Serious and fatal air gun injuries: more than meets the eye.

OBJECTIVE: To describe the epidemiology of air gun injuries to children that required hospitalization. DESIGN: A consecutive series of children with air gun injuries. SETTING: Urban pediatric teaching hospitals in Cincinnati, OH; Kansas City, MO; and Seattle, WA. METHODS: A retrospective chart review. RESULTS: A total of 101 children were studied: 81% were male; 80% were white, 18% were black, and 2% were other races. The median age was 10.9 years (range, 0.5 to 18.8). Victims were most commonly shot by a friend (30%) or sibling (21%). A total of 34% occurred at the victim's home, and 36% occurred at the home of a friend or relative. Although 71% of shootings were unintentional, 5% were assaults, and 1% were suicides. The median hospital stay was 3 days (range, 1 to 17 days). Fifteen children (15%) required treatment in intensive care. A total of 56% required at least one surgical procedure. Forty-nine had injuries to the head, including 38 with injuries to the eye, 10 with intracranial injuries, and 1 with a skull injury. Fourteen children were shot in the neck; 15 were shot in the chest, with 2 patients sustaining lacerations of the pericardium and 1 having a right ventricular foreign body. Another child had a laceration of the innominate artery. Nineteen had abdominal injuries, including laceration of the stomach (N = 3), small bowel (N = 4), colon (N = 2), and liver (N = 3). Three of 10 children with intracranial injuries died. Two had long-term neurologic deficits. Of children with eye injuries, 25 (66%) had permanent visual loss and 15 (39%) of these were blind. CONCLUSION: Air guns are associated with serious and fatal injuries. Families should be counseled that air guns may cause serious injuries and even death. Furthermore, pediatric care givers should advocate for increased regulation of air guns and expansion of safety standards.

Pediatric emergency medicine fellow clinical work requirements.

A wide range of clinical requirements exists among PEM fellowship programs. Programs are equally split concerning the question of whether fellows should work with supervision or independently in the first year; a significant number of fellowship programs require continued supervision of fellows in subsequent years. Orientation for first year fellows and requirements for completion of PALS, advanced pediatric life support (APLS), ACLS, or ATLS courses prior to their first independent shift varied greatly. In particular, a minority of programs required ATLS completion even though a majority of overall fellowship programs operate in a hospital designated as a Level 1 Trauma Center. Programs in which first-year fellows worked independently had fewer attendings and were less likely to provide 24-hour coverage. Fellows appear to work a similar or less demanding schedule than PEM attendings in most fellowship programs, and most fellowship directors feel that their fellows should continue with their current schedule.

Severe dog bites in children.

OBJECTIVE: We evaluated children less than 16 years of age who had dog bite injuries that resulted in hospitalization or death to determine the typical characteristics of the children, the dogs, and the injuries suffered. DESIGN: Retrospective chart review. SETTING: Three large city hospitals including Harborview Medical Center, Seattle, Washington; Children's Mercy Hospital, Kansas City, Missouri; and Mary Bridge Hospital, Tacoma, Washington. METHODS: Charts were reviewed for patient demographic data and canine data. Hospitalization data included total length of stay, need for intensive care, Injury Severity Score, the nature and extent of the injuries, procedures performed, complications, and outcome. RESULTS: Forty cases were reviewed. Most children were boys (60%) and were white (87%). The median age was 50 months. There were three deaths. Most dogs were medium-sized or large breeds and were familiar to the victim. The average hospital stay was 6 days (SD = 5), and 12 (30%) patients required a stay in the intensive care unit. Injuries to the face, head, and neck area were most common (82%). Major surgical procedures included craniotomy, exploration of the neck or abdomen, ocular procedures, and repair of fractures. CONCLUSIONS: Severe dog bites in children occur most frequently in those younger than 5 years old and involve the head and neck. Large dogs that are familiar to the child are usually involved. Young children should be closely supervised when around any dog.

Clinical impact of radiograph misinterpretation in a pediatric ED and the effect of physician training level.

Radiograph interpretation in the pediatric emergency department (ED) is commonly performed by pediatric emergency medicine (PEM) attendings or physicians-in-training. This study examines the effect of physician training level on radiograph interpretation and the clinical impact of false-negative radiograph interpretations. Data were collected on 1,471 radiographs of the chest, abdomen, extremity, lateral neck, and cervical spine interpreted by PEM attendings, one PEM fellow, one physician assistant, and emergency medicine, pediatric and family practice residents. Two hundred radiographs (14%) were misinterpreted, including 141 chest (16%), 24 extremity (8%), 20 abdomen (12%), 14 lateral neck (18%), and 1 cervical spine radiograph (2%). Physicians-in-training misinterpreted 16% of their radiographs versus 11% for PEM attendings (P = .01). Twenty (1.4%) radiographs had clinically significant (false-negative) misinterpretations, including 1.7% of physician-in-training and 0.8% of attending interpretations (P = 0.15). No morbidity resulted from the delay in correct interpretation. Radiograph misinterpretation by ED physicians occurs but is unlikely to result in significant morbidity.

Improved speed and accuracy of calculations with a programmable calculator in pediatric emergency scenarios.

Both mathematical and selection errors may occur when ordering drug or fluid therapy in a busy emergency department. In an attempt to improve the speed and accuracy of such calculations, we programmed a hand-held calculator to assist in drug and intravenous fluid therapy dosages and rates for three emergency situations: diabetic ketoacidosis, asthma, and asystole. Performance by 58 subjects at various levels of training was compared when using either the programmable calculator or standard materials and methods. When standard methods were used, an average of 30.6 minutes was needed to complete the three scenarios, with an accuracy of 73%; by contrast, use of programmable calculator resulted in a significant decline in time needed to calculate doses (an average of only 8.5 minutes), with an improved accuracy of 98%. The use of a programmable calculator can result in a significant improvement in both speed and accuracy of drug and fluid selection and dosage and rate calculations, regardless of the level of the subject's medical training.

Absent or minimal cerebrospinal fluid abnormalities in Haemophilus influenzae meningitis.

A case of Haemophilus influenzae type b (Hib) meningitis in which the diagnosis and treatment were delayed because of normal cerebrospinal fluid analysis is presented. A retrospective review was conducted at two children's hospitals to determine the frequency and clinical characteristics of patients with Hib meningitis whose spinal fluid had a normal total white blood cell count, normal chemistries, and negative Gram stain, but subsequent growth of Hib in culture. Of 379 cases of Hib meningitis, two had completely normal CSF, and two had CSF containing small numbers of polymorphonuclear cells as the sole abnormality. In three of the four cases, the duration of symptoms was less than 24 hours, and appropriate therapy was significantly delayed because of benign-appearing CSF. Normal CSF cell counts, chemistries, and Gram stain do not exclude the possibility of bacterial meningitis, and one should remain suspicious when a child has clinical findings suggesting meningitis.

Elevated liver transaminase levels in children with blunt abdominal trauma: a predictor of liver injury.

The medical records of 43 hemodynamically stable children with elevated serum transaminase levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) who underwent abdominal computed tomographic (CT) scan for blunt abdominal trauma were reviewed. Nineteen patients (44.2%) had AST levels greater than 450 IU/L and ALT levels greater than 250 IU/L, and 17 of these 19 patients had hepatic injury identified on abdominal CT scan. Of the 43 patients, 25 (58.1%) had AST and ALT levels of less than 450 IU/L and 250 IU/L, respectively, and none of these patients had evidence of hepatic injury on CT scan. Elevated serum transaminase levels (AST greater than 450 IU/L and ALT greater than 250 IU/L) identified all of the patients with hepatic injury visible on abdominal CT scan. The sensitivity and specificity of elevated serum transaminase levels were 100% and 92.3%, respectively, for predicting hepatic injury. It is recommended that hemodynamically stable pediatric patients with blunt abdominal trauma and AST levels greater than 450 IU/L and/or ALT levels greater than 250 IU/L undergo abdominal CT scan to determine the presence and extent of hepatic injury. Children with serum transaminase levels below these values are at decreased risk of liver injury.

Correlating reported fever in young infants with subsequent temperature patterns and rate of serious bacterial infections.

A retrospective study was performed of 292 infants younger than 2 months of age with a history of fever who received a standardized evaluation and were admitted to the hospital for possible sepsis. The purpose was to correlate the presence of this symptom with subsequent temperature patterns and the rate of serious bacterial infections (SBI). Caretakers reported fever per rectum via thermometer in 244 infants and tactile fever in 48 infants. Of 244 infants with reported fever per rectum, 224 (92%) had fever on presentation or during the subsequent 48 hours of hospitalization; by contrast, only 22 of 48 infants (46%) with reported tactile fever had fever on presentation or during the subsequent 48 hours of hospitalization (P less than 0.0001). Of 26 infants with tactile fever who were afebrile on presentation, none had subsequent fever during hospitalization and only 1 (3.8%) had SBI (urinary tract infection); of 40 infants with reported fever per rectum who were afebrile on presentation, 8 (20%) had subsequent fever during hospitalization and 4 (10%) had SBI (meningitis, bacteremia, osteomyelitis and urinary tract infection). There were a total of 19 infants (6.5%) with SBI; although 5 (27%) were afebrile on presentation (4 with reported fever per rectum, 1 with tactile fever), all 19 exhibited abnormal clinical and/or laboratory features on evaluation which were suggestive of underlying serious infection. Management decisions for young infants with reported fever should be based on both clinical findings and temperature-pattern profiles.

Comparison of topical tetracaine, adrenaline, and cocaine anesthesia with lidocaine infiltration for repair of lacerations in children.

Local anesthetic infiltration is painful and frightening for children. We prospectively compared a topical alternative, TAC solution (tetracaine 0.5%, adrenaline 1:2,000, cocaine 11.8%), with 1% lidocaine infiltration for use in laceration repair in 467 children. Adequate anesthesia of facial and scalp wounds was achieved for 81% of TAC-treated wounds versus 87% of lidocaine-treated wounds (P = .005). TAC was less effective on extremity wounds; 43% had effective anesthesia compared with 89% of lidocaine-treated extremity wounds (P less than .0001). No systemic toxicity was observed. The incidence of wound infection was 2.2% for both TAC and lidocaine. Wound dehiscence occurred in seven TAC- and two lidocaine-treated facial or scalp wounds (4.5% vs 1.8%, NS) and in five TAC- and four lidocaine-treated extremity wounds (20% vs 17.4%, NS). The unusually high rate of dehiscence was due partially to recurrent trauma or coincident infection. TAC was well accepted by patients and parents. We encourage the careful use of TAC as a less painful alternative to lidocaine infiltration for selected scalp and facial lacerations in children.