Emergency department evaluation of an infant with chaotic atrial tachycardia.

We describe the diagnostic utility of adenosine infusion in an infant with chaotic atrial tachycardia. Transient blockade of the atrioventricular node during adenosine infusion added diagnostic certainty to the emergency department evaluation of this patient. Appropriate therapy for chaotic atrial tachycardia is controversial, so it is essential to differentiate this rhythm from more serious forms of supraventricular tachycardia in children.

The emergency management of hyperglycemic-hyperosmolar nonketotic coma in the pediatric patient.

We recommend consideration of HHNK in comatose pediatric patients and advocate the prompt institution of fluid therapy. Insulin is not required during the initial course of treatment and potentially can have adverse effects. Compared to adults, pediatric patients appear to be at a greater risk of developing potentially fatal cerebral during the course of treatment. In order to prevent complications associated with the rapid decrease in serum tonicity the initial management should consist of fluid therapy directed toward repleting the intravascular volume, correcting electrolyte abnormalities, and slowly returning serum tonicity to normal.

Ptosis associated with sinusitis.

An adolescent male developed eye pain and a drooping lid. Imaging revealed adjacent pansinusitis and a swollen levator palpebrae and superior rectus muscle. Compression of a branch of the oculomotor nerve is the postulated cause because vertical eye movements were normal.

Can emergency physicians correlate between vehicle damage and velocity change?

The objective to this study was to examine the ability of emergency physicians to correlate between vehicle damage and velocity change. Participants were five emergency medicine physicians at the Emergency Department, Loyola University Medical Center, Maywood, IL. Ten slides of passenger cars crashed at speeds between 22 and 70 mph by the Insurance Institute for Highway Safety were shown to study participants. Study subjects were asked to estimate vehicular velocity based on the visible damage. Only 23 (46%) of the estimates were within 10 mph of the vehicular speed at the time of the crash. The average error was 14.5 mph (range: -20 to +45 mph). Vehicular velocity was overestimated in 70% of the appraisals. We conclude that the ability of emergency physicians to correlate between vehicle damage and velocity change is limited. Underestimation of vehicular damage associated with low velocity accidents may result in misdiagnosis of severe injuries in motor vehicle accident victims.

Telephone follow-up of patients discharged from the emergency department: how reliable?

As the result of the current emphasis on health care cost containment, outpatient management of entities previously in the domain of inpatient therapy is being proposed. The advocates of this approach stress the importance of telephone follow-up in patients chosen for outpatient therapy. Our objective was to determine the reliability of phone follow-up in patients discharged from the emergency department (ED). We attempted to contact by phone 250 consecutive children evaluated and discharged from Loyola University Medical Center Emergency Department. A maximum of six attempts per patient was made starting within 72 hours of the ED visit. Calls were placed to home, work, and contact numbers provided at the time of the ED visit, and messages were left on answering machines or with persons who answered the phone. The time needed to reach the guardian was calculated from the time of the first call until successful contact of the guardian. We were successful in contacting 68.4% of our study subjects. Patients with commercial insurance were contacted more often than those with other types of insurance. A mean of 1.61 +/- 1.09 calls were needed to reach the guardians who were successfully contacted, and the mean time required was 3.14 +/- 7.25 hours. Medical indication for telephone follow-up, as determined by the managing physician, did not influence our ability to reach the study subjects. In view of our moderate success rate in reaching patients discharged from the ED, we advocate caution in the implementation of outpatient strategies in the management of febrile children who are at high risk for life-threatening complications.

Emergency management of asthma in children: impact of NIH guidelines.

BACKGROUND: Asthma is the most common chronic disease of childhood. In 1991 the National Institutes of Health (NIH) published guidelines for the diagnosis and management of asthma, yet little is known about their impact on clinical practice. OBJECTIVE: To examine the impact of the NIH guidelines on the emergency management of asthmatic children in the United States. METHODS: A short anonymous survey concerning the emergency management of childhood asthma was mailed to 234 Directors of Pediatric Emergency Medicine in all Pediatric Residency Training Programs in the United States. The survey consisted of questions originally used in a similar study conducted in 1988 and an additional question relating to the impact of the NIH guidelines. RESULTS: One hundred and thirty-seven (59%) completed surveys were returned. Compared with the results of the 1988 survey, more physicians routinely use pulmonary function testing (73% versus 47% in 1988, P < .001), inhaled beta-agonists as the initial drug of choice (98% versus 17%, P < .001), and early corticosteroid administration (82% vs 21%, P < .001) in their emergency management of asthmatic children. Fifty percent of survey participants believe that NIH guidelines changed their emergency management of childhood asthma. CONCLUSIONS: Significant changes in the emergency management of asthmatic children have occurred since the publication of the NIH guidelines.

Acute sinusitis in children: is the Water's view sufficient?

The purpose of this study was to examine the utility of the Water's view in the diagnosis of acute sinusitis in children. The records of all pediatric (less than 18 years old) patients who underwent sinus radiography for suspected acute sinusitis between February 1991 and November 1992 were reviewed. All radiographs were reviewed by an attending radiologist and the interpretation of the Water's (occipitomental) view alone was compared to that of a three-view (anterior/posterior, lateral, Water's) series. Fifty-two three-view sinus series were obtained on pediatric patients during the study period. Twenty-eight patients were diagnosed with acute sinusitis based on the three-view series. When compared to the three-view series, the single Water's view had a sensitivity of 89%, specificity of 83%, positive predictive value of 87%, and negative predictive value of 87%. The overall accuracy of the Water's view in diagnosing childhood acute sinusitis was 87%. The authors conclude that the Water's view is usually sufficient in the evaluation of suspected acute sinusitis in children.

Plasma beta-endorphin levels and childhood intussusception.

To determine whether childhood intestinal intussusception is associated with elevated plasma beta-endorphin levels, a series of patients was studied prospectively. Fourteen patients (age range between 3 months and 7 years) presented to two university pediatric emergency departments in Chicago with clinical symptoms and signs of intussusception. Venous blood (2cc) was withdrawn for plasma beta-endorphin determination, followed by barium enema. Plasma beta-endorphin levels were measured by radioimmunoassay. The mean beta-endorphin level of the 8 patients with barium enema proven intussusception was 14.1 +/- 12.0 pg/ml. Two of these patients presented with marked lethargy and had beta-endorphin levels of 7.5 and 21.2 pg/ml. The mean plasma beta-endorphin level of the 5 patients with negative barium enema studies was 18.1 +/- 10.0 pg/ml (P = 0.56). A sixth control patient had a plasma beta-endorphin level of 1569 pg/ml. In conclusion, childhood intestinal intussusception is not associated with elevated plasma beta-endorphin levels.

Occult bacteremia: is there a standard of care?

The evaluation and management of patients with occult bacteremia is controversial. The purpose of this study was to define the prevailing practices in the emergency management of occult bacteremia. Short, anonymous surveys were mailed to all 517 members of the Section on Emergency Medicine at the American Academy of Pediatrics. Three hundred six (59%) of those surveyed returned completed questionnaires. Eleven different temperature cutoff points are used, and 105 (34%) consider occult bacteremia in patients with temperature above 39 degrees C. Seventeen different age intervals are used to define the patients at risk for occult bacteremia, and the age range three to 24 months is used by 173 (57%) of those surveyed. Complete blood cell count is the most commonly used screening test; it is routinely ordered by 225 respondents (74%). One hundred thirty-seven participants (45%) routinely obtain blood cultures in all patients at risk for occult bacteremia, whereas 111 (36%) use the clinical appearance (toxicity) of the patient to determine whether a blood culture should be drawn. One hundred sixty-one (53%) of those surveyed routinely administer antibiotics to toxic-appearing patients pending the results of the blood culture. Laboratory criteria are used by 135 (44%) in the decision whether to administer empiric antibiotics. Ceftriaxone is the most commonly used antibiotic; it is routinely administered by 230 respondents (75%). Twenty participants (7%) routinely admit all patients with Streptococcus pneumoniae, whereas 217 (71%) admit all patients with Haemophilus influenzae bacteremia and 234 (76%) admit all patients with Neisseria meningitidis bacteremia. We conclude that diversity exists in the evaluation and management of occult bacteremia.

Parental knowledge of bacterial endocarditis prophylaxis.

The aim of this study was to determine parental knowledge of bacterial endocarditis prophylaxis (BEP). Parents of 135 patients attending a pediatric cardiology clinic in a university center were mailed an eight-question survey pertaining to their knowledge of their child's cardiac disease, medications, and BEP. The patients' cardiac lesions and current medications were verified by a review of clinic and echocardiographic records. Each patient's need for BEP was determined according to American Heart Association (AHA) recommendations. Eighty-four (62%) parents returned complete surveys. The patients' mean age was 5 years with a range of 9 weeks to 19 years. Eighty-two (98%) respondents were high school graduates. Fifty-two (62%) respondents correctly defined endocarditis. Eighty-two (98%) parents knew the correct name of their child's cardiac condition and 27/32 (84%) knew the names of their child's current medications. Only 36/64 (56%) parents of at-risk children knew measures to prevent endocarditis. While most parents know the name of their child's heart lesion and current medications, parental knowledge of endocarditis and BEP was limited. Intensified education and awareness programs are needed in order to prevent potential major morbidity and mortality for pediatric patients with heart disease.

Pediatric education in emergency medicine residency programs--10 years later.

The purpose of this study is to examine the changes in the pediatric emergency medicine education of emergency medicine (EM) residents over the last decade. Questionnaires were mailed to the training directors of all EM residency programs. Sixty-five programs (79%) responded. While children represent 29 +/- 2% of all patients seen in the institutions surveyed, only 17 programs (26%) provide more than six months of pediatric education, ie, no increase in the last decade. EM residents frequently rotate through pediatric emergency departments (72%), inpatient pediatric wards (51%), and pediatric intensive care units (88%). Most physicians in charge of pediatric emergency medicine education are emergency medicine trained (75% vs 29% in 1981), and only 12% are pediatric emergency medicine fellowship trained. Despite several improvements and the increased satisfaction of program directors, the pediatric component of EM residents' training continues to be disproportionate to the number of children in the emergency medicine patient population. Specialists in pediatric emergency medicine should strive to play a more significant role in the pediatric education of EM residents.

Are skull radiographs useful in the evaluation of asymptomatic infants following minor head injury?

Head injuries constitute a common problem in the pediatric population. Recent studies indicate that infants are at increased risk for skull fractures following head trauma. The purpose of our study is to examine the utility of skull radiographs in asymptomatic infants presenting after a minor head injury. We retrospectively reviewed the records of all head-injured infants who presented to our emergency department between March 1990 and July 1991. All symptomatic patients and all infants who did not undergo radiologic evaluation were excluded from the analysis. During the study period, 35 asymptomatic infants were evaluated in our emergency department following head trauma. The mean age of the study patients was 5.5 +/- 3.8 months; 54% were male; and falls accounted for the injury in 88% of cases. The skull radiograms were normal in 30 patients, equivocal in two, and positive for a parietal skull fracture in three. The three infants who sustained skull fractures were male, were younger than three months, and had fallen from heights not exceeding three feet. Computed head tomograms revealed no intracranial pathology in these patients. We conclude that all infants who present following minor skull trauma should undergo radiologic evaluation.

Fractures in the under-3-year-old age cohort.

One hundred twenty-four urban children under 3 years of age admitted for fractures were retrospectively reviewed to determine the frequency of accidental and nonaccidental causes in this population. The fractures were categorized according to their mechanisms: motor-vehicle passenger or pedestrian accident, other accidents, or child abuse. There were no differences in the frequency of fractures by race, date of birth, or season in which the injury occurred. Skull fractures were most frequent (62%), followed by femur fractures (11%). There was a 26% increase in fractures between 1987 and 1989, especially in the non-motor vehicle cohort. Caretaker ignorance and/or carelessness was a common cause of fractures in the infant and toddler age group. Injuries were still occurring in spite of infant care seat use. The American public must be educated in preventive medicine and safety to decrease the senseless morbidity of our greatest resource.

Metal detectors: an alternative approach to the evaluation of coin ingestions in children?

Foreign body ingestions constitute a common problem in pediatric emergency medicine. Recent data indicate that, despite current recommendations, most children who ingest coins do not undergo radiologic evaluation. The purpose of this study was to determine the accuracy of a metal detector in locating coins in a model simulating coin ingestions in children. Initially, the distance between the anterior chest wall (ACW) and the esophagus was measured on 17 chest computed tomograms obtained on children between the ages of three months and six years. Subsequently, a distance equal to the mean ACW-to-gastroesophageal junction measurement was marked across the investigator's forearm. A second investigator then attempted to detect the presence of the coin through the forearm by using a Super Scanner (Garrett Security Systems, Inc, Garland, TX) metal detector. The study was conducted in a blinded manner and consisted of 50 attempts equally divided among pennies, nickels, dimes, quarters, and controls (no coin). The accuracy of the metal detector in identifying the presence or absence of coins in our model was 100%. We conclude that the metal detector evaluated by us is highly accurate in identifying coins through human tissues and that it should become a valuable and practical tool in the evaluation of children following a coin ingestion.

Successful use of a metal detector in locating coins ingested by children.

The purpose of this study was to examine the accuracy of a metal detector in locating coins ingested by children. The metal detector correctly identified the presence or absence of coins in 13 patients (93%), as confirmed by radiologic studies.