnnDESIGN AND SETTINGnDescriptive nonrandomized trial open to all patients meeting protocol criteria over a five-year period; prehospital urban and suburban area with a population of 951,000.nnnPARTICIPANTSnOne hundred fifty-two consecutive patients (age range, newborn to 102 years) who had intraosseous infusion line placement attempted by EMT-Ps.nnnINTERVENTIONnJamshidi sternal intraosseous infusion needle placed in the proximal tibia bone marrow in patients requiring emergency vascular access for fluid and/or medication administration.nnnRESULTSnEMT-Ps performed 165 attempts on 152 patients with a five-year success rate of 76% per patient and 70% per attempt. Success rates per patient age group were 78%, 0 to 11 months; 85%, 1 to 2 years; 67%, 3 to 9 years; and 50%, 10 years or older. Success rates were significantly higher in children 3 years old compared with children and adults 3 or more years old (P = .04). Proficiency was maintained over the five-year study period. Infiltration was the most common complication, occurring in 14 patients (12%). Errors in landmark identification and needle bending were the most frequent identifiable causes for unsuccessful attempts. Evidence of clinical response to fluid or medication infused was noted in 28 patients (24%).nnnCONCLUSIONnEMT-P units can successfully perform the intraosseous infusion line procedure in patients of all ages. Proficiency is maintained over time despite its infrequent use by individual EMT-Ps.

The effect of oral midazolam on anxiety of preschool children during laceration repair.

Preschool age children often experience marked anxiety and physical pain during laceration repair. Locally infiltrated anesthetics or topical tetracaine, adrenaline, and cocaine (TAC) usually control the physical pain but have little or no effect on anxiety. Midazolam is a short-acting benzodiazepine with anxiolytic, hypnotic, and antegrade amnestic effects. In a double-blind, randomized clinical trial, we evaluated the efficacy of midazolam in alleviating anxiety during laceration repair in children less than 6 years old. On admission to the emergency department, anxiety level was determined on a scale of 1 to 4 based on a predetermined behavior criteria. Patients with high anxiety level (3 or 4) received a single oral dose of either midazolam (0.2 mg/kg) or placebo. The anxiolytic effect of midazolam was considered adequate if the anxiety level decreased two or more points (from 4 to less than or equal to 2 or from 3 to 1) during laceration repair. In the midazolam group (30), 70% of the children had a two-point or more decrease in anxiety level compared with 12% in the placebo group (25) (P less than .0001). No respiratory depression or other complications were noted in the midazolam group. We conclude that a single oral dose of midazolam (0.2 mg/kg) is a safe and effective treatment for alleviating anxiety in children less than 6 years old during laceration repair in the ED.

Prehospital care of the pulseless, nonbreathing pediatric patient

The performance of life-saving procedures by prehospital care personnel was reviewed in the cases of 114 pulseless, nonbreathing pediatric patients. Children 18 months to 18 years of age had a significantly greater chance of having prehospital endotracheal intubation and vascular access established compared to children younger than 18 months of age. For all patients, witnessed arrest and initial rhythm of ventricular fibrillation were significantly associated with survival. In the younger children, endotracheal intubation also was associated significantly with survival. Nine (8%) patients survived, and only three of the survivors were without neurologic sequelae. The number of neurologically intact survivors was too small to show a statistically significant association with these factors.

Improved prehospital pediatric ALS care after an EMT-paramedic clinical training course

The objective was to determine the association between the performance rates of pediatric advanced life-support procedures, intubation and vascular access, by emergency medicine technician-paramedics (EMT-P), and introduction of an EMT-P pediatric advanced life support (PALS) clinical course. Prehospital EMT-P care records from January 1990 to December 1991 were retrospectively reviewed to determine endotracheal intubation and vascular access performance rates. These rates were compared with intubation and vascular access performance rates by EMT-Ps from January 1983 to June 1985. In 1986, an EMT-P PALS clinical course was introduced that included rotations during which an EMT-P trainee performed endotracheal intubation of children, under the supervision of a pediatric anesthesiologist, and vascular access, under the supervision of pediatric emergency medicine nurses and physicians. The trainees and all active EMT-Ps were taught the intraosseous infusion procedure. During January 1990 to December 1991, 193 children received prehospital endotracheal intubation attempts and 167 (87%) were intubated. Intubation performance rates for 90 children younger than 18 months of age was 90% and was 83% for 103 children > or = 18 months of age. Vascular access, intravenous or intraosseous, was established in 130 (73%) of the children; no attempt was made in 14 children. The vascular access performance rate was 64% for children younger than 18 months of age and 79% for children > or = 18 months old. Intubation performance rates of EMT-Ps before the EMT-P PALS clinical course (January 1983 to June 1985) were 48% for children younger than 18 months of age and 85% for children > or = 18 months old.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency intraosseous infusions in children

Vascular access during advanced life support is essential. Vascular access in the critically ill child can be particularly difficult and often causes unacceptable delay. Intraosseous infusion provides safe, rapid, reliable access to the venous circulation. A case is presented illustrating the value of familiarity with this procedure. Use of the bone marrow for emergency administration of fluids and medications should be considered early in resuscitation until vascular access is obtained.

Pediatric intraosseous infusions: Impact on vascular access time

A 1-year retrospective chart review was performed to evaluate the effect of intraosseous infusions (IO) on the time required to establish vascular access in pediatric patients requiring immediate vascular access for resuscitation. Eighty-one patients were identified, including 29 pulseless and non-breathing and 52 noncardiopulmonary arrest children, who required intravenous fluids or medication for resuscitation. Comparing the results with a previous review, the IO method effectively reduced the time needed to establish vascular access in the arrested group when standard techniques failed, particularly in the child less than 2 years old. The IO method was not used effectively in the non-arrest group, as evidenced by a significantly greater mean time required to establish vascular access. There were no significant complications related to the IO procedure. Nine (50%) of the patients receiving IO fluids or medication had clinical and/or laboratory evidence that these substances reached the central circulation. Early use of IO infusion in the resuscitation is recommended for not only the arrested patient, but also the critical nonarrested patient requiring immediate vascular access.

The role of abdominal x-rays in the diagnosis and management of intussusception

The management of intussusception requires early diagnosis and reduction with either barium enema or surgical intervention. Supine and erect abdominal radiographs are often obtained prior to ordering a barium enema. In many pediatric centers, the critical, initial interpretation of these radiographs is made by nonradiologists and, in most instances, by pediatric emergency physicians. We determined the sensitivity and specificity of abdominal radiographs in diagnosing intussusception when interpreted by these physicians. Six full-time pediatric emergency physicians evaluated 126 radiographs from 42 patients with intussusception, 42 in whom the disease was clinically suspected but ruled out, and 42 in whom the final radiology report was “normal.” These were presented to pediatric emergency physicians in a blinded, randomized sequence without any additional clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% (range, 71–93%), and the mean specificity was 58% (range, 48–69%). This compares favorably to the sensitivity of signs and symptoms, and we conclude that plain and upright abdominal films are a useful adjunct for the clinician evaluating patients for suspected intussusception.

Clinical predictors of bacterial versus aseptic meningitis in childhood

STUDY OBJECTIVEnTo assess the reliability of meningeal signs and other physical findings in predicting bacterial and aseptic meningitis at various ages.nnnDESIGNnChildren requiring lumbar puncture were evaluated prospectively for meningeal signs and other physical parameters before lumbar puncture.nnnSETTINGnEmergency department of Childrens Hospital of Wisconsin.nnnPARTICIPANTSnOne hundred seventy-two children, aged 1 week to 17 years, with meningitis (53 bacterial and 119 aseptic).nnnMEASUREMENTS AND MAIN RESULTSnNuchal rigidity was present in 27% of infants aged 0 to 6 months with bacterial meningitis versus 95% of patients 19 months or older (P = .0001). Three percent of infants 0 to 6 months old with aseptic meningitis had nuchal rigidity versus 79% of patients 19 months or older (P = .0005). Seventy-two percent of infants 12 months of age or younger with bacterial meningitis has at least one positive meningeal sign versus 17% of infants with aseptic meningitis (P = .0001). Eighty-five percent of children older than 12 months with meningitis had at least one positive meningeal sign, 93% with bacterial meningitis, and 82% with aseptic meningitis.nnnCONCLUSIONnDespite a lack of meningeal signs, a high index of suspicion for meningitis is essential when evaluating the febrile infant 12 months of age or younger.

Pediatric sexual abuse management in a sample of children’s hospitals

Medical directors of pediatric emergency departments were surveyed by mail to determine the present role of their pediatric hospitals in general, and emergency departments in particular, in the evaluation and management of pediatric sexual assault and abuse. Seventy-four percent of the responses were from communities with an estimated yearly incidence of sexual abuse cases greater than 500. Sixty-eight percent of the communities had a designated pediatric sexual assault center. Thirty-two percent were affiliated with adult facilities and 68% with pediatric facilities. Of those hospitals responding, initial evaluation was most often performed in the emergency department in 77%. Most initial evaluations were performed by resident (PL-2 or above) level physicians (59%). The availability of nonphysician professionals, eg, social workers, was felt to be always or usually adequate in 57% and occasionally, rarely, or never adequate in 43%. Estimated physician time required for evaluations averaged less than 60 minutes in 52%, 60 to 90 minutes in 32%, and greater than 90 minutes in 16%. Other patients were felt to be always or frequently compromised in 34% and occasionally compromised in another 44%. The directors rated the abilities of their respective departments to evaluate and manage these patients as excellent in 33%, good in 33%, adequate in 29%, and inadequate in 4%.

Pediatric emergency departments

Pediatric emergency departments were surveyed by mail to determine the following patient and physician characteristics: census, triage classification, and staffing characteristics. The average number of patient visits per department per year was 44,615 (SD ± 15,650). Of these, the mean percentage triaged as emergent, urgent, and nonurgent was 14.6 (SD ± 13.4%), 35.4 (SD ± 13.1%), and 52.2 (SD ± 8.7%), respectively. The average number of full-time attending physicians per department was five. Fifty-nine (91%) of the physicians were pediatric board centrified, and five (7.6%) were emergency medicine board certified. Academic standing, salaries, clinical research requirements, teaching responsibilities, and average patient care hours were also reviewed. From these data, suggestions for the management of patient care, teaching, and clinical research are presented.