Timothy G. Givens

Effect of ketorolac in pediatric sickle cell vaso-occlusive pain crisis.

BACKGROUND Ketorolac is a parenteral, nonsteroidal analgesic that does not have a narcotics risks of respiratory depression, hypotension, or dependence. Its usefulness in providing pain relief in pediatric patients with acute vaso-occlusive crisis of sickle cell disease has not been studied to date. METHODS Twenty-nine patients with sickle cell disease between the ages of 5 and 18 years who presented to The Childrens Hospital of Alabama emergency department (ED) with 41 distinct episodes of acute vaso-occlusive pain crisis were enrolled prospectively and randomized to receive either 0.9 mg/kg intravenous (IV) ketorolac or placebo in a double-blind fashion. All patients also received IV fluids and an initial 0.1 mg/kg of IV morphine. Subsequent standardized doses of morphine were given every 2 hours over a 6-hour observation period based upon severity of pain as scored by a 10-cm linear visual analog scale (VAS). Vital signs and pain severity were recorded initially and assessed hourly. Disposition was made at the end of the observation period. RESULTS Patients receiving ketorolac and those receiving placebo were of similar age, weight, gender, number of prior ED visits, number of prior hospital admissions, duration of pain prior to presentation, and initial pain score. The total dose of morphine received, reduction in severity of pain as measured by VAS, rate of hospital admission, and rate of return to the ED for discharged patients did not differ significantly between the two groups. CONCLUSION We were unable to demonstrate a synergistic analgesic effect for ketorolac in the treatment of pain from acute vaso-occlusive crisis in pediatric sickle cell disease. Further investigations involving larger samples of sickle cell patients may be needed to further define a role for ketorolac in the acute management of sickle cell vaso-occlusive pain.

Recognition and management of pregnant adolescents in the pediatric emergency department

The early initiation of comprehensive prenatal care is essential to avoid the complications associated with the more than one million adolescent pregnancies in the United States each year. Pediatric emergency physicians can play an important role in the initial diagnosis and appropriate referral of pregnant teenagers. However, previous studies have shown that the diagnosis of pregnancy can be difficult. The goals of this study were to characterize the spectrum of presenting complaints and to evaluate the assessment and disposition of pregnant teenagers presenting to a pediatric emergency department (PED). We retrospectively reviewed the medical records of 94 adolescents who presented with 95 pregnancies to our PED over an 18-month period. The mean age was 15.7 years (range 12 to 19 years). Only 8% mentioned pregnancy in their chief complaint at triage, and a concern about pregnancy was revealed by only 36% during the history of present illness. Ten percent denied they were sexually active. The most frequent complaints were gastrointestinal (77%); other complaints were gynecologic, urinary, or nonspecific. A concurrent sexually transmitted disease (32%) or urinary tract infection (31%) was frequently clinically suspected. At disposition, 26% were transported to an general emergency department for urgent obstetric evaluation; others were referred to a primary caregiver (23%) or obstetrician (39%). Pregnant teenagers present to the PED with a wide variety of complaints that may suggest other diagnoses. A high index of suspicion is required to diagnose pregnancy in adolescent girls so that appropriate care and referral can be initiated.

Sudden cardiac arrests, automated external defibrillators, and medical emergency response plans in Tennessee high schools.

Objectives Schools are important public locations of sudden cardiac arrest (SCA), and the American Heart Association (AHA) recommends medical emergency response plans (MERPs), which may include an automated external defibrillator (AED) in schools. The objective of this study was to determine the incidence of SCA and the prevalence of AEDs and MERPs in Tennessee high schools. Methods Tennessee Secondary School Athletic Association member schools were surveyed regarding SCA on campus within 5 years, AED presence, and MERP characteristics. Results Of 378 schools, 257 (68%) completed the survey. There were 21 (5 student and 16 adult) SCAs on school grounds, yielding a 5-year incidence of 1 SCA per 12 high schools. An AED was present at 11 of 21 schools with SCA, and 6 SCA victims were treated with an AED shock. A linear increase in SCA frequency was noted with increasing school size (<500 students: 3.3% incidence, 500–1000: 6.5%, 1000–1500: 12.5%, ≥1500: 18.2%; P = 0.003). Of 257 schools, 71% had an MERP, 48% had an AED, and only 4% were fully compliant with AHA recommendations. Schools with a history of SCA were more likely to be compliant (19% vs 3%, P = 0.011). Conclusions The 5-year incidence of SCA in Tennessee high schools is 1 in 12, but increases to 1 in 7 for schools with more than 1000 students. Compliance with AHA guidelines for MERPs is poor, but improved in schools with recent SCA. Future recommendations should encourage the inclusion of AED placement in schools with more than 1000 students.

Pediatric emergency medicine fellowship research curriculum: a survey of fellowship directors.

Objective: To determine how pediatric emergency medicine (PEM) fellowship directors organize research training and to identify factors believed to be associated with successful research training. Methods: A 16-question survey study of PEM fellowship directors. Results: Of the 58 fellowship directors surveyed, 39 (67%) responded. Of 38 programs, PEM faculty from 20 (53%) served as research mentors for PEM fellows. The mean percentage of PEM faculty who had performed peer-review funded research was 26%. The mean number of trainee research months was 10.9 for 3 years. Of these research months, 93% were not protected (included clinical work hours). Only 5 programs provided some completely protected research months (months without any clinical work hours), and none of these were scheduled in blocks of greater than 3 consecutive months. Most (56%) of these research months were scheduled during the third year of training. The most likely explanations of the fellow successfully becoming research competent were eagerness to apply self and number of research months during training. Least likely explanations were faculty with peer-reviewed funded grants and blocks of research time. Thirty-five fellowship directors (90%) believed that upon completion of the training, their fellows would be research competent. Conclusions Besides the fellows eagerness to apply self, scheduling adequate time for research was reported as a highly important factor in achieving research competency among PEM fellows. Providing protected (no clinical responsibilities) research months to fellows and arranging more opportunities for PEM faculty to serve as research mentors may maintain or possibly improve the likelihood of PEM fellows to becoming research competent.