Richard J. Scarfone

Oral versus intravenous corticosteroids in children hospitalized with asthma.

BACKGROUND Previous studies have demonstrated that in the emergency treatment of an asthma exacerbation, corticosteroids used in conjunction with beta-agonists result in lower hospitalization rates for children and adults. Furthermore, orally administered corticosteroids have been found to be effective in the treatment of outpatients with asthma. However, similar data in inpatients is lacking. OBJECTIVE The purpose of this study was to determine the efficacy of oral prednisone versus intravenous methylprednisolone in equivalent doses for the treatment of an acute asthma exacerbation in hospitalized children. METHODS We conducted a randomized, double-blind, double-placebo study comparing oral prednisone at 2 mg/kg/dose (maximum 120 mg/dose) twice daily versus intravenous methylprednisolone at 1 mg/kg/dose (maximum 60 mg/dose) four times daily in a group of patients 2 through 18 years of age hospitalized for an acute asthma exacerbation. All patients were assessed by a clinical asthma score 3 times a day. The main study outcome was length of hospitalization; total length of stay and time elapsed before beta-agonists could be administered at 6-hour intervals. Duration of supplemental oxygen administration and peak flow measurements were secondary outcome measures. RESULTS Sixty-six patients were evaluated. Children in the prednisone group had a mean length of stay of 70 hours compared with 78 hours for the methylprednisolone group (P =.52). Children in the prednisone group were successfully weaned to beta-agonists in 6-hour intervals after 59 hours compared with 68 hours for the methylprednisolone group (P =.47). Patients receiving prednisone required supplemental oxygen for 30 hours compared with 52 hours for the methylprednisolone group (P =.04). CONCLUSION There was no difference in length of hospital stay between asthmatic patients receiving oral prednisone and those receiving intravenous methylprednisolone. Because hospitalization charges are approximately 10 times greater for intravenous methylprednisolone compared with oral prednisone, the use of oral prednisone to treat inpatients with acute asthma would result in substantial savings.

Predictors of Primary Care Follow-Up After a Pediatric Emergency Visit for Asthma

Objective. Prior studies have reported low rates of follow-up with a primary care provider (PCP) after emergency department (ED) treatment for asthma. We sought to identify predictors associated with PCP follow-up. Methods. As part of a randomized trial we surveyed parents of children aged 2–18 years being discharged after ED asthma treatment. Parents described their childs asthma history and perceived benefits and barriers to making a PCP follow-up visit. Bivariate tests and multivariable logistic regression were used to determine association with completion of a follow-up visit within 4 weeks of the ED visit. Results. A total of 278 subjects (N = 278)were enrolled; 55% saw their PCP within 4 weeks of the ED visit. Baseline factors that were associated with an increased likelihood of follow-up included a recent hospitalization, more than one ED visit for asthma in the past year, the parents assessment that the child has “very severe” asthma, and current daily use of a controller medication. Parental beliefs that taking daily asthma medications and finding out about the causes of asthma attacks were very important and were also associated with increased PCP follow-up. Parents were less likely to follow up if they reported a lack of convenient appointments or prolonged waits in the PCP office. A multivariable model including clinical factors, parental beliefs, and the study intervention predicted the likelihood of follow-up. Conclusions. Parental beliefs about asthma severity, the benefits of controlling asthma, and organizational barriers to seeing a PCP were associated with follow-up after a pediatric ED visit for asthma.

Utility of laboratory testing for infants with seizures.

Objectives Study objectives were to 1) determine the frequency with which laboratory studies are obtained, 2) determine the proportion of results that are clinically significantly abnormal, and 3) define the clinical characteristics of those with abnormal results, among infants with nonfebrile seizures (NFSz). Methods A retrospective consecutive cohort study of infants ≤12 months old presenting to the ED of a tertiary care, children’s hospital following a seizure. A 2-year review was performed. Serum chemistry results were classified as “normal,” “outside of the normal range,” or “clinically significantly abnormal.” Results Sixty-seven of 134 (50%) with a NFSz were tested compared to 19/80 (24%) with a febrile seizure (FSz, P< 0.001). Nine (5 with hyponatremia and 4 with hypocalcemia) of the 67 (13%) tested NFSz infants had a clinically significant abnormality, as did 9 of 21 (43%) NFSz infants who seized in the ED compared to 0/46 (0%) without ED seizure activity (P< 0.0001). Hypothermia (T < 36.5°C) and age less than 1 month were common characteristics of infants with clinically significant abnormalities. Conclusions This is one of the only studies to have assessed the utility of laboratory testing for infants with seizures. Abnormal serum chemistries accounted for a greater proportion of seizures among this cohort compared to that reported previously for older children. Laboratory testing is recommended for NFSz infants who 1) are actively seizing in the ED, 2) have a temperature below 36.5°C, or 3) are less than 1 month of age.

Corticosteroids in acute asthma: past, present, and future.

TARGET AUDIENCE This CME activity is intended for physicians, medical students, nurse practitioners, and physician assistants who manage children with acute asthma exacerbations in either the emergency department (ED) or office-based settings. Pediatric emergency physicians, emergency physicians, pediatricians, and family practitioners will find this information especially useful. LEARNING OBJECTIVES After completion of this article, the reader will be able to: 1. Describe the anti-inflammatory actions of corticosteroids in the treatment of acute asthma. 2. Summarize the results of studies proving the efficacy of corticosteroids in the ED treatment of acute asthma. 3. State the basis for the current standard of care in the use of systemic corticosteroids to treat children with acute asthma. 4. Discuss the potential role for inhaled corticosteroids (ICS) in the ED treatment of children with acute asthma. 5. Describe options in the use of corticosteroids for children discharged from the ED after asthma exacerbations.

Outcomes of children referred to an emergency department by an after-hours call center

Background and objectives: After-hours call centers are increasingly prevalent, yet there is little patient outcomes data. We sought to determine compliance with referral to an emergency department (ED) and describe outcomes and clinical characteristics of referred patients including triage classifications, therapeutic interventions, diagnostic testing, diagnoses, and hospitalization rates. Design and participants: A retrospective cohort design. We studied hospital-based primary care patients who were referred to the ED of a tertiary care childrens hospital by the call center, without physician consultation. Results: Of the 8265 telephone calls to the call center, 1473 (18%) children were referred to the ED, and 931 (63%) were compliant. Compliant patients were significantly younger (P = 0.01) and were more likely to have been referred to the ED immediately (P = 0.01) compared with noncompliant patients. Among compliant patients, 48% were classified as nonurgent at ED triage; of these, half did not have a therapeutic intervention or diagnostic test or require hospitalization. Overall, therapeutic interventions were administered to 44%, diagnostic tests were performed for 45%, and 13% were hospitalized. Compared to children referred immediately to the ED, the proportion instructed to go to the ED within 4 hours of the telephone call received significantly lower ED triage classifications (93% vs. 77%, P < 0.00001) and hospitalizations (15% vs. 6%, P = 0.001). Conclusions: In this study, we report the outcomes and clinical characteristics of children referred to the ED by an after-hours call center. Data such as these may be used by call centers in the assessment of management advice and referral practices.

Hospital-based pandemic influenza preparedness and response: strategies to increase surge capacity.

In the spring of 2009, the first patients infected with 2009 H1N1 virus were arriving for care in hospitals in the United States. Anticipating a second wave of infection, our hospital leaders initiated multidisciplinary planning activities to prepare to increase capacity by expansion of emergency department (ED) and inpatient functional space and redeployment of medical personnel. Experience: During the fall pandemic surge, this urban, tertiary-care childrens hospital experienced a 48% increase in ED visits and a 12% increase in daily peak inpatient census. However, several strategies were effective in mitigating the pandemics impact including using a portion of the hospitals lobby for ED waiting, using a subspecialty clinic and a 24-hour short stay unit to care for ED patients, and using physicians not board certified in pediatric emergency medicine and inpatient-unit medical nurses to care for ED patients. The average time patients waited to be seen by an ED physician and the proportion of children leaving the ED without being seen by a physician was less than for the period when seasonal influenza peaked in the winter of 2008-2009. Furthermore, the ED did not go on divert status, no elective medical or surgical admissions required cancellation, and there were no increases in serious patient safety events. Summary: Our health center successfully met the challenges posed by the 2009 H1N1 outbreak. The intent in sharing the details of our planning and experience is to allow others to determine which elements of this planning might be adapted for managing a surge of patients in their setting.

Nebulized Budesonide Added to Standard Pediatric Emergency Department Treatment of Acute Asthma: A Randomized, Double-blind Trial

OBJECTIVES The goal was to determine if adding inhaled budesonide to standard asthma therapy improves outcomes of pediatric patients presenting to the emergency department (ED) with acute asthma. METHODS The authors conducted a randomized, double-blind, placebo-controlled trial in a tertiary care, urban pediatric ED. Patients 2 to 18 years of age with moderate to severe acute asthma were randomized to receive either a single 2-mg dose of budesonide inhalation suspension (BUD) or normal sterile saline (NSS) placebo, added to albuterol, ipratropium bromide (IB), and systemic corticosteroids (SCS). The primary outcome was the difference in median asthma scores between treatment groups at 2 hours. Secondary outcomes included differences in vital signs and hospitalization rates. RESULTS A total of 180 patients were enrolled. Treatment groups had similar baseline demographics, asthma scores, and vital signs. A total of 169 patients (88 BUD, 81 NSS) were assessed for the primary outcome. No significant difference was found between groups in the change in median asthma score at 2 hours (BUD -3, NSS -3, p = 0.64). Vital signs at 2 hours were also similar between groups. Fifty-six children (62%) were admitted to the hospital in the BUD group and 55 (62%) in the NSS group (difference 0%, 95% confidence interval [CI] = -14% to 14%). Neither multivariate adjustment nor planned subgroup analysis by inhaled corticosteroids (ICS) use prior to the ED significantly altered the results. CONCLUSIONS For children 2 to 18 years of age treated in the ED for acute asthma, a single 2-mg dose of budesonide added to standard therapy did not improve asthma severity scores or other short-term ED-based outcomes.

Children referred to an emergency department by an after-hours call center: complaint-specific analysis.

Background and Objectives: Approximately 20% of phone calls to after-hours call centers result in referrals to the emergency department (ED), but data regarding ED management and disposition are lacking. We sought to determine the acuity of illness of referred children as reflected by triage classifications and need for therapeutic interventions, diagnostic testing, and hospitalization, and to stratify the analysis of ED management and dispositions by chief complaints. Design and Methods: Patients referred to the ED by the after-hours call centers, without physician consultation, were identified. The 4 most common groups of chief complaints resulting in ED referral were determined, and the records of these children were analyzed. Results: The 525 patients with chief complaints related to the following organ systems were studied: lower respiratory tract, 263 (50%); gastrointestinal, 104 (20%); head, ears, eyes, nose, and throat, 84 (16%); and upper respiratory tract, 74 (14%). The proportion of children referred for lower respiratory tract complaints who received the after-hours call centers call dispositions (99%) or ED triage classifications (38%) of highest priorities, or who required therapeutic interventions (73%), diagnostic testing (40%), or hospitalization (22%) was significantly higher than for all other categories. Thirteen percent with gastrointestinal complaints, referred primarily for dehydration, required intravenous fluids, and 2% of head, ears, eyes, nose, and throat patients required hospitalization. Conclusions: Children referred to the ED for illnesses related to the lower respiratory tract, principally wheezing, had illnesses of high acuity. On the other hand, current criteria for ED referral for children in the gastrointestinal, head, ears, eyes, nose, and throat, and upper respiratory tract categories result in the referral of many children with nonurgent problems. These data support a reassessment of current referral practices for children with these complaints.

Cardiac tamponade complicating postpericardiotomy syndrome.

Objective A measure of research activity is an important way to gauge knowledge advances. We designed this study to analyze trends in pediatric emergency medicine (PEM) research, particularly focusing on the amount of research presented, topics investigated, location of research presentation, study design, and use of statistical analysis. Methods Every abstract presented between January 1987 and December 1999 from 4 national scientific meetings [Ambulatory Pediatric Association (APA), American Academy of Pediatrics (AAP), American College of Emergency Physicians (ACEP), and Society for Academic Emergency Medicine (SAEM)] was evaluated. Those abstracts that met study criteria were evaluated for research topic, year of presentation, and sponsoring organization. Abstracts from the first and last 5 years of the study period were assessed for study design and use of statistical analysis. Trends over time were examined. Results There were 1675 abstracts presented over the 13-year study period: 41% at APA, 27% at AAP, 7% at ACEP, and 25% at AEM. Medical topics were most frequently investigated (36%) followed by trauma (20%), administrative (17%), procedural (14%), life-threatening emergencies (12%), and surgical (3%). Two percent of abstracts was presented in the first year and the greatest proportion (14%) was presented in 1999 (P < 0.001). Eighty percent of the abstracts was assessed for study design and use of statistics. There was no change in the proportion of abstracts that were prospective [odds ratio (OR) = 0.98 (95% confidence interval (CI) = 0.76–1.26)] or analytic [OR = 1.06 (95% CI = 0.83–1.35)] between the early and the later years. Descriptive surveys increased in frequency from the early to the later years [OR = 1.92 (95% CI = 1.29–2.92)] as did multicentered clinical trials [OR = 7.71 (95% CI = 1.97–66.38)]. Case series decreased in frequency [OR = 0.71 (95% CI = 0.54–0.93)] as did bench research [OR = 0.21 (95% CI = 0.11–0.40)]. The use of statistics increased with time [OR = 1.99 (95% CI = 1.54–2.58)] as did the use of CIs [OR = 4.40 (95% CI = 2.76–7.29)]. Conclusions There was a substantial increase in the amount of research conducted in PEM. The topics investigated correspond to national recommendations. There was not an increase in the amount of research that was prospective or analytic in nature; however, there was increased statistical sophistication with time.

Acute, severe bilirubin encephalopathy in a newborn.

Abstract: In recent years, changes in health care practices including the early discharge of newborns have transformed the management of neonatal jaundice into an outpatient problem. At the same time, there has been a resurgence in the incidence of kernicterus. We report the case of a term male infant who presented to our emergency department at 4 days of age with severe jaundice and who subsequently died with autopsy findings of kernicterus. We review the infants presentation and hospital course, diagnostic and therapeutic interventions, and autopsy findings. In the current era of increased frequency of breast-feeding, shortened hospital stays, and inconsistent follow-up after hospital discharge, emergency department physicians should be alerted to the rare but increasing occurrence of severe hyperbilirubinemia and kernicterus.