Applying outpatient protocols in febrile infants 1-28 days of age: can the threshold be lowered?

The purpose of this study was to determine the applicability of two accepted outpatient management protocols for the febrile infant 1-2 months of age (Boston and Philadelphia protocols) in febrile infants 1-28 days of age. We retrospectively reviewed charts of patients 1-28 days of age with a temperature greater than or equal to 38.0 degrees C. Criteria from each of the above-cited management protocols were applied to the patients to determine their applicability in screening for serious bacterial infection (SBI). An SBI was defined as bacterial growth in cultures from blood, urine, cerebrospinal fluid (CSF), stool, or any aspirated fluid. Overall, 372 febrile infants were included in the study. Ages ranged from 1 to 28 days of age. The mean age was 15 days. SBI occurred in 45 patients (12%). The mean age of the patients with an SBI was 13 days. Thirty-two infants (8.6%) had a urinary tract infection; 12 (3.2%), bacteremia; five (1.3%), bacterial meningitis; three (0.8%), cellulitis; one (0.3%), septic arthritis; one (0.3%), bacterial gastroenteritis; and one (0.3%), pneumonia. Ten infants had more than one SBI. Of 372 patients, 231 (62%) met the Boston's laboratory low-risk criteria; eight (3.5%) would have been sent home with an SBI with these criteria. Philadelphia's laboratory low-risk criteria would have been met by 186 patients (50%); six (3.2%) would have been sent home with an SBI with these criteria. The negative predictive value of both the Boston and Philadelphia protocols for excluding an SBI was 97%. We conclude that current management protocols for febrile infants 1-2 months of age when applied to febrile infants 1 to 28 days of age would allow 3% of febrile infants less than 28 days of age to be sent home with an SBI. Current guidelines recommending admitting all febrile infants less than 28 days of age should be followed until the outcome of those 3% of febrile infants with an SBI treated as outpatients can be determined.

Evaluation of pediatric cervical spine injuries.

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.

A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages.

STUDY OBJECTIVE: To compare historical features, physical examination findings, and testicular color Doppler ultrasound in pediatric patients with epididymitis, testicular torsion, and torsion of appendix testis. METHODS: A retrospective review of patients with the diagnosis of epididymitis, testicular torsion, or torsion of appendix testis. RESULTS: Ninety patients were included in the study (64 with epididymitis, 13 with testicular torsion, and 13 with torsion of appendix testis). Historical features did not differ among groups except for duration of symptoms. Of 13 patients with testicular torsion all had a tender testicle and an absent cremasteric reflex. When compared with the testicular torsion group, fewer patients with epididymitis had a tender testicle (69%) or an absent cremasteric reflex (14%). 62 (97%) patients with epididymitis had a tender epididymis and 43 (67%) had scrotal erythema/edema. By comparison, 3 (23%) and 5 (38%) patients with testicular torsion had a tender epididymis or scrotal erythema/edema, respectively. Doppler ultrasound showed decreased or absent blood flow in 8 patients, 7 of whom were diagnosed with testicular torsion. Ten out of 13 patients with testicular torsion had a salvageable testicle at the time of surgery. CONCLUSION: The physical examination is helpful in distinguishing among epididymitis, testicular torsion, and torsion of appendix testis. Patients presenting with a tender testicle and an absent cremasteric reflex were more likely to have a testicular torsion rather than epididymitis or torsion of appendix testis. An absent cremasteric reflex was the most sensitive physical finding for diagnosing testicular torsion. Color Doppler ultrasound is a useful adjunct in the evaluation of the acute scrotum when physical findings are equivocal.

Pediatric male rectal and genital trauma: accidental and nonaccidental injuries.

OBJECTIVE: To characterize accidental pediatric rectal/genital trauma in males and compare these physical findings to a cohort of boys evaluated for sexual abuse. DESIGN: Retrospective chart review. SETTING: Tertiary pediatric trauma center/sexual abuse clinic. PARTICIPANTS: Male patients evaluated in the emergency department for rectal/genital trauma from 9/1/89 through 10/31/93 ("accidental group"). Male patients referred to Child Protection Services for suspected sexual abuse from 1/1/93 through 12/31/95 who had abnormal genital physical findings ("sexual abuse group"). MAIN OUTCOME MEASURES: Outcomes measured included age, mechanism of injury, category of diagnosis, location of injury, and type of injury. RESULTS: Forty-four male patients comprised the accidental group, aged six months to 17 years. The most common mechanism was a fall onto an object (34%). The most common injuries were lacerations/perforations of the scrotum (36%) followed by penile lacerations/perforations (25%). No patient had an isolated rectal laceration. Forty-four male patients with positive physical findings comprised the sexual abuse group. Ages ranged from seven months to 18 years. All patients had rectal lesions. Penile lacerations/perforations were the only other injuries documented, occurring in two patients. CONCLUSIONS: Accidental rectal/genital trauma in the pediatric population is uncommon; scrotal trauma occurs much more frequently than rectal trauma. Rectal/genital injury in the sexual abuse group typically involves only the rectal area. Sexual assault should be considered in patients with isolated rectal injury or whenever the alleged history does not correlate with physical findings.

Removal of nasal foreign bodies in the pediatric population.

Nasal foreign bodies requiring removal occur commonly in young children. Different techniques of removal are needed depending on the type of nasal foreign body. A retrospective chart review of a 19-month period identified 60 pediatric patients with nasal foreign bodies evaluated in a pediatric emergency department. Twenty-four different types of foreign bodies were removed; beads, rocks and plastic toys were the most common. Numerous removal techniques were used; forceps and Foley catheter techniques were the most common. Most foreign bodies can be managed with simple equipment and without requiring otolaryngology consultation. Because of the many different nasal foreign bodies found, the physician should be skilled in numerous techniques of removal. Each one of these useful techniques is reviewed.

Evaluating the effectiveness of a pediatric trauma educational program in Central America.

OBJECTIVE: To evaluate the effectiveness of a pediatric trauma course taught in a developing country. STUDY DESIGN: A pediatric trauma course was designed with didactic presentations and reinforced with small group case discussions. Subjects included a general trauma overview, head trauma, airway/chest trauma, cervical spine trauma, abdominal trauma, shock, burns, and orthopedic injuries. Evaluation consisted of a pre- and post-course test and questionnaire assessing the participants' knowledge and level of comfort in managing trauma. Nine months after the course, the participants were evaluated with the same post-course test. Also a questionnaire was given to physician and nurse co-workers from the participating institutions, who themselves had not participated in the course, to assess the perceptual and attitudinal impact of the pediatric trauma course. SETTING: Guatemala City, Guatemala. PARTICIPANTS: Forty-three physicians from Central America. RESULTS: Initial and nine-month post-test scores showed uniform improvement (P value < 0.05) when compared to pretest results using the Wilcoxon signed-ranks test. Analysis of the pre- and post-course questionnaires indicated that all participants felt more comfortable (scale 1 to 5) after the course managing pediatric trauma patients. All participants "strongly agreed" the course provided information that would improve their management of the pediatric trauma victim. Nine months after the course, 100% of their medical co-workers perceived physicians who participated in the pediatric trauma course to have better resuscitative skills, and 92% perceived these physicians to have a higher level of confidence. CONCLUSION: This course, when presented to physicians in a developing country, appears to be effective in improving their knowledge base regarding pediatric trauma and increasing their comfort level in managing major pediatric trauma.

Pediatric basilar skull fracture: do children with normal neurologic findings and no intracranial injury require hospitalization?

STUDY OBJECTIVE: To delineate complications in patients with basilar skull fractures (BSFs) and normal neurologic findings, including computed tomography (CT) scans without intracranial injury, and to assess the need for hospitalization. DESIGN: Retrospective chart review. PARTICIPANTS: All emergency department patients with the ED diagnosis or hospital discharge diagnosis of BSF. Patients were included if they had a clinical or radiographic diagnosis of BSF. A subgroup of patients ("simple BSF") with normal neurologic examination findings in the ED, Glasgow Coma Scale scores of 15, and cranial CT scans without intracranial pathology was specifically analyzed. RESULTS: We included 239 patients in the study. One hundred fourteen patients (48%) were included in the "simple BSF" subgroup. In this subgroup, vomiting (6%) was the most common complication, meningitis (1%) the most serious. There were no cases of delayed intracranial hemorrhage, and no patient with "simple BSF" required surgery. CONCLUSION: Given the relatively low frequency of serious complications, our study suggests that some patients with BSFs may not require hospital admission.

Blunt pediatric laryngotracheal trauma: case reports and review of the literature.

Blunt laryngotracheal trauma can be a life-threatening event. Two cases of isolated blunt laryngotracheal trauma in pediatric patients are presented. One case involves a 12-year-old mate who suffered isolated tracheal trauma from a fall. He developed respiratory distress and required a tracheostomy. Intraoperatively he was noted to have a thyroid cartilage fracture. The other case involves a 14-year-old female who was kicked in the neck by a horse. After unsuccessful intubation attempts that completed a tracheal transection, she required an emergency cricothyrotomy and a subsequent tracheostomy. The diagnosis, differential diagnosis, associated injuries, and treatment options for blunt laryngeal trauma are reviewed.