William A. Bonadio

Prehospital pediatric endotracheal intubation performance review.

Pediatric prehospital care was reviewed over a one year period to determine success rate, causes of unsuccessful attempts, and complications of performing endotracheal intubation. The Milwaukee County Emergency Medicine Technician-Paramedics (EMT-Ps) responded to 1467 pediatric (<19 years of age) patient calls. This accounted for 11% of the patients who received EMT-P care during the study period. Of the 63 patients requiring pediatric endotracheal intubation, 49 (78%) were successfully intubated. Of the 42 pulseless nonbreathing (PNB) patients, 39 (93%) were successfully intubated. Of the 21 patients judged to be in impending respiratory failure, 10 (48%) were successfully intubated. Common difficulties in intubating the PNB patient included inability to visualize the glottis and cords secondary to mucus and/or vomitus, use of inappropriately small endotracheal tubes, and accidental extubation during transport. Difficulties in intubating impending respiratory failure patients included patient resistance and seizure activity. We recommend that the EMT-P training curriculum include a review of these difficulties and that prehospital pediatric endotracheal intubation performance be monitored and reviewed with the EMT-Ps.

Esophageal bougienage technique for coin ingestion in children

An analysis was performed of 46 consecutive children who received esophageal bougienage for an ingested coin lodged in the esophagus. All patients met the following clinical criteria necessary for performance of this procedure: an acutely ingested single coin, radiographically localized in the esophagus; no previous history of an esophageal disease process, surgical procedure performed or foreign body removed; and no respiratory compromise upon physical examination. All coins were successfully advanced distally into the stomach after one pass of the bougie dilator. No complications were noted during or after performance of any procedure. Esophageal bougienage is a safe and effective method used to dislodge and pass an ingested coin from the esophagus when criteria for its performance are adhered to rigidly.

Cervical spine trauma in children: Part I. General concepts, normal anatomy, radiographic evaluation

It is frequently the responsibility of emergency physicians to perform the initial assessment of trauma victims and evaluate for possible cervical spine injury (CSI). In these cases, defining the anatomic and functional status of the cervical spine takes precedent after performing any necessary resuscitative measures. It requires a skill based on both knowledge and experience to accurately and expeditiously evaluate for possible cervical spine injury while ensuring controlled spinal alignment in a neutral position. The consequences of an unrecognized CSI can obviously be disastrous. It has been shown that as many as 60% of all cervical spinal cord lesions are initially incomplete postinjury, and that 5% to 10% of lesions occur after the traumatic event during the early phases of emergency care.‘-4 In a series of 300 multiple trauma victims with CSI, 11 victims had an initially unrecognized lesion and experienced neurologic deficit or death as a result of inadequate neck immobilization during the course of emergency management.’ In order to maximize the outcome of trauma victims with CSI it is incumbent on the managing physician to have a thorough understanding of the anatomy and biomechanics of the normal cervical spine and of the pathologic manifestations of CSI that can result from a myriad of traumatic events. This two-part article will review anatomic and biomechanical aspects of the cervical spine, describe common pediatric CSIs, demonstrate associated mechanisms and radiographic manifestations of CSIs, and propose guidelines for the initial clinical assessment and management of trauma victims evaluated for possible CSI.

Post-traumatic pulmonary contusion in children

We reviewed 35 consecutive cases of post-traumatic pulmonary contusion in children that occurred during a 12-year period. Of these, 19 children (54%) were more than 5 years old, 30 (86%) were involved in motor vehicle accidents, and 29 (83%) had multiple trauma. External thoracic wall contusion, fracture of the bony thorax, tachypnea, hemoptysis, and abnormal breath sounds were frequently absent on presentation. Associated intrathoracic lesions of pleural effusion, pneumothorax, and hemothorax occurred in 20 children (57%) and were particularly prevalent in those with fracture of the bony thorax (93%); the radiographic appearance of these lesions was delayed up to 48 hours in 40% of cases. In 34 children (97%), radiographic evidence of pulmonary contusion was present on admission and did not progress radiographically during hospitalization. No child experienced respiratory deterioration subsequent to presentation or required mechanical ventilation for respiratory insufficiency. Pulmonary contusion in children is usually a consequence of significant-impact injury associated with multiple trauma and has a good prognosis. Despite a paucity of abnormal physical findings, children who sustain high-impact trauma should receive radiographic evaluation of the chest to assess for possible intrathoracic injury. When pulmonary contusion is accompanied by fracture of the bony thorax, serial radiographic evaluation of the chest should be performed during the initial 48 hours of hospitalization.

Efficacy of measuring BUN in assessing children with dehydration due to gastroenteritis

We conducted a prospective study of 50 consecutive cases of children with gastroenteritis and dehydration to assess the correlation of alterations in the blood urea nitrogen (BUN) concentration. Symptoms included 24 children with vomiting and 26 with vomiting and diarrhea. All children were estimably dehydrated-appearing on examination by traditionally used criteria and had metabolic acidosis (serum bicarbonate concentration of less than 20 mEq/L) and increased anion gap (more than 12 mEq/L). Of these 50 children, 44 (88%) had a BUN concentration within the limits of normal--17 were less than or equal to 10 mg/dL, 17 were between 11 and 14 mg/dL, and ten were between 14 and 18 mg/dL. We discuss the physiologic factors that influence the BUN concentration in conditions of dehydration. Although commonly used, measurement of the magnitude of the BUN concentration is not an accurate method for assessing the hydration status of children with dehydration due to gastroenteritis.

Relationship of Fever Magnitude to Rate of Serious Bacterial infections in Infants Aged 4-8 Weeks:

We correlated the height of fever with underlying infectious etiology in 683 consecutive febrile infants aged four to eight weeks who received outpatient evaluation for sepsis during a five-year period. The relative number of infants with fever was inversely proportional to fever height, as 51 % had a temperature 38.1 - 38.9°C, 45% had a temperature 39 - 39.9°C, and 4% had a temperature >40°C [hyperpyrexia]. There were 34 cases of serious bacterial infections [SBI], including 16 cases of urinary tract infection, 8 cases of bacteremia, 6 cases of bacterial meningitis, and 4 cases of Salmonella enteritis. The rate of SBI increased in direct proportion to fever height, being 3.2% in those with a temperature 38.1-38.9°C, 5.2% in those with a temperature 39-39.9°C, and 26% in those with a temperature >40°C. The 6.8% rate of SBI in those with fever >39°C was significantly greater than the 3.2% rate in those with fever <39°C [p <0.035]; and the 26% rate of SBI in those with hyperpyrexia was significantly greater than the 4.1 % rate in those with fever <40°C [p <0.000004]. In identifying those with SBI, the presence of hyperpyrexia had a sensitivity of 21 %, specificity of 97%, positive-predictive value of 25%, and negative-predictive value of 96%. The rate of SBI in febrile infants aged four to eight weeks is proportional to the height of fever documented at the time of evaluation; yet the predictive-value of hyperpyrexia in identifying individual infants with SBI is low. It is important that all febrile infants aged four to eight weeks receive complete evaluation for sepsis, regardless of height of fever.

Correlating Changes in Body Temperature With Infectious Outcome in Febrile Children Who Receive Acetaminophen

We reviewed the body-temperature patterns of 140 children ages 2 to 24 months who had fever >39.0°C, received acetaminophen 10 to 15 mg/kg, and had their temperatures remeasured 60 to 90 min later. The children comprised three groups: 22 had bacterial meningitis; 59, isolated bacteremia; and 59, nonbacterial febrile illness. Percentages of patients who became afebrile (temperature < 38.0°C) after receiving acetaminophen were not significantly different among the three groups. Differences in mean temperature decrease after antipyretic was given were significant within each group but not between groups. An inverse relation (P < .004) between patient age and magnitude of temperature was revealed by the following formula: °C of defervescence = 1.66 -(0.028 x patient age in months). Thus, highly febrile young children with and without invasive bacterial infections who receive a therapeutic dose of acetaminophen experience a significant temperature drop after 60 to 90 min but do not commonly defervesce to an afebrile state. The degree of defervescence is age-dependent and does not distinguish between infectious outcomes.

Intussusception Reduced by Barium Enema Outcome and Short-term Follow-up

A retrospective study was performed of 88 consecutive cases of intussusception that occurred during a 3-year period. Forty-eight patients experienced hydrostatic reduction of intussusception with barium enema and 40 patients required surgical correction of intussusception when barium enema reduction was unsuccessful. Patients with fever or duration of symptoms greater than 24 hours, or ileo-ileocolic type of intussusception had a significantly greater rate of unsuccessful hydrostatic reduction (p < 0.001). Of 48 cases of intussusception hydrostatically reduced by barium enema, 47 patients received repeat physical examination after reduction, 45 having normal findings. Oral feeding was tolerated in these 47 patients within 12 hours after reduction. All 41 hospitalized patients were discharged within 24 hours of reduction without developing complication; of seven non-hospitalized patients, six reported no complications during the initial 24 hour post-reduction period. The single complication that occurred was recurrence of intussusception (ileo-ileocolic type) in a patient 6 hours after initial reduction; this was the only case in which neither post-reduction physical examination nor trial of feeding had been performed. Children with intussusception hydrostatically reduced by barium enema are at low risk for complication during the subsequent 24 hour post-reduction period. When the pre-reduction course has been relatively uncomplicated, the post-reduction physical examination does not reveal abnormalities, and the patient is able to tolerate oral feeding, close outpatient monitoring appears to be safe.

Bacterial Meningitis in Children Whose Cerebrospinal Fluid Contains Polymorphonuclear Leukocytes Without Pleocytosis

A retrospective study was performed of 424 children who received diagnostic lumbar puncture for analysis of cerebrospinal fluid during evaluation of an acute illness. In 106 children, the CSF contained polymorphonuclear leukocytes without pleocytosis. Of these 106 patients, 90 percent had a CSF differential cell count with 20 percent or less PMNs and 88 percent had glucose and protein concentrations within the range of normal limits. All patients had a Gram-stained smear of CSF that revealed no organisms. In no instance was a CSF culture positive for a bacterial pathogen. In most instances, cerebrospinal fluid that contains total white cell count and glucose/protein concentrations within limits of normal, Gram-stained smear which reveals no organisms, and a differential cell count with less than 20 percent PMNs is not indicative of risk for bacterial meningitis. If the clinical situation warrants, the majority of children with this profile do not require hospitalization and initiation of empiric antibiotic therapy pending CSF culture results.

Enterobacter Cloacae Bacteremia in Children: A Review of 30 Cases in 12 Years

A review was performed of the 30 cases of pediatric Enterobacter cloacae (EBC) bacteremia which occurred at our institution during a 12-year period. These 30 cases represented 88% of all cases in which EBC was isolated by blood culture (four other instances were considered contaminants); the rate of isolation of this organism relative to all positive blood cultures was 0.6%. There were 14 patients <12 months of age, with 10 <2 months of age. Infection was nosocomially-acquired in 17 cases. At the time the positive blood culture was obtained, 5 patients were afebrile, and 8 patients (five immunocompromised) had been receiving parenteral antibiotic therapy to which the organism exhibited in-vitro sensitivity for at least 24 hours. EBC was a constituent of polymicrobial bacteremia in 6 cases; in 5 instances the associated organisms were also gram-negative bacteria. There were a total of 33 underlying medical conditions or foci of infection associated with EBC bacteremia identified in 27 patients, the most common of which were immune-deficiency state (17) and gastrointestinal tract lesions (6). There were 3 patients who died. EBC bacteremia is a relatively rare pediatric infection. It is commonly nosocomially-acquired, and afflicts children who are younger-aged or compromised by underlying medical problems.