Accidental injection of epinephrine by a child: a unique approach to treatment.

A 9-year-old girl accidentally injected her right thumb with an adult dose of epinephrine through an auto-injector syringe, delivering 0.3 mg of 1:1000 epinephrine. This injection caused immediate ischemic changes in the digit. This is the first reported case of accidental self injection by a child of an adult dose of epinephrine and its successful treatment with low-dose phentolamine simultaneously infiltrated directly into the puncture area and along the course of the digital artery. The use of phentolamine as a specific competitive alpha-adrenergic antagonist to epinephrine has been well documented in adults and animal models. This report compares the management of a pediatric case to that of all reported adult cases of accidental subcutaneous epinephrine injections. This case suggests a pattern of infiltration with low-dose phentolamine that may be the most effective form of treatment for this condition in a patient of any age.

Ankle radiograph utilization after learning a decision rule: a 12-month follow-up.

OBJECTIVE: To test whether the reduction in ankle radiograph ordering was sustained during a 12-month period after a formal trial to introduce the Ottawa ankle rules. METHODS: A before-after clinical trial of ankle radiograph ordering practice was performed in a university-based ED. All 1,884 (947 "during intervention," 937 "postintervention") adults seen with acute ankle injuries during 2 12-month trial periods were evaluated. The behavioral intervention was the teaching of the Ottawa ankle rules and feedback of compliance with the rules during the intervention period. No further education about the ankle rules or feedback regarding compliance occurred during the postintervention year. Physicians were unaware of any postintervention surveillance. The primary outcome was the proportion of eligible patients referred for an ankle radiograph during the intervention and postintervention periods. RESULTS: During the intervention period (January 1-December 31, 1993), the proportion of patients who received an ankle radiograph [609 x-rayed of 947 patients seen (64.3%; 95% CI 61.2-67.4%)] did not differ from the proportion who received an x-ray in the postintervention period (January 1-December 31, 1994) [583 x-rayed of 937 patients seen (62.2%; 95% CI 59.1-65.3%), p = 0.65, power > 0.80 to detect a 10% increase in the radiograph ordering rate]. There was also no difference in the radiograph ordering rate in the first 3 months of the postintervention period compared with the last 3 months of the postintervention period (68.8% vs 64.7%, respectively, p > 0.30). CONCLUSIONS: Compliance with the Ottawa ankle rules was sustained during a 12-month postintervention surveillance period when physicians did not know they were being observed. Physicians will continue to use a simple clinical guideline once it has been learned.

A critical comparison of the history of sudden-death infants and infants hospitalised for near-miss for SIDS.

To determine whether significant historical differences distinguish the near-miss for Sudden Infant Death from the infants who died of SIDS, we analysed the histories and clinical data from two groups of infants seen in our University Hospital and from collaborative research group. The data were obtained with the use of a standardised questionnaire and consultation of all available medical data. Sixty-five infants were identified as near-miss for SIDS after they had suffered a severe cardiorespiratory incident during sleep for which no cause could be found despite a complete medical examination. After an autopsy had failed to reveal a cause for the unexpected death 95 cases of SIDS were retained in the study. A series of 353 variables were collected from the parents, the gynaecologists, neonatologists and attending physicians. After statistical analysis, only 15 of the 353 items studied significantly differentiated between the two groups. A step-wise discriminant analysis performed on these items led to the identification of six independent variables: the time of the incident; the circumstances leading to the observation of the child; the child's sleep position; previous minor intestinal problems; the size of the family and the mother's coffee consumption. Most variables indicate that the near-miss infants were discovered and rescued earlier than the infants who died. No other historical information appeared significantly to differentiate between the two groups of infants. These data need confirmation from a prospective epidemiological survey.