Rohit Shenoi

Insulin reverses haemodynamic changes and pulmonary oedema in children stung by the Indian red scorpion Mesobuthus tamulus concanesis, Pocock.

The efficacy of insulin administration in reversing haemodynamic changes in pulmonary oedema in victims of poisonous scorpion sting is assessed by a study based on animal experiments in which insulin administration reversed metabolic and electrocardiographic changes induced by scorpion envenomation. Six previously healthy children aged 18 months to 11 years were admitted to hospital five to 17 hours after scorpion sting. Frusemide for raised central venous pressure and pulmonary oedema, crystalloid infusion for reduced central venous pressure, and hydrocortisone and dopamine for hypotension were used as standard therapy. Insulin (0.3 units g-1 of glucose) was administered when the standard therapy failed to produce an improvement, and at the earliest sign of haemodynamic instability. Reversal of pulmonary oedema and haemodynamic changes, and attainment or normal respiratory rate, blood pressure and central venous pressure, were observed. It is concluded that insulin administration may be useful in reversing haemodynamic changes and pulmonary oedema in victims of scorpion stings.

Ambulance Diversion as a Proxy for Emergency Department Crowding: The Effect on Pediatric Mortality in a Metropolitan Area

OBJECTIVES The objective was to determine the prevalence of emergency department (ED) ambulance diversion among Houston pediatric hospitals and its association with mortality of pediatric patients. METHODS Hospital diversion and patient data between August 2002 and December 2004 were used to examine the impact of diversion on mortality of children under age 18 years. Patients were assumed to be exposed to ED crowding if diversion and admission or ED arrival times overlapped. Univariate and logistic regression were performed to determine if diversion was associated with mortality while controlling for age, illness severity, injury, and transfer status. RESULTS Mean hospital diversion hours as a percentage of operating hours were 10.58 (standard deviation [SD] +/- 9). Overall, of 63,780 admissions, there were 4,095 (6.4%) children admitted during diversion. Fewer severely ill patients were admitted during diversion than nondiversion times (odds ratio [OR] = 0.72; 95% confidence interval [CI] = 0.66 to 0.78). The presence of diversion was protective for mortality (OR = 0.51; 95% CI = 0.34 to 0.77) in bivariate analysis. Mortality was associated with presence of major or extreme illness (OR = 60.7; 95% CI = 45.2 to 81.5), injury (OR=1.7; 95% CI = 1.4 to 2.1), and transfer status (OR = 6.3; 95% CI = 5.4 to 7.3). Using conditional logistic regression, major or extreme illness (OR = 50.7; 95% CI = 37.7 to 68.3), injury (OR 3.7; 95% CI = 2.9 to 4.7), and transfer (OR = 2.7; 95% CI = 2.2, 3.2) were associated with mortality, but diversion did not show any association with mortality. After combining ED and inpatient deaths, no association between diversion and mortality was observed. CONCLUSIONS Hospital diversion due to ED crowding is common in pediatrics. The authors found no evidence of an association between diversion and ED and inpatient pediatric mortality.

The Spatial Relationship of Child Homicides to Community Resources in a Large Metropolitan Area

We evaluated the relationship between neighborhood sociodemographic factors, community resources, and homicides involving young children. We performed spatial analysis of children under age five murdered in Harris County, Texas, from 1997 to 2003. Data on county population, household, socioeconomic, and residential mobility characteristics were allocated to census block groups. Age-adjusted spatial clusters of the homicides were identified. A Markov Chain Monte Carlo negative binomial regression risk model tested the relationship of age-adjusted number of child homicides to block group characteristics and distance of victim’s residence to community resources. Child maltreatment accounted for 94% of 125 homicides. In all, 64% were concentrated in 12 age-adjusted spatial clusters involving 3% of county area. Predictors for number of homicides were a larger number of single-parent households (male and female) and lower median household income. Distance to nearest community resources was not significant. Spatial clusters of child homicides were associated with low-income neighborhoods and single-parent (male and female) households. No association between the spatial clusters of child homicides and their proximity to community resources was observed. A high percentage of child homicides were concentrated in a small area of the county, which offers the potential for targeted, cost-effective interventions.

Emergency department crowding and analgesic delay in pediatric sickle cell pain crises.

Objectives: The objectives of the study were to test the impact of emergency department (ED) crowding and to identify factors associated with delay in analgesic administration in pediatric sickle cell pain crises. Methods: This was a cross-sectional study at a childrens hospital ED. Data included demographics, clinical features, triage acuity, 10-level triage pain score, and arrival-to-analgesic-administration time. Emergency department census was the crowding measure assigned to each patient at arrival. Severe pain was a triage pain score of more than 7. Delays of more than 60 minutes from arrival to analgesic administration represented poor care. Logistic regression tested the effect of ED census on time to analgesic administration after adjusting for patient demographic and clinical characteristics. Results: From 243 encounters (161 patients), we excluded 11 visits (missing charts [n = 7], no pain at triage [n = 3], analgesic refusal [n = 1]). Final analysis involved 232 encounters (150 patients). Most were black with hemoglobin SS. Median age was 12 years. Mean ED census was 57. Median time from arrival to analgesic administration was 90 minutes. Analgesics were administered in less than 60 minutes in 70 encounters (30%). Most delays occurred after triage. Univariate analysis revealed that analgesic administration within 60 minutes of arrival was associated with severe pain at triage. After controlling for other factors, analgesic administration was significantly delayed during higher ED census and significantly earlier for young children and those with severe pain at triage. The time to analgesic administration from arrival significantly increased per increasing quartile of ED census (P = 0.0009). Conclusion: Emergency department crowding is associated with delay in analgesic administration in pediatric patients with sickle cell pain crisis.

An emergency department intervention to improve knowledge of child passenger safety.

Objectives: The objective of the study was to test the impact of an educational video in improving child passenger safety knowledge. Methods: This was a prospective randomized study performed in the emergency department of an urban childrens hospital involving parents of non-critically ill children younger than 9 years. Parents were randomized to observe a video on child passenger safety or comparison group. All completed a survey, 8-question pretest at enrollment, and posttest after 1 month and received written safety materials at discharge. The outcome measure to test knowledge was the difference in mean pretest-posttest scores on a questionnaire. Results: We enrolled 274 parents (137 intervention, 137 comparison). Thirty subjects were found ineligible for analysis after enrollment because their children were outside the age range for inclusion. Analysis was restricted to131 parents in the intervention group and 113 in the comparison group. No significant differences existed between groups when comparing demographics and child passenger safety characteristics except for the number of children in the household. After excluding those lost to follow-up (91 parents) and who dropped out (14 parents), analysis was restricted to 74 subjects in the intervention group and 65 in the comparison group. Mean pretest scores were as follows: intervention, 4.95 (SD, 1.49); comparison, 5.12 (SD, 1.32). Mean posttest scores were as follows: intervention, 5.24 (SD,1.60); comparison, 4.77 (SD, 1.39). Difference in mean pretest-posttest scores showed a significant improvement in the intervention group compared with the comparison group: 0.65 (95% confidence interval, 0.14-1.16) on independent-samples t test (P = 0.012). Conclusions: Child passenger safety education can be effectively imparted to parents in the emergency department.

Screening for carbon monoxide in children.

Objective: Carbon monoxide (CO), a colorless, odorless gas, accounts for the majority of fatal poisonings in the United States. To date, few screening studies that evaluate pediatric exposure are available. The objectives of this study were to determine the value of a CO breath analyzer for detecting pediatric CO exposure and to identify potential CO sources. Design: Prospective screening study. Setting: Emergency department of an urban childrens hospital. Patients: A convenience random sample of 470 noncritically ill children, aged five to 20 years, who presented to a pediatric emergency department and could blow into a CO breath analyzer. Intervention: After informed consent and demographic and clinical variables were ascertained, eligible patients blew into a CO breath analyzer. Those with breath CO levels ≥ 9 ppm underwent confirmatory cooximetric analysis of capillary blood. Sources of CO exposure were determined by history and a home-site evaluation by the local gas company. Patients with carboxyhemoglobin (COHb) levels of more than 5% were given normobaric 100% oxygen until their COHb levels were less than 5%. Results: 1.9% (9/470) of patients had elevated breath CO levels and COHb levels by cooximetry. Putative sources of CO exposure were active cigarette smoking for five patients and a faulty furnace in the home for one patient On the basis of the history, we believe environmental tobacco smoke or automobile exhaust or both contributed to the elevated COHb levels in the other three patients. There was a good correlation between COHb by cooximetry and breath analysis (concordance correlation = 0.739) Conclusion: Breath analysis for CO is a convenient tool to estimate exposure and identify older children at risk.

Factors Associated With Poor Outcome in Childhood Swimming Pool Submersions.

Objectives The aims of the study were to determine factors associated with poor outcome in childhood swimming pool submersions and to study the association of bystander resuscitation with clinical outcome. Methods This was a retrospective study of swimming pool submersion victims younger than 18 years in a metropolitan area from 2003 to 2007. Submersion, prehospital, and victim data were obtained from hospital, Emergency Medical Services, and fatality records. Outcome based on survival at hospital discharge was favorable (baseline/mild impairment) or poor (death/severe impairment). Logistic regression determined factors associated with poor outcome. Results There were 260 submersions. Outcomes were available for 211 (81%). The median age was 4 years; 68% were males. Most incidents occurred at single residential pools (48%) and multiresidential pools (35%). Mortality was 23%; 75% had favorable outcomes. Favorable outcomes occurred in 8.6% (3/35) of victims with absent pulse at the scene. Descriptive analyses revealed significant differences in submersions that occurred on weekdays, during the summer, submersions lasting 5 minutes or more, with on-scene apnea or cardiac arrest needing cardiopulmonary resuscitation, rescuer type, and transfer to tertiary care. Logistic regression revealed that poor outcome was significantly associated with prolonged submersions and those that occurred on a weekday. Furthermore, hospitalization reduced the odds of a poor outcome by 81% when compared with victims who were not hospitalized. Bystander resuscitation was not significantly associated with outcome. Conclusions Childhood swimming pool submersions, which occur on weekdays and with prolonged submersion times, are associated with poor outcome. Bystander resuscitation is not significantly associated with outcome.

Spatial analysis of paediatric swimming pool submersions by housing type

Objective Drowning is a major cause of unintentional childhood death. The relationship between childhood swimming pool submersions, neighbourhood sociodemographics, housing type and swimming pool location was examined in Harris County, Texas. Study design and setting Childhood pool submersion incidents were examined for spatial clustering using the Nearest Neighbor Hierarchical Cluster (Nnh) algorithm. To relate submersions to predictive factors, an Markov Chain Monte Carlo (MCMC) Poisson-Lognormal-Conditional Autoregressive (CAR) spatial regression model was tested at the census tract level. Results There were 260 submersions; 49 were fatal. Forty-two per cent occurred at single-family residences and 36% at multifamily residential buildings. The risk of a submersion was 2.7 times higher for a child at a multifamily than a single-family residence and 28 times more likely in a multifamily swimming pool than a single family pool. However, multifamily submersions were clustered because of the concentration of such buildings with pools. Spatial clustering did not occur in single-family residences. At the tract level, submersions in single-family and multifamily residences were best predicted by the number of pools by housing type and the number of children aged 0–17 by housing type. Conclusions Paediatric swimming pool submersions in multifamily buildings are spatially clustered. The likelihood of submersions is higher for children who live in multifamily buildings with pools than those who live in single-family homes with pools.

An Education Program on Office Medical Emergency Preparedness for Primary Care Pediatricians

Background: Pediatric clinics are ill-prepared in handling medical emergencies. Life-support education, though recommended, has not been evaluated in pediatric primary care. Purpose: The objective is to evaluate effectiveness of education in improving knowledge and learner-perceived comfort in managing pediatric office emergencies. Methods: An education program was conducted at 6 pediatric practices. Pre–post program knowledge improvement (15-item questionnaire) and comfort (10-level Likert scale) was assessed using T tests and Cohens d. Long-term knowledge was assessed. Results: Physicians demonstrated significant improvement in mean knowledge scores: 1.83, 95% confidence interval (CI) [0.76, 2.91], effect size (d = 0.98), whereas nurses had a smaller, nonsignificant improvement: 0.59, 95% CI [–0.19, 1.37], effect size (d = 0.24). A significant improvement in mean comfort scores was observed among both physicians: 1.3, 95% CI [0.9, 1.7] and nurses, 1.4, 95% CI [0.7, 2.1]. Among physicians, percentage correct answers on the knowledge test was 79% (baseline), 91% (posttest), and 80% at 3 years. Conclusions: Education in pediatric office emergency preparedness leads to short-term knowledge improvement among physicians, but gains are not sustained.

Previous Emergency Medical Services Use by Victims of Child Homicide

Introduction The medical diagnoses and frequency of emergency department visits made by children who are later given a diagnosis of maltreatment do not differ much from those of nonabused children. However, the type of medical complaints and frequency of emergency medical services (EMS) use by child homicide victims before their death are not known. We compared EMS use between child homicide victims and children who died from natural causes before their death. Methods This was a retrospective case-control study of children 0 to 5 years old who died in Houston, Texas, from 2005 to 2010. Cases were child homicide victims. Controls were children who died from natural causes. We reviewed death data and EMS and child protective services (CPS) encounter information before the victims death. The association between death type (natural vs homicide) and EMS use was assessed using Poisson regression with EMS count adjusted for exposure time. Results There were 89 child homicides and 183 natural deaths. Age at death was significantly higher for homicides than natural deaths (1.1 vs 0.2 y, P < 0.001). Homicide victims used EMS services (39% vs 14%, P < 0.001) and had previous CPS investigations (55% vs 7%, P < 0.001) significantly more often than children who died from natural causes. Poisson regression, after adjustment for age, revealed that the homicide group had more EMS calls than the natural death group (β = 0.55; 95% confidence interval, 0.04–1.07; P = 0.03). However, the EMS use frequency and working assessments were not helpful in identifying maltreatment victims. Conclusions Child homicide victims use EMS more often and have a higher number of CPS investigations before their death than children who die from natural causes. However, the frequency and nature of EMS medical complaints are not helpful in identifying maltreatment.