Gartland classification concordance of supracondylar fractures among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

BACKGROUND: The modified Gartland classification is the most widely accepted grading method of supracondylar humeral fractures among orthopedic surgeons and is relevant to identifying fractures that may require surgery. OBJECTIVE: To assess the interobserver reliability of the modified Gartland classification among pediatric radiologists, pediatric orthopedic surgeons, and pediatric emergency medicine physicians. MATERIALS AND METHODS: Elbow radiographs for 100 children with supracondylar humeral fractures were retrospectively independently graded by two pediatric radiologists, two pediatric orthopedic surgeons, and two pediatric emergency medicine physicians using the modified Gartland classification. A third grader of the same subspecialty served as a tie-breaker as needed to reach consensus. Readers were blinded to one another and to the medical record. The modified Gartland grade documented in the medical record by the treating orthopedic provider was used as the reference standard. Interobserver agreement was assessed using kappa statistics. RESULTS: There was substantial interobserver agreement (kappa = 0.77 [95% CI, 0.69-0.85]) on consensus fracture grade between the three subspecialties. Similarly, when discriminating between Gartland type I and higher fracture grades, there was substantial interobserver agreement between specialties (kappa = 0.77 [95% CI, 0.66-0.89]). The grade assigned by pediatric radiologists differed from the reference standard on 15 occasions, pediatric emergency medicine differed on 19 occasions, and pediatric orthopedics differed on 9 occasions. CONCLUSION: The modified Gartland classification for supracondylar humeral fractures is reproducible among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

Characteristics and diagnoses of neonates who revisit a pediatric emergency center.

OBJECTIVE: Families with neonates may utilize emergency centers (ECs) for nonurgent complaints. We sought to describe the demographic and clinical characteristics of neonates evaluated in an urban tertiary children's EC more than once in a 5-day period and to determine the frequency of serious illnesses and admission at the second visit. METHODS: We conducted a retrospective case series of neonates (aged <29 days) who visited the EC, were discharged home, and returned within 5 days during a 3-year period. RESULTS: There were 147 study neonates (2.4% of all newborn EC patients) with an average age of 16 days at the first visit and a median 3 days between visits. Sixteen patients (11% of returning patients) returned with fever (≥38 °C); 15 patients (10%) returned with respiratory distress or hypoxemia, and 56 (38%) required admission at the second visit. Patients diagnosed with gastroesophageal reflux and/or vomiting at the first visit had a high frequency of admission (55%) and pyloric stenosis (26%) at the second visit. CONCLUSIONS: Of neonates discharged from the EC with nonurgent medical issues, more than a third of those revisiting the EC required admission within 5 days. The risk of fever, respiratory distress, and admission was higher in neonates who originally presented with infectious symptoms than neonates who presented with noninfectious process. Of neonates presenting twice with gastroesophageal reflux and/or vomiting, almost a third had pyloric stenosis, indicating that close follow-up of vomiting neonates is needed.

The use of incentive spirometry in pediatric patients with sickle cell disease to reduce the incidence of acute chest syndrome.

INTRODUCTION: To determine if incentive spirometry (IS) in pediatric patients admitted with sickle cell disease for nonrespiratory complaints will decrease acute chest syndrome (ACS). METHODS: This was an Institutional Review Board-approved before-after 2-year retrospective cohort study evaluating an evidence-based guideline (EBG) initiating mandatory IS in admitted pediatric sickle cell patients from a tertiary children's emergency center. Student t testing and χ² analysis were performed. RESULTS: There were 1551 patient visits. About 258 visits were enrolled in the pre-EBG year, and 230 in the EBG year. Between year characteristics were similar. The EBG year reported higher use of hydroxyurea (P<0.01), analgesics (P=0.02), and chest pain (P=0.03). Sixty-seven patients (25.9%) in the pre-EBG year received transfusions versus 51 (22.5%) in the EBG year (NS). Twenty-five (9.6%) of the pre-EBG patients received blood for ACS versus 14 (6.1%) in the EBG group (absolute risk reduction: 3.5%, 95% confidence interval: -1-8.4%). Subgroup analysis revealed that patients who presented with back pain experienced a significant decrease in the development of ACS in the EBG year (P=0.04, absolute risk reduction: 14%, 95% confidence interval: 1-28%, number needed to treat: 8). CONCLUSION: Mandatory IS for sickle cell disease patients admitted without respiratory complaints reduces transfusions and ACS, particularly for those presenting with back pain.

The efficacy of ketamine in pediatric emergency department patients who present with acute severe asthma.

STUDY OBJECTIVE: We determine whether a continuous infusion of ketamine can decrease the severity of a moderately severe acute asthma exacerbation by a clinically significant 2 points using a 15-point Pulmonary Index scoring scale. METHODS: A double-blinded, randomized, placebo-controlled trial was performed to evaluate patients aged 2 to 18 years who presented to a pediatric emergency department with an acute asthma exacerbation. Exclusion criteria included temperature greater than 39 degrees C (102 degrees F), focal infiltrate on radiograph, or any glucocorticoid use in the last 72 hours. Eligible patients received 3 treatments with albuterol, ipratropium bromide, and a dose of oral or parenteral glucocorticoids. If the Pulmonary Index score remained 8 to 14, enrollment proceeded. All enrolled patients received continuous nebulized albuterol at 10 mg/hour and were randomized to receive an intravenous bolus of 0.2 mg/kg of ketamine, followed by a 2-hour ketamine infusion at 0.5 mg/kg per hour or an equal-volume regimen with normal-saline placebo. A Pulmonary Index score was performed on patients at 0, 30, 60, 90, and 120 minutes. RESULTS: Sixty-eight patients were enrolled, with 33 randomized to the ketamine infusion and 35 randomized to placebo. Mean ages of patients enrolled, chronic severity of asthma, and duration of symptoms before presentation were similar between groups. At enrollment, the mean Pulmonary Index score in the placebo group was 10.3+/-1.1 versus 10.5+/-1.5 for the ketamine group (difference of means 0.2; 95% confidence interval [CI] -0.5 to 0.8). Sixty-two patients completed the entire 2-hour infusion protocol. No significant difference between groups was seen in rate of improvement in the Pulmonary Index score at completion. The mean decrease in the Pulmonary Index scores at the end of the infusion was 3.6+/-1.3 in the placebo group versus 3.2+/-2.0 in the ketamine group (difference of means 0.4; 95% CI -0.4 to 1.3). No short-term adverse effects necessitating discontinuation of the infusion or adverse behavioral impacts at 48 hours after discharge were noted. CONCLUSION: We conclude that ketamine given at 0.2 mg/kg followed by an infusion of 0.5 mg/kg per hour for 2 hours provided no incremental benefit to standard therapy in this cohort of children with a moderately severe asthma exacerbation.