Removing the pediatric cervical collar: current practice patterns.

OBJECTIVES: To identify the current practice patterns of emergency medicine practitioners and the typical criteria used in discontinuing cervical spine immobilization (CSI) in the pediatric patient. DESIGN: Mail-in survey. PARTICIPANTS: All physicians on the mailing list of the American Academy of Pediatrics Section of Emergency Medicine and an equal number of randomly chosen members of the American College of Emergency Physicians. The total number of participants was 1360. METHODS: The survey consisted of a case scenario describing a 3-year-old child brought to the emergency department with CSI. The approach to such a scenario was assessed. Surveys were mailed with self-addressed stamped envelopes; repeat mailings were sent at 4 and 8 weeks after the first mailing. Those not currently in active practice or not involved in the decision to discontinue CSI were excluded from the study. RESULTS: The response rate was 55%. Most respondents were younger than 44 years (71%), in practice less than 10 years (56%), and practiced in an urban setting (68%). Nearly two thirds (62.6%) had completed residency training in pediatrics, 24% in emergency medicine and 36% a pediatric emergency medicine fellowship. Most (63%) would discontinue CSI without obtaining radiographs. Factors associated with removal were residency training in pediatrics and being in practice for less than 10 years. The most common criteria for discontinuing CSI were normal neurological (96%) and cervical spine (98%) examinations, normal mental status (92%), and absence of neck pain (93%). CONCLUSIONS: Discontinuing CSI without obtaining radiographs is common, especially among those with residency training in pediatrics and those in practice for less than 10 years. Knowledge of current practice is essential to future development of guidelines for managing pediatric trauma patients for whom cervical spine injury is a consideration.

Evaluation of the prenatal developmental toxicity of orally administered arsenic trioxide in rats.

A thorough review of the literature revealed no published repeated-dose oral developmental toxicity studies of inorganic arsenic in rats. In the present study, which was conducted according to modern regulatory guidelines, arsenic trioxide was administered orally beginning 14 days prior to mating and continuing through mating and gestation until gestational day 19. Exposures began prior to mating in an attempt to achieve a steady state of arsenic in the bloodstream of dams prior to embryo-foetal development. Groups of 25 Crl:CD(SD)BR female rats received doses of 0, 1, 2.5, 5 or 10mg/kg/day by gavage. The selection of these dose levels was based on a preliminary range-finding study, in which excessive post-implantation loss and markedly decreased foetal weight occurred at doses of 15 mg/kg/day and maternal deaths occurred at higher doses. Maternal toxicity in the 10mg/kg/day group was evidenced by decreased food consumption and decreased net body weight gain during gestation, increased liver and kidney weights, and stomach abnormalities (adhesions and eroded areas). Transient decreases in food consumption in the 5mg/kg/day group caused the maternal no-observed-adverse-effect level (NOAEL) to be determined as 2. 5mg/kg/day. Intrauterine parameters were unaffected by arsenic trioxide. No treatment-related foetal malformations were noted in any dose group. Increased skeletal variations at 10mg/kg/day were attributed to reduced foetal weight at that dose level. The developmental NOAEL was thus 5mg/kg/day. Based on this study, orally administered arsenic trioxide cannot be considered to be a selective developmental toxicant (i.e. it is not more toxic to the conceptus than to the maternal organism), nor does it exhibit any propensity to cause neural tube defects, even at maternally toxic dose levels.

Interpreting the toxicologic significance of alterations in anogenital distance: potential for confounding effects of progeny body weights.

Anogenital distance (AGD) is an endpoint that was recently added to the U.S. EPA testing guidelines for reproductive toxicity studies. This endpoint is sensitive to hormonal effects of test chemicals. It is possible that apparent alterations in AGD might occur after treatment with agents that affect overall pup body size. In such cases, hormonal activity might be associated incorrectly with the test treatment. The analyses in this report evaluated statistical correlations between pup body weight and AGD in control litters. AGDs were measured on postnatal day 1 in 1501 pups derived from 113 untreated female Sprague-Dawley rats in two independent two-generation reproductive toxicity studies. Significant correlations were detected between AGD and body weight and between AGD and the cube root of body weight. In males, AGD increased 0.26 mm for each 1 g increase in body weight. In females, AGD increased 0.13 mm per 1 g increase in body weight. Although there were essentially no differences between the regression models developed to predict AGD in either males or females using body weight as a covariate and those based on the cube root of body weight, such similarities in predictivity might not occur in larger animals with broader weight ranges than those encountered in this analysis. Normalization of AGD by dividing by body weight significantly overcompensated for differences in body size. Normalizing with the cube root of body weight resulted in an AGD/cube root of body weight ratio that was constant across the range of body weights observed in this study. In conclusion, as a preferred method to account for body size effects on AGD, analysis of covariance is recommended. If a normalization is done directly, the ratio of AGD to the cube root of body weight is the more appropriate metric.

Bridging the emergency medical services for children information gap.

OBJECTIVE: To determine the epidemiological features of pediatric usage of prehospital emergency medical services (EMS) in a defined urban population. METHODS: Residents of Kansas City, Mo, younger than 15 years who used EMS during the calendar years 1993-1995 were included. In this geographic area there is a single provider of prehospital care; all numerator data were taken from this single source. Denominator data were provided by 1995 intercensal estimates based on the 1990 US Census. Rates were calculated as an annual average and reported as the number of children transported per 1 000 persons per year. RESULTS: There were a total of 7296 pediatric EMS transports during the study period, for an annual rate of 21.9. Infants younger than 1 year had the highest rate (47.4), followed by those aged 1 to 4 years (26.2), 10 to 14 years (17.5), and 5 to 9 years (17.3). Medicaid was the insurer for half and 27% were uninsured. One quarter of the patients used EMS more than once. Children living in ZIP codes in the lowest median income tertile were 5.8 times more likely to use EMS than those in the upper income tertile (95% confidence interval, 5.4-6.3). One third of all transports occurred between the hours of 4 and 8 PM. CONCLUSIONS: Children using the Kansas City EMS were more likely to be infants, insured by Medicaid or uninsured, and live in low-income ZIP codes. Further study is needed to determine if this increased usage is due to greater incidence and severity of illness and injury, lack of transportation, lack of education, or other factors.

Updates in wound management for the pediatrician.

Lacerations are common in children, and skills in wound management, especially laceration repair, are important. The minimization of pain and anxiety should be considered an essential part of the procedure. Newer techniques using topical anesthetics and tissue adhesives have significantly simplified the process of laceration repair promoting application in office, clinic, and emergency department settings. In situations inappropriate for topical anesthesia and closure, the use of buffered lidocaine and attention to the technique of infiltration are important. Although infection is the most common complication, the percentage of lacerations, which become infected in children, is low. Antibiotic prophylaxis is seldom needed. Human and animal bites raise special concerns in the assessment for primary repair and prophylactic antibiotic use.

Practical issues in the care of pediatric trauma patients.

Childhood injuries are a preventable problem that continue to occur with alarming frequency. The pediatrician has a broad role in the prevention and treatment of injuries. When primary prevention fails, trauma care providers must recognize that an injured child is a unique patient who requires special considerations. Use of an organized approach will assure that injuries are not missed. The care of an injured child presents pediatricians with a tremendous responsibility. Injury prevention presents the pediatrician with a formidable challenge.

The impact of children witnessing violence.

Over the past decade, Americans have recognized that violence has deeply permeated the lives of the most vulnerable among us--children. There is great concern over the effect these terrible experiences will have on present and future generations. It has also awakened the collective consciousness of our society that the impact of violence extends well beyond the child who is physically victimized to other larger groups of children such as those who witness these events. This article reviews the impact violence has on children.

The summer penile syndrome: seasonal acute hypersensitivity reaction caused by chigger bites on the penis.

OBJECTIVE: To describe the seasonal acute hypersensitivity reaction of the penis due to chigger bites, known as the summer penile syndrome. DESIGN: A consecutive series of patients. SETTING: The emergency department of an urban academic children's hospital in the midwestern United States. PARTICIPANTS: Male pediatric patients with an acute hypersensitivity reaction of the penis. RESULTS: Ninety-four patients were treated for summer penile syndrome during the four-month period from June through September. Patients ranged in age from seven months to 11 years (mean = 5.1, SD = 2.5). Twenty-one percent of patients had also experienced a similar prior episode of penile swelling. Symptoms included pruritus in 84% of cases, dysuria in 33%, and decreased strength of urine stream in 8% of patients. Eighty-four percent of patients had recent exposure to the woods, park, lawn, or poison ivy. In addition to edema, findings on physical examination included a papule or bite puncture mark in 50% of patients, erythema in 32%, and excoriation in 6% of patients. Fifty-six percent of patients had bites on other areas of the body. The emergency physician attributed the penile edema to an insect or chigger bite in 98% of cases. Treatment consisted of an oral antihistamine and cold compresses in most cases. The reported duration of penile swelling ranged from one to 18 days with a mean of 4.1 days (SD = 3.5), and the reported duration of pruritus ranged from 0 to 14 days with a mean of 3.0 days (SD = 2.6). CONCLUSION: This study provides an understanding of the summer penile syndrome for pediatric care providers. To our knowledge, this study is the first to describe this seasonal syndrome in the medical literature.

Cardiopulmonary response to maximal exercise in young athletes following the Ross procedure.

BACKGROUND: Aortic prosthetic devices offer limitations that make them less than optimal valve substitutes because the vast majority are innately obstructive, especially at increased levels of hemodynamic function. The present study is designed to demonstrate the hemodynamics of the pulmonary autograft in 11 conditioned athletes who have undergone the Ross (pulmonary autograft) procedure. Data was compared to a group of 13 age-matched "normal athletes." METHODS: All the Ross athletes had undergone the autograft procedure using the root replacement technique and were at least 3 months into their postrecovery phase. All athletes (both normal and Ross) underwent resting transthoracic echo followed by maximal exercise stress test (modified Bruce protocol) to exhaustion. Post-operative transesphogeal echocardiogram obtained within 90 seconds documented aortic valve gradient and velocity across the aortic valve. RESULTS: In the Ross athlete group, maximum heart rate was 188 beats per minute, peak aortic valve gradient at rest (mm Hg) 7.69 (mean), velocity across the aortic valve at rest (cm per second) 129.40 (mean), peak aortic valve gradient at maximal exercise (mm Hg) 16.30 (mean), velocity across the aortic valve at maximal exercise (cm per second) 190.00 (mean). In the normal athlete group, maximum heart rate was 176 beats/minute, peak aortic valve gradient at rest (mm Hg) 5.97 (mean), velocity across the aortic valve at rest (cm per second) 120.54 (mean), peak aortic valve gradient at maximal exercise (mm Hg) 14.61 (mean), velocity across the aortic valve at maximal exercise (cm per second) 190.23 (mean). CONCLUSION: The pulmonary autograft exhibits hemodynamic characteristics similar to the normal human aortic valve under conditions of enhanced cardiac output.

Childhood burn injuries related to gasoline can home storage.

OBJECTIVE: To examine the risks associated with home storage of gasoline and to outline prevention strategies to avoid further injury and death. DESIGN: Case series. PATIENTS AND OTHER PARTICIPANTS: Twenty-five patients less than 6 years old were selected for study (3 by presentation to a tertiary care Children's Hospital Emergency Department, and 22 from the National Electronic Injury Surveillance System Data during the same calendar year). MAIN OUTCOME MEASURES: Data collected included child's age; burn injury, either percent body surface area or minor, moderate, or major burn classification; mortality; circumstances related to ignition of gasoline, such as behaviors, and if can was opened or closed; and flame source. RESULTS: Boys were involved in 95% of cases. Mean age was 2.7 years. The source of ignition was a pilot light in 100% of cases. Forty-four percent of patients died. Only vapors were ignited in 56% of cases. The gasoline can was described as closed in 64% of cases. CONCLUSION: Gasoline is dangerous. The rectangular red metal gasoline can is not safe either. National building codes and can specifications are needed to prevent serious injury and deaths among young children.