Rodrick Lim

Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial

Background: Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain. Methods: We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale — Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose. Results: We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre–post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) −0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI −0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ −0.1 [95% CI −0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI −0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p < 0.01). Interpretation: We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures. Trial registration: ClinicalTrials.gov, no. NCT01690780.

Pediatric ovarian torsion: case series and review of the literature

BACKGROUND Ovarian torsion in children is an uncommon cause of acute abdominal pain but mandates early surgical management to prevent further adnexal damage. The clinical presentation mimics other pathologies, such as appendicitis. We sought to more completely characterize ovarian torsion with respect to pain and ancillary studies, such as urinalysis. METHODS We performed a retrospective review of hospital charts of all patients aged 0-18 years with a diagnosis of ovarian torsion at the Childrens Hospital at London Health Sciences Centre, in London, Ont., from 1993 to 2008. RESULTS We analyzed 13 charts of patients aged 7 months to 18 years. Most patients presented with peripheral leukocytosis, vomiting and right lower quadrant pain that did not radiate or migrate. On urinalysis, about half the patients demonstrated pyuria without bacteruria. Pelvic ultrasound revealed an ovarian cyst on the same side of the pain in 11 of 13 patients. Most were found to have a hemorrhagic cyst or ovary and underwent salpingo-oophorectomy or cystectomy within 48 hours of presentation. CONCLUSION Ovarian torsion should be considered in any female child with acute onset lower abdominal pain accompanied by vomiting. Pain can be characterized as constant or colicky, but unlike with appendicitis, does not typically migrate. Sterile pyuria is found in a substantial proportion of cases. Ultrasound is the most useful initial diagnostic modality, but the absence of flow on Doppler imaging is not always present. Conservative management with detorsion and oophoropexy is recommended.

Appendix not seen: the predictive value of secondary inflammatory sonographic signs.

Background Acute appendicitis is the most prevalent emergency surgical diagnosis in children. Although traditionally a clinical diagnosis, the diagnosis of acute appendicitis is uncertain in approximately 30% of pediatric patients. In attempts to avoid a misdiagnosis and facilitate earlier definitive care, imaging modalities such as ultrasonography have become important tools. In many pediatric studies, the absence of a visualized appendix with no secondary sonographic features has been reported as a negative study result, and a study where the appendix is not seen but demonstrates secondary features is often deemed equivocal. With ultrasound appendiceal detection rates reported at 60% to 89%, the dilemma of the nonvisualized appendix or equivocal study is frequently faced by clinicians. Objective This study aimed to assess the value of the nonvisualized appendix on ultrasound and the association of secondary sonographic findings in pediatric patients with acute right lower quadrant pain undergoing ultrasound, in whom acute appendicitis was a diagnostic consideration. Methods Retrospective case review of 662 consecutive children (age < 18 years) presenting to a pediatric emergency department with clinically suspected appendicitis, who had graded compression sonographic studies during the 24-month study period, was performed. Results The appendix could not be visualized in 241 studies (37.7%). An alternate diagnosis was identified via sonography in 47 patients (19.5%). Twenty-five patients (12.9%) were taken for surgery where 17 (8.8%) had acute appendicitis confirmed via pathology. The specificity of moderate-to-large amounts of free fluid is 98%, phlegmon at 100%, pericecal inflammatory fat changes at 98%, and any free fluids with prominent lymph nodes at 81%. The odds ratio of appendicitis increases from 0.56 to 0.64 to 2.3 and 17.5, respectively, when there were 2 and 3 ultrasonographic inflammatory markers identified. Conclusions Although uncommonly seen, large amounts of free fluid, phlegmon, and pericecal inflammatory fat changes were very specific signs of acute appendicitis. In the absence of a distinctly visualized appendix, the presence of multiple secondary inflammatory changes provides increasing support of a diagnosis of acute appendicitis.

Additive value of nuclear medicine shuntograms to computed tomography for suspected cerebrospinal fluid shunt obstruction in the pediatric emergency department.

Objective: To measure the predictive value of nuclear medicine studies (cerebrospinal fluid [CSF] shuntograms) and radiographic studies (computed tomographic [CT] scans) in a cohort of children undergoing evaluation for suspected shunt obstruction in a tertiary care pediatric emergency department (ED). Methods: A retrospective chart review was conducted on patients younger than 18 years who presented to the pediatric ED of the Childrens Hospital of Western Ontario and had both CT of the head and a CSF shuntogram ordered by the attending pediatric emergency medicine physician between December 1998 and April 2003 because of suspected shunt obstruction. Results: A total of 69 patients were evaluated for suspected shunt obstruction in the ED during this period with both a CT and a CSF shuntogram. Twenty-seven patients (39.1%) subsequently required corrective surgery for suspected shunt obstruction that was confirmed intraoperatively. The CT scans showed abnormalities suggestive of CSF shunt obstruction in 21 of the patients who required surgery (sensitivity, 77.8%; negative predictive value, 82.4%), whereas the CSF shuntograms showed abnormalities suggestive of CSF obstruction in 25 of the patients who required surgery (sensitivity, 92.6%; negative predictive value, 92.6%). The CT scans and the shuntograms combined revealed abnormalities suggestive of CSF shunt obstruction in 26 of the 27 patients who required surgery (sensitivity, 96.3%; negative predictive value, 97.4%). Conclusions: Over one third of pediatric ED patients evaluated with CT and CSF shuntograms required surgical management. Sensitivity was increased with CT and CSF shuntogram compared with CT alone. Prospective studies are required to assess the use of radiographic and nuclear medicine tests for the shunt evaluation in conjunction with the development of a clinical prediction rule for the pediatric emergency physician.

Self-reported experience and competence in core procedures among Canadian pediatric emergency medicine fellowship trainees

OBJECTIVE We sought to determine the frequency with which fellows in accredited Canadian pediatric emergency medicine (PEM) fellowships perform specific procedures, the level of confidence fellows have in their abilities and whether there are differences in self-perceived success between first- and second-year fellows. METHODS A national survey was developed that focused on 24 PEM procedural skills. The survey asked respondents how many times they had performed these procedures within the past 12 months and within the past 3 years. Respondents were then asked to rate their confidence in successfully performing each of the 24 procedures. RESULTS Of the 46 surveys sent to PEM fellows, 32 (70%) were returned. Most respondents were in their second year of training and the vast majority had previous training in pediatrics. In order of frequency, the most common procedures performed were closed reduction of fractures, peripheral intravenous insertion, complex laceration repair and endotracheal intubation. Of the surveyed skills, oropharyngeal/nasopharyngeal airway insertion was deemed the most successful (100% success rate for second-year fellows v. 92.5% success rate for first-year fellows, p=0.01). Similarly, second-year fellows had a higher self-perceived success rate for intraosseous line insertion than did first-year fellows (95.0% v. 80.0% for second- and first-year fellows, respectively, p>0.001). CONCLUSION In surveying PEM trainees across Canada, we have described the frequency and self-perceived success rate for 24 important procedures. This information may be helpful for program directors in evaluating future directions and opportunities for training of their PEM trainees.

All-terrain vehicle major injury patterns in children: a five-year review in Southwestern Ontario

OBJECTIVE The aim of the study was to characterize the nature of the injuries sustained by children involved in all-terrain vehicle (ATV) crashes in Southwestern Ontario over a 5-year period. METHODS A retrospective chart review was conducted of children who sustained ATV-related trauma and who presented to the emergency department at the Childrens Hospital of Western Ontario between Sept. 1, 1998, and Aug. 31, 2003, with an Injury Severity Score (ISS) = 12. Patients were identified by the London Health Sciences Centre Trauma Program Registry. Patient charts were then retrieved and reviewed to record patient demographics, injuries, interventions and length of stay in hospital. RESULTS Seventeen patients, 14 male and 3 female, met inclusion criteria. Ages ranged from 8-17 years, with an average age of 13.7 years. Thirteen were <16 years of age. Overall there were 7 different systems injured in these 17 patients. Fourteen patients sustained an injury to more than 1 system. The average ISS was 22.8. The average length of hospital stay was 9.7 days. Six patients sustained significant head injuries; 4 of these 6 patients were not wearing helmets. Eight patients suffered splenic injuries, and 3 required a splenectomy. Thirteen patients sustained fractures. CONCLUSION ATV trauma is a significant threat to the children in Southwestern Ontario. These results clearly support the Canadian Paediatric Societys recommendation that children <16 years of age should be prohibited from operating or riding on ATVs.

E-Cigarette Liquid Nicotine Ingestion in a Child: Case Report and Discussion

Nicotine poisoning is well described in the pediatric population, and even small oral doses may result in toxic effects. The source of nicotine is usually tobacco products and nicotine replacement products such as gum and patches. With the more frequent use of novel products such as e-cigarettes, concern has arisen regarding liquid nicotine. As there are no regulations regarding childproof bottling and packaging, there may be increased potential for unintentional ingestion of these colorfully and appealingly packaged products by children. We present and discuss a case of this nature, as we feel emergency physicians should be aware of this new mode of poisoning, and public health efforts should be made to minimize such exposures.

Acute Appendicitis: Investigating an Optimal Outer Appendiceal Diameter Cut-Point in a Pediatric Population

BACKGROUND Acute appendicitis is the most common cause of abdominal pain in children requiring operative intervention. Among a number of sonographic criteria to aid in the diagnosis of appendicitis, an outer diameter >6 mm is the most objective and widely accepted. However, there is a lack of evidence-based standards governing this consensus. STUDY OBJECTIVES The aim of this study was to determine the outer appendiceal diameter that maximizes sensitivity and specificity in a pediatric population. METHODS A retrospective review of all urgent diagnostic ultrasounds (US) was performed over 2 years in children aged <18 years. The diagnostic accuracy of various cut-points was assessed by calculating the sensitivity and specificity and plotting a receiver operating characteristic (ROC) curve. RESULTS The study sample consisted of 398 patients in whom the appendix was visualized on US. The median outer appendiceal diameter was significantly higher in the surgical group compared to the nonsurgical group (9.4 mm; range = 8.1-12.0 vs. 5.5 mm; range = 4.4-6.5, p < 0.01). The optimal cut-point with the greatest area under the ROC curve was determined to be an outer appendiceal diameter of 7.0 mm. CONCLUSIONS In our patients, adopting a 7-mm rather than a 6-mm appendiceal diameter threshold would balance a greater number of missed cases of acute appendicitis for a reduction in the number of unnecessary surgeries.

Opioid Analgesia for Acute Abdominal Pain in Children: A Systematic Review and Meta‐analysis

OBJECTIVES There are long-held concerns that analgesia in patients with acute abdominal pain may obscure the physical examination and lead to missing a diagnosis of appendicitis. Despite evidence to the contrary, analgesia continues to be underutilized and suboptimally dosed in children with acute abdominal pain. The objective of this systematic review and meta-analysis was to determine if opioids provide analgesia without an increase in side effects and appendicitis-related complications. METHODS Trials were identified through electronic searches of MEDLINE (1946-2013), EMBASE (1980-2013), Cochrane Central Register of Controlled Trials (2013), CINAHL (1981-2013), and Google Scholar (2013). All randomized controlled trials (RCTs) of children aged 0-18 years with acute abdominal pain that compared any opioid analgesic to placebo were included. The methodologic qualities of studies and the overall quality of evidence were evaluated using the Cochrane Collaborations Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. RESULTS Six RCTs met inclusion criteria, and each compared a single-dose parenteral opioid to a placebo, providing data on 342 children aged 5 to 18 years. The pooled mean pre/post difference in self-reported pain scores was 19.61 mm (95% confidence interval [CI] = -1.16 to 40.37 mm) lower in those receiving opioid analgesia. There was no significant increase in the risk of perforation or abscess associated with opioids in cases of appendicitis (relative risk [RR] = 1.03, 95% CI = 0.55 to 1.93). The risk of side effects was significantly greater in patients who received opioids (RR = 6.06, 95% CI = 1.10 to 33.49). Subtherapeutic dosing of opioids was detected in all six trials. CONCLUSIONS The use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects. However, there is no increased risk of perforation or abscess. The overall quality of evidence is low, suggesting the need for larger, high-quality trials that are powered to detect both serious complications of appendicitis and determine the most efficacious opioid dosing for children.

Massive gastric pneumatosis from pyloric stenosis

A 12-week-old infant presented with a one-day history of increased vomiting and lethargy. Gastroesophageal reflux had been diagnosed when he was four weeks old, but the symptoms had not lessened, despite a change of formula. The infant was severely dehydrated and had gastric distension, a decreased