Stephen Ludwig

Shaken baby syndrome: a review of 20 cases

Twenty cases of shaken baby syndrome are reviewed to determine important signs, symptoms, physical findings, laboratory parameters, and prognosis. The signs and symptoms of this form of head trauma are nonspecific. The findings may mimic infection, intoxication, or metabolic abnormalities. Diagnosis depends on a high index of suspicion and the physical findings of a bulging fontanelle, head circumference greater than the 90th percentile, and retinal hemorrhage. The finding of bloody fluid from a lumbar or subdural tap is also highly suggestive. Computed cranial tomography findings confirm the diagnosis. The prognosis in the shaken baby syndrome is poor. Three of our 20 patients died and ten others sustained significant morbidity. The emergency physician must be alert to making this diagnosis in order to promptly institute therapy for acute head trauma.

Pediatric Cardiopulmonary Resuscitation: A Review of 130 Cases

Cardiopulmonary resuscitation (CPR) records of 130 pediatric patients with cardiac arrest were reviewed. Ninety-six resuscitations were performed on patients hospitalized on the Medical and Surgical units of the Childrens Hospital of Philadelphia (HP) and 34 on Emergency Department patients (EDPs). In HP, initial survival was 90%. In 27% of HPs, airway and breathing techniques alone were life saving. A mean of 2.45 drugs per patient were used for HP. In EDP, initial survival was 56%. There had been advanced CPR during the prehospital transport phase for the EDPs. All but two EDPs required drug management. The mean was 4.25 drugs per patient. Lidocaine and direct current defibrillation were used only rarely. Glucose was used frequently (33%) and should be considered in the list of essential resuscitation drugs. The necessity for resuscitation was most commonly associated with pulmonary diseases. These findings reflect differences between pediatric CPR and adult CPR, and suggest limitations in applying adult standards to infants and children. It is suggested that the medical community develop separate pediatric CPR courses as independent modules for those who assume responsibility for resuscitating children.

Factors influencing outcome of cardiopulmonary resuscitation in children

We evaluated 47 pediatric patients after cardiopulmonary arrest. Patients entered the study with the onset of advanced life support. We followed them until death, or discharge from the hospital, occurred. We identified three groups of patients: (1) long-term survivors, who survived to discharge, (2) short-term survivors, who survived longer than 24 hours after CPR but not until discharge, and (3) nonsurvivors, who died within 24 hours of their arrest. All of the long-term surviving patients were discharged from the hospital without gross neurologic deficit attributable to the arrest or resuscitation effort. Twenty-seven (57%) children were successfully resuscitated. Eighteen (38%) were long term-survivors, while nine (19%) were short-term survivors. Favorable outcome is associated with the following factors: (1) inhospital arrest, (2) extreme bradycardia as the presenting arrhythmia, (3) successful resuscitation with only ventilation, oxygen and closed chest massage, and (4) a duration of CPR of less than 15 minutes. Age, sex, and race, as well as pupillary reaction and motor response at the onset of advanced life support, did not correlate with long-term survival.

Interpretation of pediatric x-ray films by emergency department pediatricians

This study compared the interpretation of pediatric roentgenograms by emergency department pediatricians and radiologists. Data were available from 532 of 600 children who had 564 radiographic studies during a six-week period: 217 examinations of the chest, 200 of the extremities, 74 of the skull, 35 of the abdomen, and 38 of miscellaneous structures. The emergency department pediatricians and the radiologists were in agreement in 91.1% of the cases. Among the 50 of 564 (8.9%) discordant studies, only seven (1.2%) required changes in therapy. The results attest to the accuracy of emergency department pediatricians in interpreting the usual types of films ordered in their department. However, this group specifically erred in the identification of subtle fractures and the detection of abnormalities incidental to the primary purpose for which the film was obtained. Future educational programs should address these areas of deficiency.

Pediatric Hospitalists: Report of a Leadership Conference

OBJECTIVES. To summarize a meeting of academic pediatric hospitalists and to describe the current state of the field. METHODS. The Ambulatory Pediatric Association sponsored a meeting for academic pediatric hospitalists in November 2003. The purpose of the meeting was to discuss and to define roles of academic pediatric hospitalists, including their roles as clinicians, educators, and researchers, and to discuss organizational issues and unique hospitalist issues within general academic pediatrics. Workshops were held in the areas of organization and administration, academic life, research, and education. A literature review was also conducted in the areas discussed. RESULTS. More than 130 physicians attended. Thirteen workshops were held, and all information was summarized in large-group sessions for all attendees. CONCLUSIONS. Pediatric hospital medicine is a rapidly growing field, with an estimated 800 to 1000 pediatric hospitalists currently practicing. Initial work has defined the clinical environment and has begun to stake out a unique knowledge and skill set. The Pediatric Hospitalists in Academic Settings conference demonstrated the audience for additional development and the resources to move forward.

Carboxyhemoglobin levels in children with nonspecific flu-like symptoms

Although carbon monoxide intoxication is thought to account for approximately half of all deaths caused by poisons] the incidence of sublethal toxicity has not been well investigated in a pediatric population. The manifestations of CO poisoning may be severe or subtle. 24 Commo nly, signs and symptoms are gradual and simulate other illnesses.? ,3.5 Flu-like symptoms such as headache, dizziness, weakness, nausea, vomiting, and drowsiness are frequent? The purpose of our study was to determine the possibility of carbon monoxide poisoning as a cause of nonspecific flu-like symptoms in children who had no recognized exposure. METHODS Children younger than 18 years of age, consecutively seen in The Childrens Hospital of Philadelphia Emergency Department for evaluation of flu-like symptoms (headache, dizziness, weakness, nausea, vomiting, altered mental status), were eligible for entry into the study. Excluded were patients with symptoms specifically suggestive of a viral illness, including fever >38.9 ~ C, watery stools, viral exanthem or enanthem, or with a history of smoke inhalation. Enrollees were also required to have one or more exPosure criteria, including the occurrence of symptoms while (1) a motor vehicle passenger; (2) a resident of a home with combustible fuel heat, including kerosene heaters, wood stoves, fireplaces, natural gas appliances, Sterno units, or central heating systems older than 10 years; or (3) exposed to chemical fumes such as those generated by paint strippers.

Factors influencing termination of resuscitative efforts in children: A comparison of pediatric emergency medicine and adult emergency medicine physicians

Objectives: To examine factors that influence termination of resuscitative efforts (TORE) and compare pediatric emergency medicine (PEM) and general emergency medicine (GEM) physicians regarding TORE in children. Design: Cross-sectional survey. Participants: All physicians board-certified in PEM as of November 1993 and a random sample of board-certified GEM physicians listed in the 1993 American College of Emergency Physicians directory. Interventions: Self-administered questionnaires were mailed to participants who were asked about experience providing pediatric cardiopulmonary resuscitation (CPR) and demographic information. We posed a series of management questions eliciting factors that influence TORE decision-making in single context and case scenario format. Specific emphasis was placed on the influence of time and epinephrine dosing. Results: One hundred and sixty (70%) PEM and 127 (62%) GEM responded. These groups differed significantly in years of experience (PEM 8.2, GEM 11.8), urban practice setting (PEM 84%, GEM 32%) and number of pediatric cardiopulmonary resuscitations per year (PEM 10.6, GEM 4.8), P<0.001 for all. There were no significant differences between groups regarding features pathognomonic of death. PEM were more likely to consider low blood pH and iatrogenic causes of arrest as factors influencing TORE; GEM were more likely to consider co-morbid conditions (P<0.05 for all). Medians for time estimates of minimum minutes of pulselessness that influence TORE were: PEM 26 to 30 minutes, GEM 31 to 35 minutes for both prehospital and emergency department settings (P<0.05 for each). Approximately 20% of all respondents did not place a strict limit on time of pulselessness when determining TORE. No difference was observed between groups regarding maximum doses of epinephrine used prior to TORE. However, fewer GEM (50%) than PEM (75%) utilize “high dose” epinephrine according to current Pediatric Advanced Life Support (PALS) guidelines (P<0.05). PEM physicians were more than two times more likely to terminate resuscitative efforts if return of spontaneous circulation was not achieved by 25 minutes compared to GEM physicians for both prehospital time of pulselessness [odds ratio 2.1,95% confidence interval (1.01,4.5)] and emergency department time of pulselessness [odds ratio 2.2, confidence interval (1.1,4.6)]. Conclusions: 1) Several laboratory and clinical factors significantly influence physician’s decisions regarding TORE; 2) regardless of setting, time of pulselessness does appear to be an influential factor in determining when to terminate resuscitation in children for most physicians; 3) PEM physicians are more likely to terminate resuscitative efforts than are GEM physicians if return of spontaneous circulation is not achieved by 25 minutes; 4) a significant number of PEM and GEM physicians do not use high dose epinephrine in accordance with current PALS recommendations.

Child abuse prevention

The past two decades have seen a dramatic rise in substantiated reports of child abuse in the United States. (cite NIS studies) National attention has followed with a shift toward focusing on prevention strategies to reduce the growing burden on the child welfare system. The shift of focus toward prevention of child abuse is not surprising, considering its appeal to a broader community, whether the goal is to provide more community based services or the strengthening of family values.

Temperature response to antipyretic therapy in children: Relationship to occult bacteremia

The response of rectal temperature to antipyretic therapy was studied in an attempt to identify a clinical characteristic that would distinguish children with occult bacteremia from those with sterile cultures of blood. Children 3-24 months of age with initial temperature recordings of 38.9 degrees C or greater had a blood culture drawn and received a standard dose (10mg/kg) of either aspirin or acetaminophen. Temperature was again recorded 60-120 minutes later. During the period of investigation, 255 patients were studied; 16 had bacteremia, and 239 had sterile blood cultures. There was no difference in the response to antipyretic therapy between the two groups. The mean decrease in temperature for each was similar (1.3 versus 1.05 degrees C, P = 0.14). The authors conclude that response to antipyretic therapy does not distinguish children who are bacteremic from those who are not.

Ten-Year Review of Pediatric Bathtub Near-Drownings: Evaluation for Child Abuse and Neglect

STUDY OBJECTIVE To evaluate the risk factors associated with bathtub submersion injury and their relationship to child abuse and neglect. DESIGN Retrospective chart review. SETTING An urban childrens hospital. PARTICIPANTS Any child sustaining a bathtub near-drowning over the 10-year period from 1982 to 1992. INTERVENTIONS None. RESULTS Twenty-one patients were treated for bathtub near-drownings during the 10-year period, accounting for 24% of all submersion injuries. A significant number (67%) had historic and/or physical findings suspicious for abuse or neglect, including incompatible history for the injury, other physical injuries, previous child abuse reports, psychiatric history of the caretaker, and/or psychosocial concerns noted in the chart. The mortality rate of 42% was significant. No demographic characteristics identified the children at risk. CONCLUSION Many children who are injured in the bathtub suffer from abuse or neglect. Medical evaluation should include social work consultation and a search for other accompanying injuries.