Robert G. Bolte

A Retrospective Review of Pediatric Patients With Epididymitis, Testicular Torsion, and Torsion of Testicular Appendages

Study Objective. To compare historical features, physical examination findings, and testicular color Doppler ultrasound in pediatric patients with epididymitis, testicular torsion, and torsion of appendix testis. Methods. A retrospective review of patients with the diagnosis of epididymitis, testicular torsion, or torsion of appendix testis. Results. Ninety patients were included in the study (64 with epididymitis, 13 with testicular torsion, and 13 with torsion of appendix testis). Historical features did not differ among groups except for duration of symptoms. Of 13 patients with testicular torsion all had a tender testicle and an absent cremasteric reflex. When compared with the testicular torsion group, fewer patients with epididymitis had a tender testicle (69%) or an absent cremasteric reflex (14%). 62 (97%) patients with epididymitis had a tender epididymis and 43 (67%) had scrotal erythema/edema. By comparison, 3 (23%) and 5 (38%) patients with testicular torsion had a tender epididymis or scrotal erythema/edema, respectively. Doppler ultrasound showed decreased or absent blood flow in 8 patients, 7 of whom were diagnosed with testicular torsion. Ten out of 13 patients with testicular torsion had a salvageable testicle at the time of surgery. Conclusion. The physical examination is helpful in distinguishing among epididymitis, testicular torsion, and torsion of appendix testis. Patients presenting with a tender testicle and an absent cremasteric reflex were more likely to have a testicular torsion rather than epididymitis or torsion of appendix testis. An absent cremasteric reflex was the most sensitive physical finding for diagnosing testicular torsion. Color Doppler ultrasound is a useful adjunct in the evaluation of the acute scrotum when physical findings are equivocal.

Applying Outpatient Protocols in Febrile Infants 1-28 Days of Age: Can the Threshold Be Lowered?

The purpose of this study was to determine the applicability of two accepted outpatient management protocols for the febrile infant 1-2 months of age (Boston and Philadelphia protocols) in febrile infants 1-28 days of age. We retrospectively reviewed charts of patients 1-28 days of age with a temperature greater than or equal to 38.00C. Criteria from each of the above-cited management protocols were applied to the patients to determine their applicability in screening for serious bacterial infection (SBI). An SBI was defined as bacterial growth in cultures from blood, urine, cerebrospinal fluid (CSF), stool, or any aspirated fluid. Overall, 372 febrile infants were included in the study. Ages ranged from 1 to 28 days of age. The mean age was 15 days. SBI occurred in 45 patients (12%). The mean age of the patients with an SBI was 13 days. Thirty-two infants (8.6%) had a urinary tract infection; 12 (3.2%), bacteremia; five (1.3%), bacterial meningitis; three (0.8%), cellulitis; one (0.3%), septic arthritis; one (0.3%), bacterial gastroenteritis; and one (0.3%), pneumonia. Ten infants had more than one SBI. Of 372 patients, 231 (62%) met the Bostons laboratory low-risk criteria; eight (3.5%) would have been sent home with an SBI with these criteria. Philadelphias laboratory low-risk criteria would have been met by 186 patients (50%); six (3.2%) would have been sent home with an SBI with these criteria. The negative predictive value of both the Boston and Philadelphia protocols for excluding an SBI was 97%. We conclude that current management protocols for febrile infants 1-2 months of age when applied to febrile infants 1 to 28 days of age would allow 3% of febrile infants less than 28 days of age to be sent home with an SBI. Current guidelines recommending admitting all febrile infants less than 28 days of age should be followed until the outcome of those 3% of febrile infants with an SBI treated as outpatients can be determined.

Effect of a Pediatric Trauma Response Team on Emergency Department Treatment Time and Mortality of Pediatric Trauma Victims

Objective. Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system. Design. A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team. Setting. A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States. Subjects. Pediatric trauma victims identified as critically injured (designated as “trauma one”) and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team. Interventions. A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as “trauma one”) is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes. Outcome Measures. Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation ofz score. Results. Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 ± 2 vs 21 ± 4 minutes), operating room (63 ± 16 vs 623 ± 27 minutes) and total time in the ED (85 ± 8 vs 821 ± 9 minutes). Calculation ofz score showed that survival for the control group was not different from the reference population (z = −0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102). Conclusion. Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.

Prehospital use of intraosseous infusion by paramedics.

Vascular access in young children frequently proves difficult in the prehospital setting. To assess the feasibility of training paramedics in the placement of intraosseous (IO) lines as an alternative to intravenous (IV) access, this pilot project studied a training program and treatment protocol for prehospital IO use. Paramedics underwent a training program in IO placement. Patients enrolled were less than five years of age and in cardiac arrest. During a 10-month period, paramedics attempted 12 IO placements, of which 10 (85%) were successful, nine on the first attempt. Although no patients achieved long-term survival, three were initially resuscitated from arrest. Paramedics can be trained in IO placement, and IO infusion can be used in prehospital pediatric care. Training methods, limitations, and implications for future use are discussed.

Appendiceal perforation in children diagnosed in a pediatric emergency department.

Objective To determine the incidence of appendiceal perforation (AP) among children with acute appendicitis (AA) and determine factors associated with AP. Design Retrospective chart review. Setting Emergency department (ED) of Primary Children’s Medical Center (PCMC). Patients 131 children less than 17 years of age with AA diagnosed in the PCMC ED. Results The overall rate of AP was 47%. One hundred eleven (85%) children with AA were correctly diagnosed on their first ED visit. Patients with AP had a significantly (P< 0.05) lower median age (8.0 vs 11.0 years), longer duration of illness (3.0 vs 1.4 days), greater incidence of vomiting and fever by history (91% vs 69% and 83% vs 58%, respectively), higher median temperatures (39.0° vs 38.3°C), and higher proportions of leukocyte (WBC) band forms (14% vs 5%). Patients with AP did not differ from those without AP with respect to total WBC count, hour of arrival, or number of ED visits. Conclusions The rate of AP among pediatric patients with AA is greater among younger children and is associated with vomiting, prolonged illness, and higher body temperatures. Unexpectedly, patients with AP did not have higher total WBC values, more frequent late night arrivals, a longer time interval prior to surgery, or more ED visits prior to diagnosis. These findings suggest that efforts to decrease the rate of AP should be directed toward heightening awareness among primary care physicians regarding the high rate of AP in children, with an emphasis on early ED and surgical referral.

The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis.

The use of an initial bolus of insulin prior to the initiation of low-dose insulin infusion therapy was evaluated in 56 episodes of diabetic ketoacidosis (DKA) in 38 children. The cases were randomly assigned to a group that received a bolus of insulin (n = 24) and to a group that did not (n = 32). After the first hour of insulin therapy, the decline in serum glucose level and the changes in serum osmolality were statistically similar in the two groups, regardless of the degree of acidosis. The time required to reach a serum glucose level of less than 250 mg/dl and the total duration of insulin infusion likewise were similar in the two groups. The use of a bolus of insulin at the onset of treatment for DKA appears unnecessary.

Risks of intravenous administration of hypotonic fluids for pediatric patients in ED and prehospital settings: Let's remove the handle from the pump

Fluid resuscitation of infants and children is a common management problem in prehospital and emergency department care. We present two cases of children who received 5% dextrose in water as the initial resuscitation fluid. Bolus administration of hypotonic fluid contributed to fatal outcomes in these cases. Recommendations are made for eliminating hypotonic fluids as stock items in both the prehospital and emergency department settings.

The clinical presentation of pediatric pelvic fractures

Background Few studies have addressed the presentation and clinical impact of pediatric pelvic fractures. We sought to describe pediatric blunt trauma patients with pelvic fracture (PF) and to evaluate the sensitivity and specificity of physical examination at presentation for diagnosis. Methods Retrospective analysis of all PF and control (NPF) patients from our pediatric institution over an 8-year period. Results A total of 174 patients (88 PF, 86 NPF) were included. Median patient age was 8 years (range, 3 months to 18 years), with 54% males. The most common mechanisms of injury for PF patients were automobile-related accidents (75%). There were 140 patients (87%) who were transported by air or ground medical services. At presentation, approximately 16% of PF patients had a Glasgow Coma score of <15, a mean Revised Trauma Score of 7.49, and a median Injury Severity Score (ISS) of 9. Thirty-one PF patients (35%) had an ISS of >15 indicating severe, multiple injuries. Sixty-eight PF patients (77%) had severe isolated injuries (Abbreviated Injury Scale 1990 value of >3); 11% of PF patients required transfusions, and 2% died. Fifteen PF patients (17% ) had no pelvic ring disruption; 39 (43%) had a single pelvic ring fracture, 22 (2%) had two pelvic ring fractures, 2 (2%) had acetabular fractures, and 10 (11%) had a combination of pelvic fractures. An abnormal physical examination of the pelvis was noted in 81 patients with PF (92% sensitivity, 95% confidence interval [CI] = 0.89–0.95), 15 NPF patients had an abnormal examination (79% specificity, 95% CI = 0.74–0.84). The positive predictive value of the pelvis examination was 0.84, and the negative predictive value was 0.89. The most common abnormal pelvis examination finding was pelvic tenderness in 65 PF patients (73%). A total of seven PF patients had a normal examination of the pelvis; four had a depressed level of consciousness (defined as GCS <15), and six patients had a distracting injury. Conclusions Pediatric blunt trauma patients with pelvic fracture represent a severely injured population but generally have lower transfusion rates and mortality than noted in adult studies. The pelvis examination appears to be sensitive and specific in this retrospective study. However, an altered level of consciousness and/or distracting injuries may affect examination sensitivity and specificity. Based on this retrospective study, we cannot advocate eliminating pelvic radiographs in the severely injured, blunt trauma patient. Prospective studies are recommended.

Pulmonary embolism in the pediatric patient

TARGET AUDIENCE This CME activity is intended for physicians, nurse practitioners, and physician assistants who evaluate and care for children with minor illnesses. Specialists including pediatricians, emergency physicians, pediatric emergency physicians, family practitioners, otolaryngologists, pediatric nurse practitioners, and nurses working in school or camp setting will find this information particularly useful.

Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children's hospital.

Background: Freestanding childrens hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways. Materials and Methods: At a tertiary care childrens hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology. Results: A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score ≥15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07. Conclusions: Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.