Tommy Y. Kim

Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department.

Objectives: Pediatric patients with cerebrospinal fluid shunts frequently present to the emergency department for evaluation of possible shunt malfunction. Most shunt studies appear in the neurosurgical literature. To our knowledge, none have reviewed presenting signs and symptoms of shunt malfunction in patients who present to the pediatric emergency department. The study objective was to evaluate the medical record of children with cerebrospinal fluid shunts who presented to a pediatric emergency department to determine if any signs and/or symptoms were predictive of shunt malfunction. Methods: A retrospective chart review was conducted on 352 pediatric patients aged 0 to 18 years, who presented to the pediatric emergency department between January 1, 1998, and December 31, 2002, with signs and/or symptoms that prompted an evaluation for possible shunt malfunction. Results: Univariate analysis of all signs and symptoms revealed lethargy (odds ratio, 1.99; 95% confidence interval, 1.15-3.42; P = 0.02) and shunt site swelling (odds ratio, 2.56, 95% confidence interval, 1.08-6.07, P = 0.03) to be significantly predictive of shunt malfunction. Logistic regression analysis continued to show significance for lethargy (odds ratio, 2.20; bias-corrected 95% confidence interval, 1.11-3.63) and shunt site swelling (odds ratio, 3.10; bias-corrected 95% confidence interval, 1.38-9.05), but found no other study variable to be significant. Bootstrap resampling validated the importance of the significant variables identified in the regression analysis. Conclusions: In this study, lethargy and shunt site swelling were predictive of shunt malfunction. Other signs and symptoms studied did not reach statistical significance; however, one must maintain a high index of suspicion when evaluating children with an intracranial shunt because the presentation of malfunction is widely varied. A missed diagnosis can result in permanent neurological sequelae or even death.

Inter-rater Reliability for Noninvasive Measurement of Cardiac Function in Children

Introduction: A transcutaneous ultrasound monitor has recently been developed which noninvasively and quickly measures cardiac output. Validity and reliability testing has been reported in adults. No reliability testing has been undertaken in the pediatric population. Objective: Our objective was to evaluate the inter-rater reliability of a transcutaneous Doppler ultrasound technique to measure cardiac index (CI) and stroke volume index (SVI) in pediatric emergency department patients. Methods: An 8-month prospective observational study was conducted on a convenience sample of emergency department patients younger than 18 years old. Five raters were trained to use an ultrasound cardiac output monitoring device. Two raters, blinded to each others results, obtained independent measurements from the same patient within 15 minutes of each other. Inter-rater agreement was measured with the Pearson product correlation coefficient. Bland-Altman analysis demonstrated the extent of deviation from a line of agreement between raters. Results: Ninety-seven patients were enrolled. Major diagnostic categories included infection, trauma, and gastrointestinal disorders. There was significant inter-rater correlation for CI (r = 0.76; 95% confidence interval, 0.66-0.83; P < 0.0001) and SVI (r = 0.79; 95% confidence interval, 0.70-0.86; P < 0.0001). Bland-Altman analysis of CI measurements between 2 raters showed bias of 0.06, SD of bias 1.00, and 95% limits of agreement −1.91 to 2.02 L/min/m2. Stroke volume index showed bias of −0.5, SD of bias 11.01, and 95% limits of agreement −22.08 to 21.08 mL/m2. Conclusions: Transcutaneous Doppler ultrasound technique demonstrates acceptable inter-rater agreement for measuring CI and SVI in children.

Analysis of medication errors in simulated pediatric resuscitation by residents.

Introduction The objective of our study was to estimate the incidence of prescribing medication errors specifically made by a trainee and identify factors associated with these errors during the simulated resuscitation of a critically ill child. Methods The results of the simulated resuscitation are described. We analyzed data from the simulated resuscitation for the occurrence of a prescribing medication error. We compared univariate analysis of each variable to medication error rate and performed a separate multiple logistic regression analysis on the significant univariate variables to assess the association between the selected variables. Results We reviewed 49 simulated resuscitations. The final medication error rate for the simulation was 26.5% (95% CI 13.7% – 39.3%). On univariate analysis, statistically significant findings for decreased prescribing medication error rates included senior residents in charge, presence of a pharmacist, sleeping greater than 8 hours prior to the simulation, and a visual analog scale score showing more confidence in caring for critically ill children. Multiple logistic regression analysis using the above significant variables showed only the presence of a pharmacist to remain significantly associated with decreased medication error, odds ratio of 0.09 (95% CI 0.01 – 0.64). Conclusion Our results indicate that the presence of a clinical pharmacist during the resuscitation of a critically ill child reduces the medication errors made by resident physician trainees.

Tracheoinnominate artery fistula : A rare and often fatal complication of indwelling tracheostomy tubes

Abstract: Fistula formation between the innominate artery and the trachea is a rare but potentially catastrophic complication after tracheostomy. Although surgery is the definitive treatment of tracheoinnominate artery fistula, the responsibility for making the proper diagnosis and stabilizing the patient before surgery often falls on the personnel in the emergency department. We describe the emergency department management of a 14-year-old girl with a tracheoinnominate artery fistula. A discussion of the risk factors, diagnostic considerations, and emergency department management strategies of tracheoinnominate artery fistula is presented.

Incidence of Serious Bacterial Infections in Febrile Children With Sickle Cell Disease

Objective. To determine the incidence of serious bacterial infections in febrile children with sickle cell disease and to describe the outcomes of children discharged from the pediatric emergency department. Methods. We conducted a retrospective chart review of 188 febrile patients with sickle cell disease presenting to our pediatric emergency department over a 10-year period. Serious bacterial infection was defined as bacteremia, meningitis, urinary tract infection, osteomyelitis, or pneumonia. Results. Our overall incidence rate for serious bacterial infections was 16.0% (95% confidence interval [CI] = 10.8% to 21.2%). Pneumonia had the highest incidence rate of 13.8% (95% CI = 8.8% to 18.8%). This was followed by bacteremia and urinary tract infections, both with incidence rates of 1.1% (95% CI = 0.0% to 2.5%). We had no cases of meningitis or osteomyelitis in our study group. Conclusion. We had an incidence of 16.0% for serious bacterial infections in febrile children with sickle cell disease, with the majority of patients diagnosed with pneumonia.

The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study

OBJECTIVE There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure. METHODS This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004. RESULTS Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems. CONCLUSIONS This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.

Pediatric procedural sedation with propofol using a higher initial bolus dose.

ObjectivesWe sought to describe the doses of propofol used for sedation in our pediatric emergency department, along with the range of procedures performed under propofol sedation. We also planned to describe clinically important physiologic changes seen and physician satisfaction with propofol at the doses observed. MethodsThis was a prospective observational case series. Physicians completed a data collection form after the propofol sedation. The physicians were asked to report physiologic changes that occurred during sedation and rate their satisfaction with propofol as a sedation agent on a 100-mm visual analog scale. ResultsEight hundred eighty-six sedation events were reported. The median initial dose of propofol given was 2.0 mg/kg and the median total dose was 3.6 mg/kg. Propofol was used for a wide range of procedures. The most common physiologic change was desaturation/hypoxia (desaturation to <90% in 7.2%). No deaths, unplanned intubations, or surgical airway placements were reported. Treating physicians reported a median satisfaction score of 97 mm. ConclusionsA 2-mg/kg initial bolus dose of propofol for pediatric sedation was well tolerated and useful for a wide range of procedures. Physicians should expect to find a high level of satisfaction with this dose.

Pediatric emergency department census during major sporting events

Objectives Our study attempted to evaluate the effects of major sporting events on the census of a pediatric emergency department (ED) in the United States specifically related to the National Football League Super Bowl, National Basketball Association (NBA) Finals, and Major League Baseball World Series. Methods We performed a retrospective data analysis of our pediatric ED census on the number of visits during major sporting events over a 5-year period. Data during the same period 1 week after the major sporting event were collected for comparison as the control. We evaluated the medians of 2-hour increments around the event start time. Subgroup analysis was performed for games involving the local sporting teams. Results Our results showed no significant difference in ED census during the sporting events, except in the post 6 to 8 hours of the NBA finals. Subgroup analysis of the Los Angeles Lakers showed the same significant findings in the post 6 to 8 hours of the NBA finals. Conclusions No major difference in pediatric ED census is observed during the most major sporting events in the United States.

Os Odontoideum Discovered After Minor Cervical Trauma.

Abstract Minor cervical spine injury is a common cause of pediatric emergency department visits. We present a case of a 10-year-old boy with transient paresthesia after minor cervical trauma found to have a rare cervical spine abnormality requiring surgical fusion. We present and discuss the management options for os odontoideum.

Intraabdominal Abscess Masquerading as a Properly Replaced Gastrostomy Tube

Percutaneous endoscopic gastrostomy (PEG) tubes have been used as a means of supporting nutrition in children since 1980. Since 1984, gastrostomy “button” tubes have been available and have gained popularity for their cosmetic appeal and greater acceptance by parents and families.1 Emergency physicians need to be comfortable with replacement of malfunctioned gastrostomy tubes. The perils of gastrostomy tube replacement are well documented,1-3 and with difficult replacements, it is recommended to check gastrostomy tube placement with different techniques including a contrast-enhanced study.4 To our knowledge, this is the first case report of an error in interpretation of the contrast study due to an abscess formation. Case