Applicability of Ottawa knee rule for knee injury in children.

OBJECTIVE: Previous studies have shown that the application of the Ottawa knee rule (OKR) reduces the need for radiographs in adults with acute knee injuries. Our objectives were to describe the epidemiology and incidence of knee injuries in children with acute knee trauma and to validate the OKR in a pediatric population. DESIGN: A prospective, consecutive study. SETTINGS: Two urban pediatric emergency departments. METHODS: All children 18 years of age and under who presented with acute traumatic knee injury of less than 1 week's duration, excluding patients with a normal knee examination, superficial skin injuries, prior history of knee injury, underlying bone disease, serious injuries involving two or more organ systems, or altered mental status were enrolled. Physicians assessed each patient for 22 standardized clinical findings prior to radiography. The OKR was applied to each patient by the investigating physician. RESULTS: All 234 patients eligible for the study had radiographs of the affected knee. The median age was 13 years with a range of 2 to 18 years. Using the OKR criteria for obtaining knee radiographs, 12 of 13 patients with fractures were identified (sensitivity 92%; 95% CI= 64-99). The missed case was an 8-year-old male who had sustained a nondisplaced fracture of the proximal tibia after a fall. If the OKR were applied to the pediatric population, it would have reduced the need for radiography in 46% of children. CONCLUSIONS: In the pediatric population studied, the OKR did not identify all patients with knee fractures. Future studies may consider modifying the OKR to accommodate the differences between pediatric and adult patients to improve the sensitivity of the rule while maintaining its specificity, before it can be applied routinely in clinical practice.

Seat belt use by children brought to an inner-city hospital.

OBJECTIVE: To characterize restraint use among children brought to an inner-city hospital by private car or taxicab. DESIGN: Cross-sectional survey and direct observation of a convenience sample. SETTING: Main entrance and clinic entrance of a large urban public hospital. PARTICIPANTS: Direct observation was made on 352 children brought by 257 vehicles. One hundred seventy-seven parents or caretakers responded to questionnaires for 240 children. INTERVENTION: None. MEASURES AND MAIN RESULTS: Of the 352 children who were directly observed, 256 (73%) arrived by taxicabs and 96 (27%) by private cars. Thirty-three of 352 (9%) children were observed to be appropriately restrained. Children brought by taxicabs were significantly less likely to be restrained than children brought by private cars (1% vs 31%, P < 0.001). Caretakers reported that seat belts were available in 46 of 54 (85%) private cars, compared to 38 of 88 (43%) taxicabs (P < 0.01). Twenty percent of caretakers who came by taxicabs did not check for seat belts. CONCLUSION: Taxicabs, which are exempt from the New York State's mandatory seat belt law, are a common mode of transportation for children in the inner city. While the overall use of child restraints in the study sample is low, it is particularly low for children in taxicabs. The low rate may be related to both the decreased availability of seat belts and the lack of the mandatory seat belt law for taxicabs. Strategies should be sought to improve child restraint availability in taxicabs and mandate seat belt use.

A comparison of New York City playground hazards in high- and low-income areas.

OBJECTIVE: To compare playground hazards in high- and low-income neighborhoods. DESIGN: Forty-five playgrounds were randomly selected from the 9 New York City community districts that met our study criteria and were divided into high-and low-income groups based on comparison to the median of the median incomes ($24452 per year) of the 9 districts. Playgrounds are maintained by the City of New York Parks and Recreation Department and were assessed by one of us (S.A.S.) using a standardized on-site survey based on the US Consumer Product Safety Commission's guidelines for public playground safety. MAIN OUTCOME MEASURES: Total hazards per play area were subdivided into 3 categories: park design hazards, equipment maintenance hazards, and equipment hazards relating to fall injuries. A play area was defined as an individual set of equipment. RESULTS: Twenty-five (56%) of the parks were located in low-median-income districts and contained 98 (53%) of the total play areas. High- and low-income playgrounds did not differ significantly in the amount or type of equipment, mean fall injury hazards per play area, or mean park design hazards per play area. Low-income districts had a significantly higher mean total hazards per play area (6.1 vs. 4.2; P = .02) and mean equipment maintenance hazards per play area (2.1 vs. 1.0; P = .02). CONCLUSION: Significantly more hazards per play area were identified in the low-income group compared with the high-income group.

The efficacy of routine outpatient management without antibiotics of fever in selected infants.

BACKGROUND: A previous study produced a protocol for outpatient management of febrile infants (FIs) judged to be at low risk for serious bacterial illness (SBI). This Philadelphia protocol demonstrated that 40% of FIs seen in the emergency department could be safely managed without antibiotics at home; and it was established by the emergency department staff as the standard of care at our institution. OBJECTIVE: To determine 1) the actual practices of management of FIs 18 months after establishment of the Philadelphia protocol as the standard of care, and 2) the continued efficacy of noninvasive outpatient management of fever in FIs who, using the Philadelphia protocol, were identified as low risk for SBI. DESIGN: Thirty-six-month consecutive cohort study. SETTING: Urban pediatric emergency department. PARTICIPANTS: Four hundred twenty-two infants, 29 to 60 days of age, with rectal temperatures >/=38.0 degrees C. Interventions. After a complete history taking, physical examination, and workup for SBI, infants were managed at the discretion of the attending physician in the emergency department. Subsequently, those management practices were reviewed and compliance with the Philadelphia protocol was evaluated. In addition, the overall efficacy and safety of that standard during 8 years of use was assessed. RESULTS: Of the 422 FIs enrolled, 101 (24%) were prospectively identified as low risk for SBI, and safe for management without antibiotics. Twenty-eight (6%) FIs were managed out of accordance with the Philadelphia protocol. Seven were admitted out of accordance, 10 (2 with UTI) were discharged out of accordance, and 11 inpatients (1 with bacterial gastroenteritis) initially received no antibiotics out of accordance with the protocol. Physician failure to consider the results of the complete blood count or urinalysis accounted for errors involving FIs with SBI. None of the 43 FIs with SBI were identified by the Philadelphia protocol to be at low risk for SBI. CONCLUSIONS: The Philadelphia protocol for outpatient management without antibiotics of FIs at low risk for SBI remains practical, reliable, and safe. Because breaches do occur, physicians must carefully scrutinize protocol compliance, especially with regard to the complete blood count and urinalysis.

A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children.

To evaluate the relative utility of clinical and laboratory parameters of dehydration in children for predicting the magnitude of percent less of body weight (PLBW), we studied 97 children who required intravenous fluids for acute dehydration. After a complete history and physical examination, the managing physician made a clinical estimation of dehydration for each child, based on a standard clinical scale. Serum electrolytes were obtained in all children prior to intravenous hydration therapy. PLBW was calculated after recovery from acute dehydration by comparing the weight on presentation to the emergency department with the weight measured at a follow-up visit when the child was judged well. Children were classified according to PLBW into three groups which reflect the categories in a standard clinical scale: mild = PLBW < or = 5 (n = 50), moderate = PLBW 6-10 (n = 30), and severe = PLBW > 10 (n = 17). The physician's clinical estimate of dehydration compared to PLBW had a sensitivity of 74% (95% confidence interval (CI): 60-85) for mild dehydration, 33% (95% CI: 17-53) for moderate dehydration, and 70% (95% CI: 44-89) for severe dehydration. There was a significant difference in the mean serum bicarbonate concentrations (HCO3) between the PLBW groups (P < 0.01). The sensitivity of the HCO3 < 17 mEq/L in predicting PLBW was 77% (95% CI: 58-90) for PLBW 6-10, and 94% (95% CI: 71-100) for PLBW > 10. The combination of the clinical scale and the serum bicarbonate identified all 17 children with PLBW > 10 and 90% (27 of 30) children with PLBW 6-10. Our data suggest that physicians should not rely solely on clinical assessment to rule out severe dehydration in children, and that obtaining a serum bicarbonate may improve the accuracy of predicting serious dehydration.

Outpatient management without antibiotics of fever in selected infants.

BACKGROUND: In many academic centers it is standard practice to hospitalize all febrile infants younger than two months of age, whereas in community settings such infants are often cared for as outpatients. METHODS: We conducted a controlled study of 747 consecutive infants 29 through 56 days of age who had temperatures of at least 38.2 degrees C. After a complete history taking, physical examination, and sepsis workup, the 460 infants with laboratory or clinical findings suggestive of serious bacterial illness were hospitalized and treated with antibiotics. The screening criteria for serious bacterial illness included a white-cell count of at least 15,000 per cubic millimeter, a spun urine specimen that had 10 or more white cells per high-power field or that was positive on bright-field microscopy, cerebrospinal fluid with a white-cell count of 8 or more per cubic millimeter or a positive Gram's stain, or a chest film showing an infiltrate. The 287 infants who had unremarkable examinations and normal laboratory results were assigned to either inpatient observation without antibiotics (n = 148) or outpatient care without antibiotics but with reexaminations after 24 and 48 hours (n = 139). RESULTS: Serious bacterial illness was diagnosed in 65 infants (8.7 percent). Of these 65 infants, 64 were identified by our screening criteria for inpatient care and antibiotic treatment (sensitivity = 98 percent; 95 percent confidence interval, 92 to 100). Of the 287 infants assigned to observation and no antibiotics, 286 (99.7 percent) did not have serious bacterial illness. Only two infants assigned to outpatient observation were subsequently admitted to the hospital; neither was found to have a serious illness. Outpatient care without antibiotics of the febrile infants at low risk for serious illness resulted in a savings of about $3,100 per patient. CONCLUSIONS: With the use of strict screening criteria, a substantial number of febrile one-to-two-month-old infants can be cared for safely as outpatients and without antibiotics.

Follow-up of patients with occult bacteremia in pediatric emergency departments.

Blood cultures are frequently obtained in pediatric emergency departments (EDs) from febrile young children at risk for bacteremia and subsequent development of serious bacterial infections. This study of 105 children with occult bacteremia treated in two large urban pediatric EDs describes the follow-up of these patients and the impact that positive blood culture results have on the detection of serious illness. Seventy-seven percent of patients had a follow-up visit in the ED, 8% had follow-up by telephone alone, and 15% were not contacted. Of the patients who returned to the ED, 49% did so because they were notified of the positive blood culture result. The mean time interval for these patients from registration at the initial visit to report of positive blood culture result was 30.0 hours and, from registration at the initial visit to follow-up visit, was 42.7 hours. Thirty-seven percent of those who returned did so because a follow-up visit was scheduled at the initial encounter, and 13% returned because of persistent illness. Ten children (9.6%), five of whom had been notified of the positive blood culture, returned with serious illnesses. Patients whose diagnosis of serious illness was facilitated by blood culture results had shorter delay in identifying cultures as positive than did patients notified of positive results who did not develop serious illness (16.2 vs 31.6 hours; P < 0.05). The delay in follow-up of children with occult bacteremia limits the usefulness of blood cultures in the early detection of serious illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Lacerations involving glass. The role of routine roentgenograms.

OBJECTIVE: To determine, when evaluating a laceration caused by glass, whether seeing that the bottom of the wound is free of glass eliminates the possibility that glass is present in the wound. RESEARCH DESIGN: Prospective patient series. SETTING: Two pediatric emergency departments. PARTICIPANTS: 226 children with lacerations due to glass occurring in a period of 21 months. SELECTION PROCEDURES: Consecutive sample. INTERVENTIONS: Before obtaining a roentgenogram, the triage nurse or the managing physician visually inspected each wound and recorded whether the bottom of the wound was seen, if glass was seen in the wound, and the length and depth of the wound. Further treatment of the wound was at the discretion of the managing physician. MEASUREMENTS/MAIN RESULTS: Glass was seen in the wounds of 10 children on initial inspection. Of the remaining 216 injuries, glass was contained in 12 (21.4%) of the 56 lacerations when the bottom of the wound was not visualized, and in 11 (6.9%) of the 160 lacerations when the bottom of the wound was visualized. There was a significant association between the depth of the wound and an inability to see the bottom of the wound, and deeper wounds were significantly more likely to contain glass. All but one of the lacerations containing glass had a depth of at least 0.5 cm. CONCLUSIONS: In the population studied, seeing that the bottom of the laceration was free of glass reduced, but did not eliminate, the possibility that glass was present in the wound. In addition, superficial lacerations (less than 0.5 cm) rarely contained undetected glass fragments. We recommended that further investigation concerning the mechanism of injury, the depth of the wound, and the type of glass involved is needed before physicians abandon routine roentgenography for lacerations due to glass.

Dog bites in urban children.

As a result of a perceived increase in pit bull injuries, all children who presented to The Children's Hospital of Philadelphia during 1989 for evaluation of dog bite injuries were prospectively studied. Epidemiologic information was collected from parents, either at the time of visit or by phone on the following day. A total of 168 children were enrolled; the mean age was 8 years. Males outnumbered females 1.5:1. Most (61%) injuries occurred in or around the home and involved dogs known to the patient (77%). Types of injuries included abrasions (33%), punctures (29%), and lacerations (38%). Thirteen bites had associated complications; nine developed infection. Twelve (7%) children required admission to the hospital. More than 12 different purebreeds or cross-breeds were identified as perpetrators, including German shepherds (n = 35), pit bulls (n = 33), rottweilers (n = 9), and Dobermans (n = 7). Most (54%) animals were contained (ie, leashed, fenced, in-house) at the time of injury. Fewer (46%) were provoked prior to biting. Significantly more pit bull injuries (94% vs 43%, P less than .001) were the consequence of unprovoked attacks and involved freely roaming animals (67% vs 41%, P less than .01). Children aged 5 or younger were more likely to provoke animals prior to injury than were older children (69% vs 36%, P less than .001). It is recommended that families with young children be the target of pet safety education and that measures be sought that would lead to early identification of a potentially dangerous dog and restrict ownership.

Acquired methemoglobinemia. The relationship of cause to course of illness.

To better characterize methemoglobinemia in children, we reviewed the charts of 17 patients who were admitted to a children's hospital over the last 10 years. Two distinct groups were identified: (1) The endogenous group (n = 9) included patients with methemoglobinemia associated with an intercurrent illness. (2) The exogenous group (n = 8) included patients with methemoglobinemia secondary to drug exposure. Despite similar initial methemoglobin levels in the endogenous (mean, 29%) and exogenous (mean, 28%) groups, children in the endogenous group had more acidosis (serum bicarbonate levels of 5.9 vs 19.1 mmol/L and arterial pH of 7.01 vs 7.35). All the children in the exogenous group with methemoglobinemia secondary to an accidental ingestion stayed only 1 day in the hospital, while children in the endogenous group were admitted for an average of 19 days. Children with methemoglobinemia secondary to a drug exposure have a more benign illness with a shorter duration than children with methemoglobinemia associated with an intercurrent illness. It appears that the absolute level of methemoglobin is not as important as the underlying cause in determining both the course and severity of illness.

Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week-old infants.

All infants aged 29 to 56 days with rectal temperatures in excess of 38.2 degrees C who presented to the Emergency Department of The Children's Hospital of Philadelphia from July 1987 through July 1988 were studied. Each infant was scored (1 to 5) on each of the six items in the Yale Observation Scale by an Emergency Department attending physician before history and physical examination. Individual scores were then added to yield a total score for each patient. An observation score of 10 or less was indicative of a generally well-appearing child, and a score of 16 or more represented an ill-appearing child. Of 126 infants enrolled, 37 (29%) had serious illness; 12 (9.5%) had culture-proven bacterial disease. Of all infants with an observation score less than or equal to 10 (n = 91), 22% had serious illness, and of all infants with an observation score greater than or equal to 16 (n = 20), only 45% had serious illness. The findings suggest that even in experienced hands, the Yale Observation Scale alone does not provide sufficient data to identify serious illness in febrile, 1- to 2-month-old infants.