To improve survival: an overview of pediatric resuscitation and the updated PALS guidelines.

The updated 2005 American Heart Association Pediatric Advanced Life Support guidelines aim to improve overall survival from cardiac arrest. These revised guidelines are result of extensive evaluation of scientific evidence and have become simplified to emphasize quality basic life support (BLS) and effective cardiac compressions. Successfully applied techniques of both basic and advanced life support are crucial in improving neonatal and pediatric resuscitation outcomes. This article reviews the scientific evidence and the updated management and treatment guidelines essential for the health care provider in caring for children with cardiac and respiratory arrest.

Tracheobronchitis as an initial presentation of ulcerative colitis.

We describe a patient with ulcerative colitis (UC) and the rare extraintestinal manifestation of fulminant tracheobronchitis. A 50-year-old man presented with respiratory compromise and bloody diarrhea. His evaluation showed large airway inflammation with fibrinopurulent debris and colonic inflammation and ulcerations consistent with UC. The etiology for the pulmonary pathology was thoroughly investigated and was thought to be an extraintestinal manifestation of the UC.

Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy.

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.

Foster parents of medically fragile children can improve their BLS scores: results of a demonstration project.

OBJECTIVES: 1) To assess performance and comfort level with cardiopulmonary resuscitation (CPR), foreign body removal (FBR), and seizure management in foster parents of medically fragile children; 2) To determine if the parents' performance and comfort levels increase with an individual teaching session with a medical professional to review CPR and FBR. METHODS: In this single cohort pilot study, 18 foster parents of medically fragile children were asked to rate their comfort level with pediatric CPR and FBR on a 5-point scale (1 = very uncomfortable, 5 = very comfortable). They then underwent five mock code scenarios and were evaluated using a 5-point scale (1 = poor performance, 5 = outstanding performance). A 6-month follow-up evaluation using similar scenarios was conducted. RESULTS: At visit 1, the percentage of parents demonstrating adequate performance of CPR, FBR, and seizure management was: 1) CPR: infant (78%); child (78%); 2) Foreign body removal: age <1 year (17%); age >1 year (65%); 3) Seizures (94%). At visit 2, performance improved in all areas, especially FBR, where the percentage of parents demonstrating adequate performance increased to 71% for children <1 year and 82% for children >1 year. As measured by the 5-point scales, CPR and FBR performance and parent comfort level with CPR improved significantly (Wilcoxon signed-ranks test, P < 0.004), but parent comfort level with FBR did not (P = 0.12). CONCLUSIONS: Based on this pilot study, foster parents of medically fragile children benefit from an individual teaching session by a medical professional. CPR instruction for this group of foster parents should include adequate review and assessment of foreign body removal procedures.

Pediatric patients with bleeding dyscrasias: what is the cause of delays in initiating replacement therapy?

INTRODUCTION: The objectives of this study were to (a) evaluate the emergency department management of pediatric patients with bleeding disorders, specifically regarding time intervals from triage to administration of replacement therapy, and (b) to review resultant patient outcomes. METHODS: A retrospective review was performed of charts from June 1996 to June 1998 for all patients with known bleeding disorders whose course was followed by the hematology clinic. Records were reviewed for all emergency department visits that required replacement therapy. Time intervals from triage to initiation of therapy were evaluated. RESULTS: Eleven of 24 patients required administration of factor or desmopressin acetate. The mean time from triage to therapy administration was 103 minutes (range, 7 to 175 minutes; SD +/- 38). The mean time from triage to placement in a room was 34.3 minutes (SD +/- 32.6). The mean time to order replacement therapy was 26.7 minutes (SD +/- 27.4). The mean time from physician evaluation to administration of replacement therapy was 34.2 minutes (SD +/- 15.9). These intervals were believed to be suboptimal, and a new nursing driven protocol was established to expedite patient care. DISCUSSION: Simple delays in time to replacement therapy may result in increased patient morbidity. We present an easy-to-follow algorithm that can be implemented to expedite the care of pediatric patients with a known bleeding disorder.

Can portable bedside fluoroscopy replace standard, postreduction radiographs in the management of pediatric fractures?

OBJECTIVE: To determine the accuracy of portable bedside fluoroscopy in documenting postreduction fracture alignment in the pediatric emergency department (ED). DESIGN/SETTING: Prospective trial in an urban pediatric ED. PARTICIPANTS: Convenience sample of 80 pediatric patients requiring ED reduction of isolated long bone fractures. METHODS: Patients who underwent closed fracture reduction using portable fluoroscopic guidance (FluoroScan) in the ED were enrolled in the study. Postreduction images were obtained using both bedside fluoroscopy and conventional radiographs. A pediatric orthopedic subspecialist, blinded to clinical outcome, reviewed the fluoroscopic and radiographic images for adequacy of alignment and rated the utility of conventional radiography for fracture management. RESULTS: The patients were 2.5 to 16 years of age (mean 8.3). Distal radial and radioulnar fractures comprised 96% (76/80) of cases. Sixty-three percent of the fractures were displaced, and the mean angulation of the primary fracture site was 24 degrees . Fluoroscopy was found to be 100% sensitive (75/75 cases) and 100% specific (5/5 cases) in predicting postreduction fracture position when compared to conventional radiographs. Intra-rater observer agreement on the necessity of conventional postreduction radiographs was 0.92 (95% CI 0.82-1.00) using the kappa coefficient. In no case did postreduction radiographs alter acute fracture management. CONCLUSIONS: Bedside fluoroscopy with printed fluoroscopic images are highly reliable in evaluating fracture reduction and can replace conventional radiography in documenting adequate distal forearm fracture reduction when there is no intraarticular involvement.

Atypical presentation of Henoch-Schoenlein purpura in two children.

Henoch-Schoenlein purpura (HSP) is a common vasculitic disorder of childhood. Patients with this disorder typically present with palpable purpura or petechia associated with one or more of the following signs and symptoms: abdominal pain, arthritis/arthralgias, and nephritis. The diagnosis may be difficult to make, however, when a patient presents with isolated symptoms such as abdominal pain without the typical rash. A high index of suspicion must be maintained to diagnose HSP in this setting and to avoid unnecessary interventions. This report describes two unusual patients with the presenting complaint of abdominal pain who had delayed onset of the purpuric rash, making the diagnosis of HSP difficult.

An unusual case of mesenteric ischemia in a patient with new-onset diabetes mellitus.

The early detection of acute mesenteric ischemia is crucial for the preservation of bowel viability. The emergency physician must have a high index of suspicion to identify mesenteric ischemia when there is a paucity of physical examination findings. We discuss the case of a patient who presented to the emergency department with confusion, hyperglycemia, abdominal tenderness, and metabolic acidosis who also developed mesenteric ischemia.