"Refuses to walk" as an ED presentation of acute childhood leukemia.

New onset of childhood acute leukemia may present to the emergency department in a variety of ways. This report describes the case of a 3-year-old boy who refused to walk and had minimal physical findings, normal X-rays, and nearly normal lab screening results. His white blood cell count differential led to the diagnosis of acute leukemia. The presentation and evaluation of acute leukemia in children is reviewed. Emergency physicians must be prepared to rule out malignancy in the child who refuses to walk when other more common causes, such as infection and trauma, seem unlikely.

Prospective crossover study of the effect of phlebotomy and intravenous crystalloid on hematocrit.

OBJECTIVE: To compare the changes in hematocrit (Hct) between phlebotomized and nonphlebotomized individuals given IV crystalloid. METHODS: A prospective, crossover volunteer study was performed comparing Hct changes immediately and 30 minutes after IV crystalloid bolus in 20 healthy adults with and without prebolus phlebotomy. In the control portion, volunteers were given a 15-mL/kg bolus of normal saline over 30 minutes with Hct determination before (H1), immediately after (H2), and 30 minutes after (H3) crystalloid infusion. At least 7 days later, the same subjects were phlebotomized 1 unit of blood and then administered a 15-mL/kg IV bolus of normal saline 30 minutes later. Hcts were obtained before (H4) and 30 minutes after (H5) phlebotomy (immediately prior to crystalloid infusion). Hcts were also obtained immediately after (H6) and 30 minutes after (H7) crystalloid infusion. A post-hoc test performance analysis was then performed to determine the Hct drop thresholds that would yield the maximal sensitivity and specificity for 500 mL of blood loss (via phlebotomy) in this population. RESULTS: The Hct (%) drops in the nonphlebotomized individuals receiving IV fluids averaged 4.5 +/- 1.3 immediately and 3.2 +/- 1.3 30 minutes after infusion. These drops were different (p < 0.05) from the Hct drop in individuals receiving IV fluids after phlebotomy, which averaged 6.6 +/- 1.5 and 5.7 +/- 1.1, respectively. Post-hoc analysis revealed that Hct drops of 5.4 immediately, or 4.3 at 30 minutes after infusion, had a sensitivity of > 90% and a specificity of 75% for identification of patients in the phlebotomy group. CONCLUSIONS: The practice of measuring serial Hcts may be helpful to identify trauma patients with occult blood loss. A prospective clinical trial is needed to validate these Hct drop thresholds (immediate and 30 minutes postinfusion) in crystalloid-resuscitated trauma patients.

Single breath counting in the assessment of pulmonary function.

STUDY OBJECTIVES: To assess the correlation of single breath counting (SBC) and peak expiratory flow rate (PEFR) to forced expiratory volume in the first second (FEV1). DESIGN: Prospective comparison of pulmonary function measurements. SETTING: University hospital pulmonary function test (PFT) laboratory. TYPE OF PARTICIPANTS: Consenting patients scheduled to have PFTs May 1, 1992, through November 1, 1992. INTERVENTIONS: SBC was measured by asking patients to take a deep breath and count as far as possible in their normal speaking voice without taking another breath. Counting was timed to a metronome set at 2 counts per second. A hand-held peak flowmeter was then used to measure PEFR. Standard PFTs then were performed. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients were enrolled. The correlation of SBC to FEV1 (r = .68) was slightly better than of PEFR to FEV1 (r = .63). SBC was also found to correlate well with PEFR (r = .68). CONCLUSION: SBC is a reasonable alternative to PEFR. Further investigation in an emergency department setting is warranted.