Otitis media in infants aged 0-8 weeks: frequency of associated serious bacterial disease.

OBJECTIVE: To determine the frequency of serious bacterial infection in well appearing infants aged 0-8 weeks with isolated otitis media (OM). METHODS: Infants with confirmed OM underwent tympanocentesis with middle ear fluid (MEF) culture and complete sepsis evaluation. Enrolled infants were admitted to the hospital for parenteral antibiotics until blood, urine, and CSF cultures were negative for 48 hours. RESULTS: Forty non-toxic appearing infants were enrolled between January 1994 and April 1995, of whom 15 (38%) had a documented rectal temperature > or =38 degrees C. Bacterial pathogens were isolated from MEF cultures in 25 (62.5%) infants. All afebrile infants had negative blood, urine, and cerebrospinal fluid cultures (upper limit (UL) 95% CI 0.11). Only two febrile infants had positive cultures from sites other than the MEF (UL 95% CI 0.36). CONCLUSION: In our study population, previously healthy, non-toxic appearing afebrile infants aged 2-8 weeks and having isolated OM infrequently have an associated serious bacterial infection, suggesting that outpatient treatment with oral antibiotics and close follow-up may be an option. Further studies with large numbers of infants are necessary to confirm this conclusion.

A randomized clinical trial of dermal anesthesia by iontophoresis for peripheral intravenous catheter placement in children.

STUDY OBJECTIVE: To assess the efficacy of dermal anesthesia by lidocaine iontophoresis in children undergoing peripheral intravenous (PIV) catheter placement in the emergency department. METHODS: A double-blind, randomized, clinical trial was conducted at a tertiary children's hospital ED. Alert children 7 years or older requiring nonemergency PIV were eligible. Patients in the lidocaine group received 1 mL of 2% lidocaine with 1:100,000 epinephrine over a potential PIV site by iontophoresis. The control group received 1 mL of.9% saline solution with 1:100,000 epinephrine. After PIV placement, patients ranked the procedural pain using a visual analog scale. Complications were noted by visual inspection or telephone follow-up. RESULTS: During a 6-month period, 22 patients were assigned to the lidocaine group and 25 to the control group. There was no significant difference in age, sex, or ethnic background between the 2 study groups, and mean application time was 12.0 minutes. The median pain score was.5 in the lidocaine group compared with 4 in the control group (P =.0002; 95% confidence interval [CI] 1 to 5). No significant immediate or delayed complications were observed. CONCLUSION: Lidocaine iontophoresis provides effective dermal anesthesia for children older than 7 years of undergoing nonemergency PIV placement in the ED.

False-positive preliminary radiograph interpretations in a pediatric emergency department: clinical and economic impact.

A prospective, case control study at a university-affiliated, academic pediatric emergency department was undertaken to determine the clinical impact and cost of false-positive preliminary radiograph interpretations and to compare the cost of false-positive interpretations with the estimated cost of a 24-hour on-site pediatric radiologist. Data were collected on all patients undergoing radiography of the chest, abdomen, lateral (soft tissue) neck, cervical spine, or extremities during a 5-month period. A total of 1,471 radiograph examinations was performed, and 200 (14%) misinterpretations (false-positive and false-negative) by the pediatric emergency medicine physicians were identified. As reported previously, 20 (10%) of the false-negative interpretations were noted to be clinically significant, in the current analysis, 103 (7%) false-positive radiograph interpretations were identified. False-positive interpretations were noted more frequently (14%) for soft tissue lateral neck radiographs than for any other radiograph type. Of the 103 total false-positive radiographs, nine (0.6%) resulted in an increased patient cost totaling $764.75. These data show that false-positive radiograph interpretations have limited economic and clinical impact.

Chest radiography in the initial episode of bronchospasm in children: can clinical variables predict pathologic findings?

STUDY OBJECTIVE: To determine whether historical or clinical variables can accurately discriminate among children, experiencing a first episode of bronchospasm, with chest radiography findings that are normal, consistent with reactive airway disease (RAD), or pathologic. METHODS: We assembled a prospective case series of patients in our tertiary, academic, pediatric emergency department. All patients aged newborn to 18 years presenting to the ED with their initial episode of wheezing were enrolled. RESULTS: Six hundred thirty-three patients presented to the ED during the study period. Pathologic radiographic findings were identified in 39 (6.2%). Radiographs revealing normal findings and evidence of RAD were noted in 25.4% and 68%, respectively. No single variable accurately predicted all pathologic radiographs. Discriminant function analysis identified nine variables, which we combined into a model. The model failed to accurately discriminate among patients with radiographs revealing evidence of a pathologic condition, normal chest findings, and RAD. CONCLUSION: No clinical variables, isolated or combined into a model, accurately identify patients with pathologic radiography findings. Continued use of chest radiography as a diagnostic intervention in the initial episode of childhood bronchospasm is recommended.

Upper airway compromise in acute chlorpromazine ingestion.

A 16-year-old boy developed symptoms of acute upper airway compromise after chlorpromazine ingestion. The patient took six 100-mg Thorazine tablets "to help him sleep". Laryngeal-pharyngeal dystonia is a life-threatening form of dystonic reaction that is dose-dependent. In children, acute upper airway compromise should raise the suspicion of exposure to phenothiazines.

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.

The role of abdominal x-rays in the diagnosis and management of intussusception.

The management of intussusception requires early diagnosis and reduction with either barium enema or surgical intervention. Supine and erect abdominal radiographs are often obtained prior to ordering a barium enema. In many pediatric centers, the critical, initial interpretation of these radiographs is made by nonradiologists and, in most instances, by pediatric emergency physicians. We determined the sensitivity and specificity of abdominal radiographs in diagnosing intussusception when interpreted by these physicians. Six full-time pediatric emergency physicians evaluated 126 radiographs from 42 patients with intussusception, 42 in whom the disease was clinically suspected but ruled out, and 42 in whom the final radiology report was "normal." These were presented to pediatric emergency physicians in a blinded, randomized sequence without any additional clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% (range, 71-93%), and the mean specificity was 58% (range, 48-69%). This compares favorably to the sensitivity of signs and symptoms, and we conclude that plain and upright abdominal films are a useful adjunct for the clinician evaluating patients for suspected intussusception.

Clinical predictors of bacterial versus aseptic meningitis in childhood.

STUDY OBJECTIVE: To assess the reliability of meningeal signs and other physical findings in predicting bacterial and aseptic meningitis at various ages. DESIGN: Children requiring lumbar puncture were evaluated prospectively for meningeal signs and other physical parameters before lumbar puncture. SETTING: Emergency department of Children's Hospital of Wisconsin. PARTICIPANTS: One hundred seventy-two children, aged 1 week to 17 years, with meningitis (53 bacterial and 119 aseptic). MEASUREMENTS AND MAIN RESULTS: Nuchal rigidity was present in 27% of infants aged 0 to 6 months with bacterial meningitis versus 95% of patients 19 months or older (P = .0001). Three percent of infants 0 to 6 months old with aseptic meningitis had nuchal rigidity versus 79% of patients 19 months or older (P = .0005). Seventy-two percent of infants 12 months of age or younger with bacterial meningitis has at least one positive meningeal sign versus 17% of infants with aseptic meningitis (P = .0001). Eighty-five percent of children older than 12 months with meningitis had at least one positive meningeal sign, 93% with bacterial meningitis, and 82% with aseptic meningitis. CONCLUSION: Despite a lack of meningeal signs, a high index of suspicion for meningitis is essential when evaluating the febrile infant 12 months of age or younger.

Surfactant replacement therapy in respiratory distress syndrome. Meta-analysis of clinical trials of single-dose surfactant extracts.

Replacement therapy with surfactant extracts in premature infants with respiratory distress syndrome has been evaluated in several clinical trials. The results of individual trials do not provide conclusive evidence that administration of a single dose of surfactant improves morbidity or mortality. Meta-analysis is a statistical method to combine the results of such clinical trials, and combined analysis provides a means to overcome the problem of not being able to detect significant small differences in individual trials due to these small sample sizes. Seven clinical trials (277 patients treated with nonhuman surfactant extract and 263 controls) met the criteria for analysis; five outcome measurements (mortality, patent ductus arteriosus, pneumothorax, intraventricular hemorrhage, and bronchopulmonary dysplasia) were selected to estimate the treatment effect. The meta-analysis showed that a single dose of surfactant administered before the first breath or within 15 hours of birth significantly decreased the mortality rate (95% confidence interval = -0.19 to -0.03) and the risk of developing pneumothorax (95% confidence interval = -0.28 to 0.14) in infants with respiratory distress syndrome. Further clinical trials are needed to evaluate other aspects of surfactant replacement therapy in premature infants because inconsistent results were observed among the seven analyzed studies.

The effect of oral midazolam on anxiety of preschool children during laceration repair.

Preschool age children often experience marked anxiety and physical pain during laceration repair. Locally infiltrated anesthetics or topical tetracaine, adrenaline, and cocaine (TAC) usually control the physical pain but have little or no effect on anxiety. Midazolam is a short-acting benzodiazepine with anxiolytic, hypnotic, and antegrade amnestic effects. In a double-blind, randomized clinical trial, we evaluated the efficacy of midazolam in alleviating anxiety during laceration repair in children less than 6 years old. On admission to the emergency department, anxiety level was determined on a scale of 1 to 4 based on a predetermined behavior criteria. Patients with high anxiety level (3 or 4) received a single oral dose of either midazolam (0.2 mg/kg) or placebo. The anxiolytic effect of midazolam was considered adequate if the anxiety level decreased two or more points (from 4 to less than or equal to 2 or from 3 to 1) during laceration repair. In the midazolam group (30), 70% of the children had a two-point or more decrease in anxiety level compared with 12% in the placebo group (25) (P less than .0001). No respiratory depression or other complications were noted in the midazolam group. We conclude that a single oral dose of midazolam (0.2 mg/kg) is a safe and effective treatment for alleviating anxiety in children less than 6 years old during laceration repair in the ED.

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.