Utility of toxicology screening in a pediatric emergency department.

OBJECTIVE: To determine the types of patients who undergo toxicology screen testing (TS) and the clinical utility of the test in a pediatric emergency department. DESIGN: Retrospective chart review. SETTING: Urban pediatric emergency department. PATIENTS OR PARTICIPANTS: All patients, n = 338, less than 18 years of age who had a TS sent from the Kosair Children's Hospital Emergency Department between 1/1/91 and 12/31/91. RESULTS: Three hundred and thirty-eight charts were available for review from 344 patients who had TS testing. Seventy-eight patients (23%) were less than 12 years old; 164 patients (49%) were female. Forty-four patients were tested by serum TS only; 195 patients by serum plus urine TS; 94 patients by urine TS; four patients by serum, urine, and gastric aspirate TS, and one patient by urine and gastric aspirate TS. Chief complaints of patients who had TS sent were as follows: ingestion (211), abnormal behavior (56), seizures (30), trauma (18), syncope/tingling (7), depression/suicide (6), chest pain/palpitations (3), headaches (3), and other (4). While 195 patients (57%) had positive TS for at least one item, only 22 patients (7%) had a positive TS for an unexpected item, including seven patients with ingestions, eight with abnormal behavior, four with seizures, two with syncope, and one with trauma. Only three patients with unexpected positive TS had a change in medical management as a result of the TS findings. All three of these patients had abnormal physical examinations. CONCLUSION: A minority of patients have unexpected TS results. TS results rarely necessitate a change in medical management. Emergency physicians should reevaluate indications for TS testing in pediatric patients.

Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma.

PURPOSE: Microscopic hematuria (> or = 20) RBCs per high-power field [HPF] has been used frequently as an indicator for genitourinary (GU) tract injury in pediatric cases of blunt trauma. The aim of this study was (1) to determine whether a certain threshold of microscopic hematuria was associated with GU tract injury in our patient population, and (2) to identify additional factors warranting evaluation of the GU tract. METHODS: The records of 100 patients under 18 years of age whose discharge diagnosis in the trauma registry included hematuria or GU tract injury were reviewed retrospectively (1989 through 1993). The following data were collected: age, sex, mechanism of injury, physical findings, associated injuries, urinalysis results, radiographic study results, disposition, and outcome. Data were analyzed using the SPSS program. RESULTS: The majority of children were victims of motor vehicle accidents. All but one study patient had an intravenous pyelogram and/or computed tomography scan. Twenty-seven patients had GU tract injuries or previously unrecognized congenital anomalies (9 contusions, 5 lacerations, 1 vascular pedicle injury, 4 bladder injuries, 3 urethral/vaginal tears, 5 anomalies). Twenty-seven percent (3 of 11) of children with minor injuries and 25% (2 of 8) of those with major injuries had microscopic hematuria of less than 20 RBCs/HPF. Mechanism of injury and hypotenison were not associated with GU tract injury. One third of the patients with isolated chest or abdominal injuries, and 50% of those with combined chest/abdominal injuries had GU tract injuries or anomalies identified. Pelvic fracture was associated with GU tract injury or anomaly in 50% of cases (P < 0.02). CONCLUSION: The authors found that (1) a threshold of > or = 20 RBCs/HPF as an indication for radiograph evaluation would have missed 28% of cases with GU tract injuries or occult anomalies, and (2) pelvic fractures and abdominal/chest injuries help to identify patients who require evaluation of the GU tract. The need for GU tract evaluation in pediatric trauma patients is based as much on clinical judgment as on the presence of hematuria.

Adequacy of follow-up in children diagnosed with urinary tract infections in a pediatric emergency department.

A retrospective chart review was undertaken to determine primary care provider (PCP) notification of patient visits and appropriateness of follow-up in children discharged from an inner city, university-affiliated children's emergency department with the diagnosis of urinary tract infection (UTI). Seventy-five charts met criteria for review, and phone calls were made to the PCP/families to obtain follow-up information. Statistical analysis was performed using the chi2 analysis and Fisher's exact test. The PCP was notified of the patient's diagnosis at the time of the ED visit in 24 cases (32%) and was aware of the ED visit/diagnosis of UTI in a total of 53 (71%). Children were more likely to have a repeat urine culture in follow-up if the PCP was aware of the diagnosis (60%) than if the PCP was not aware (9%) chi2 = 14.496 P < 0.001. Forty-seven children met criteria commonly accepted for radiographic evaluation. Nineteen children, whose PCPs were aware of their diagnosis, met criteria and had studies performed. Children were more likely to receive appropriate radiographic evaluation if their PCPs were aware of their diagnoses of UTI 19/35 (54%) than if their PCPs were unaware of their diagnoses 0/12 (0%). Fisher's exact two-tailed t test P < 0.001. We conclude that failure of PCP notification can impact negatively on appropriate patient follow-up and that, in many cases, PCPs are not following current recommendations in the management of children with UTIs.

Subgaleal abscess: an unusual presentation.

We report a case of subgaleal abscess formation in a 16-year-old boy with varicella and minor head trauma. He presented four weeks after injury with left-sided scalp swelling and periorbital edema. There was no break in the skin over the involved area. Diagnosis was made on the basis of prolonged swelling, an elevated erythrocyte sedimentation rate, and computed tomography that showed a subgaleal fluid collection. Aspirated material grew Group A beta-hemolytic Streptococcus. Subgaleal abscess formation without an overlying wound is previously unreported. Management of subgaleal abscess usually requires operative debridement and IV antibiotics. However, in our patient, needle aspiration and oral antibiotics sufficed.

Fatty acid transfer between multilamellar liposomes and fatty acid-binding proteins.

A simple experimental system was developed for studying the movement of long-chain fatty acids between multilamellar liposomes and soluble proteins capable of binding fatty acids. Oleic acid was incorporated into multilamellar liposomes containing cholesterol and egg yolk lecithin and incubated with albumin or hepatic fatty acid-binding protein. It was found that the fatty acid transferred from the liposomes to either protein rapidly and selectively under conditions where phospholipid and cholesterol transfer did not occur. More than 50% of the fatty acid contained within liposomes could become protein bound, suggesting that the fatty acid moved readily between and across phospholipid bilayers. Transfer was reduced at low pH, and this reduction appeared to result from decreased dissociation of the protonated fatty acid from the bilayer. Liposomes made with dimyristoyl or dipalmitoyl lecithin and containing 1 mol per cent palmitic acid were used to show the effect of temperature on fatty acid transfer. Transfer to either protein did not occur at temperatures where the liposomes were in a gel state but occurred rapidly at temperatures at or above the transition temperatures of the phospholipid used.