Evaluation of resuscitation skills in new residents before and after pediatric advanced life support course.

OBJECTIVE: Acquisition of resuscitation skills taught in advanced resuscitation courses has not been evaluated. We sought to determine the interobserver reliability of a resuscitation performance skills checklist to assess resident performance of bag mask ventilation, intubation, defibrillation, and intraosseous vascular access, and to measure skill acquisition by entering residents after a pediatric advanced life support (PALS) course. DESIGN: The resuscitation skills of all 39 pediatric R1's in 2 university-based training programs were assessed immediately before and after completion of a PALS course just before starting residency. Independent observers scored and timed resident performance of bag mask ventilation, endotracheal intubation, intraosseous access, and defibrillation. Scores before and after the PALS course were compared. Four independent observers scored 4 residents' videotaped skills performance. Observers' scores for each resident were compared. RESULTS: Successful performance improved for bag mask ventilation from 62% to 97% after the PALS course; for successful endotracheal intubation, from 64% to 90%; for successful intraosseous needle placement, from 54% to 92%; and for successful defibrillation, from 77% to 97%. Interobserver reliability was high for continuous and noncontinuous variables. CONCLUSIONS: New residents demonstrated significant acquisition of pediatric resuscitation skills immediately after completion of the PALS course. The skills performance checklist has excellent interobserver reliability and is a useful tool for evaluation of other training venues.

Do parents choose appropriate automotive restraint devices for their children?

This study aims to describe parental choices of childhood automotive restraints and compare them with guidelines based on weight and height. Parents were surveyed and their children's heights and weight were measured. Results indicated that many parents believed their child fit a lap or shoulder belt when their children were too short to fit these devices. For children weighing < 40 pounds, 45% of parents believed the lap belt fit. Thirteen percent of 4-7-year-olds used booster seats, appropriate for 72% by sitting height criteria; and 33% of children < or = 7 years used the lap/shoullder belt, appropriate for 8% by sitting height criteria. Implications are that parental perceptions of fit may lead to inappropriate restraint choices for children. Practitioners should discuss child restraint use with parents in the context of their child's weight and height.

Costs of sedation using oral midazolam: money, time, and parental attitudes.

OBJECTIVE: Many agents suitable for pediatric outpatient sedation have been identified and compared, but less data have appeared on the effect of sedation use on Emergency Department (ED) length of stay (LOS) or visit costs. We sought to discover the relationship between one commonly used method of sedation, orally administered midazolam, and ED LOS and visit costs. Parents were then surveyed to determine their attitudes toward sedation given knowledge of these costs. METHODS: All ED patients under 10 years of age seen in a pediatric ED during April and May of 1996 for repair of lacerations <2.5 cm in length were identified via retrospective chart review. Children were excluded if they had other significant injuries, received sedatives other than oral midazolam, or were repaired by non-ED physicians. Preliminary cost and LOS data from this review was used to create a parental survey measuring attitudes toward the costs of an unnamed form of sedation (not mentioning oral midazolam). A convenience sample of parents in an ED waiting room were asked if they would want sedation administered to a child needing sutures if this increased the visit cost by $100 and/or increased LOS by 30 minutes. Parents were then asked to re-answer these questions assuming that the sedation medication was effective only 50% of the time. RESULTS: Of 120 patients meeting entry criteria, 57 (48%) received oral midazolam. Children sedated with this agent were significantly younger (3.6 vs. 4.6 years, P = 0.015), had more layered repairs (30% vs. 14%, P = 0.047), and more facial lacerations (84% vs. 63%, P = 0.01) when compared with nonsedated patients. Mean LOS for patients with simple lacerations receiving oral midazolam increased by 17.1 minutes (P = 0.03) compared with nonsedated children; for layered repairs, the mean increase was 30.9 minutes (P<0.05). The use of oral midazolam did not effect physician charges, but did significantly increase mean combined nurse/hospital charges and total charges by 73 to 87 dollars, depending on laceration type (P<0.001 all cases). Of 81 parents surveyed, 81% said that they would be willing to wait 30 extra minutes for sedation to be used; this figure fell to 73% if sedation was effective 50% of the time. Seventy-five percent of parents were willing to pay $100 extra for sedation; 67% if sedation was effective only half the time. Willingness to endure a longer LOS or pay increased charges was not associated with parental sex or insurance status. CONCLUSION: The use of oral midazolam significantly increases ED visit LOS and cost. This information is important to review with parents when discussing sedation options. Up to one third of parents surveyed would not want to wait extra time or pay extra money for sedation to be administered, especially if the efficacy of the chosen method was not assured.

Vaginal injury from a water slide in a premenarcheal patient.

BACKGROUND: Water under high pressure can produce vaginal injury. Previous reports suggest that postmenarcheal maturation and the presence of a vaginal foreign body contributed to water slide injuries in women. METHODS: A case of a vaginal injury from a water slide in a premenarcheal patient is presented. A literature review of water-related vaginal injuries in adults and children compares the mechanism of injury with that previously reported. RESULTS: The patient underwent operative repair of her injury. CONCLUSIONS: Vaginal injury in premenarcheal patients may result from a water slide. The emergency physician must be aware of this potential injury mechanism and the need for complete examination under anesthesia when vaginal bleeding is present.

Use of racemic epinephrine, dexamethasone, and mist in the outpatient management of croup.

This study aims to determine whether a subpopulation of children with croup, given mist and dexamethasone, can be treated with nebulized racemic epinephrine and safely discharged after observation in the emergency department. A prospective study was designed, enrolling children aged three months to six years with a clinical diagnosis of croup. Croup scores were assigned on arrival, after 30 minutes of saline mist, and 30, 120, and 240 minutes after nebulized racemic epinephrine. All children received mist; those with a croup score > 3 after mist were given nebulized racemic epinephrine. All patients received intramuscular dexamethasone. Patients were discharged if they were significantly improved after four hours of observation. Phone follow-up occurred 24 to 48 hours after discharge. Sixty children received racemic epinephrine for croup. The median croup score on arrival was 5, and there was no difference in arrival croup score by disposition. The two-hour croup score was significantly higher for admitted patients (P < 0.05 by the Mann-Whitney U test). Forty children (66%) were discharged after nebulized racemic epinephrine and four hours of observation. No patients returned to the emergency department within 24 hours for further treatment. Two patients could not be contacted. The 95% confidence interval for 0/38 patients with a negative outcome is (0-9.3%). We conclude that children with croup treated with dexamethasone and mist, receiving one nebulized racemic epinephrine treatment, can be discharged after a four-hour period of observation if they appear clinically well to an experienced physician, and if close follow-up can be established.

Utilization of a pediatric emergency department by patients with sickle cell disease.

When considering an alternative site to the emergency department (ED) for the care of acutely ill patients with sickle cell disease, it is necessary first to determine utilization of and satisfaction with ED care. Such data serve as guidelines for the planning and evaluation of alternative treatment facilities. We reviewed 137 consecutive ED visits by 98 patients with sickle cell diseases at The Children's Hospital of Philadelphia over a three-month period to determine ED utilization and waiting times. A follow-up telephone survey determined reasons for coming to the ED, duration of symptoms, and patient satisfaction with the ED visit. Our results reveal that an alternative facility open only during regular working hours would not serve the majority of patients with sickle cell disease. We describe the services provided to acutely ill sickle cell disease patients, and identify areas for improved service delivery within our ED or an alternative facility.

Pulse oximetry and factors associated with hemoglobin oxygen desaturation in children with sickle cell disease.

The observation of low transcutaneous arterial oxygen saturation (SaO2) in otherwise well sickle cell patients has lead to questions about the interpretation of pulse oximetry values in these patients. We undertook a prospective study of children with sickle cell disease to (1) determine the prevalence of, and factors associated with, low transcutaneous SaO2 in clinically well patients, (2) develop an algorithm for the use of pulse oximetry in acutely ill patients, and (3) assess the accuracy of pulse oximetry in these patients. Eighty-six clinically well children with hemoglobin (Hb) SS had a lower mean transcutaneous SaO2 than 22 Hb SC patients and 10 control subjects (95.6% v 99.1% v 99.0%, respectively; p < .001). In Hb SS patients, a history of acute chest syndrome and age greater than 5 years were associated with lower transcutaneous SaO2 (mean 93.8% for those with a history of acute chest syndrome v 97.8% for those without a history of acute chest syndrome, and 94.0% for patients > 5 years old v 97.2% for those < or = 5 years old; P < .001). These associations were not seen in Hb SC patients. During acute illness, Hb SS patients with acute chest syndrome had transcutaneous SaO2 values that were less than 96% and at least 3 points lower than measurements made when they were well. A nomogram was designed to aid in the interpretation of transcutaneous SaO2 in acutely ill Hb SS patients when a comparison value is not available. The accuracy of pulse oximetry was shown by the correlation between SaO2 measured by pulse oximetry and calculated by using the patient's oxygen dissociation curve and PaO2 (r = .97). This study provides evidence that Hb oxygen desaturation is not a universal finding among children with sickle cell disease and identifies factors associated with Hb oxygen desaturation. We conclude that pulse oximetry may be useful to assess whether progressive pulmonary dysfunction begins at an early age in Hb SS patients, and to assess acutely ill patients for the presence of hypoxemia associated with acute chest syndrome.

Histone gene transcripts in the cleavage and mesenchyme blastula embryo of the sea urchin, S. purpuratus.

Two distinct populations of histone gene transcripts have been identified in the sea urchin embryo. Both late cleavage and mesenchyme blastula stages contain histone transcripts which hybridize to a full-length histone repeat recombinant DNA, pCO1. The histone RNAs of the two stages, however, are dissimilar in sequence. While the transcripts of the cleavage embryo form well matched hybrids with the plasmid DNA which are relatively resistant to RNAase, the hybrids containing the mesenchyme blastula transcripts melt some 10 degrees C lower and are twice as sensitive to RNAase. Hybridization of the two RNA samples to the Hha I fragments of the histone DNA, or to segments of the histone repeat subcloned in other plasmids, shows that many regions scattered along the repeat are complementary to widely diverged transcripts in the mesenchyme blastula RNA. The two RNA populations consist predominantly of polysomal RNA sequences and are most probably mRNAs for the five histones. The mesenchyme blastula RNA sequences in both S. purpuratus and L. pictus form hybrids with pCO1 DNA that are less stable than those containing L. pictus cleavage RNA, indicating the wide divergence of the two histone RNA populations. The bulk of the histone genes in S. purpuratus appear to be of the type coding for the early mRNAs. Only a small percentage of the several hundred gene copies are candidates for the type coding for the late mRNAs. The melting characteristics of the hybrids and the sensitivity of RNAase provide an assay for the late embryonic histone genes. Of the total RNA labeled during a 10 min pulse in the cleavage embryo, histone transcripts represent approximately 9.7 and 6.5% of the radioactivity in S. purpuratus and L. pictus, respectively. These values fall to 0.57 and 1.4%, respectively, at the mesenchyme blastula stage. Although histone genes are transcribed during these two periods, the type of gene which is active is switched at some point prior to the mesenchyme blastula stage.