Predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures.

STUDY OBJECTIVE: To develop a preliminary clinical decision guideline, using characteristics of ED pediatric patients presenting with seizures, that successfully predicts all abnormal results of computed tomography (CT) of the head. METHODS: We assembled a retrospective case series in the ED of a tertiary care children's hospital without trauma designation. The series comprised all patients who presented between January 1, 1992, and December 31, 1994, with seizures (febrile and afebrile) who underwent head CT as part of ED evaluation. RESULTS: Our inclusion criteria were met by 203 patients. Of these patients, who had a median age of 3.1 years, 53% were boys; 18% had been transferred from another facility; 25% had received anti-convulsant medication in the field, at the referring facility, or both; 32% had a history of seizures before the presenting episode; 6% had sustained a closed-head injury (CHI); 15% had a cerebrospinal fluid (CSF) shunt; 4% had an underlying malignancy or neurocutaneous disorder (NCT); and 30% had a documented fever. CT findings were abnormal in 25 patients (12%). CT showed evidence of hemorrhage in eight patients (32%), small focal abnormalities in four (16%), cerebral edema in three (12%), and shunt obstruction in two (8%). chi 2 Recursive-partitioning analysis revealed that CT scan results were always normal when the patient did not have an underlying high-risk condition (malignancy, NCT, recent CHI, or recent CSF shunt revision), was older than 6 months, had sustained a seizure of 15 minutes or less, and did not have a history of a new-onset focal neurologic deficit. Retrospective application of these criteria revealed that 41% of the CT scans could have been deferred. CONCLUSION: In this case series, the absence of defined high-risk factors predicted normal head CT findings. The deferral of emergency CT in this population should be considered.

Outbreak of Escherichia coli O157:H7 hemorrhagic colitis and hemolytic uremic syndrome: effect on use of a pediatric emergency department.

STUDY OBJECTIVE: To evaluate the effect of an outbreak of Escherichia coli O157:H7 colitis, and media coverage of the outbreak, on use of an emergency department. DESIGN: Review of pediatric ED use and charges for gastrointestinal illness during the epidemic and during a control period. SETTING: Pediatric ED in Seattle, Washington. PARTICIPANTS: All children seen in the ED with a gastrointestinal illness during the epidemic period (January and February 1993) and during a control period (January and February 1992). RESULTS: During the epidemic, 31 patients with E coli O157:H7 infection had 45 visits to the ED. The number of visits for gastrointestinal illness not caused by E coli O157:H7 was 103% higher in the epidemic period than in the control period (653 in 1992, 1,327 in 1993). The number of visits was closely associated with the number of newspaper stories about E coli O157:H7 illness (correlation coefficient, .88; P = .002). The increased number of evaluations for gastrointestinal illness not caused by E coli O157:H7 infection during the epidemic period was associated with an additional $101,193 in charges per month compared with the control period. There were no important differences in the evaluation of gastrointestinal illness between 1992 and 1993 except for an increase in the proportion of patients with stool cultures (13.1% versus 26.4%, P < .001). CONCLUSION: For every visit by a patient with E coli O157:H7 infection, there were 15 additional visits (above the baseline from the control period) by patients with other gastrointestinal illness. The true cost of this epidemic included not only the evaluation of patients with disease but also the evaluation of those who presented because they were worried they had the disease. The intensity of media coverage of a disaster may correlate with the number of visits to the ED, and understanding of this fact may help in disaster planning.

Paramedic intubation training in a pediatric operating room.

The authors conducted a prospective study to assess the performance of paramedics with prior adult endotracheal intubation experience in pediatric intubation in the operating room of a teaching hospital. Nineteen paramedic students were observed attempting endotracheal intubation on a total of 57 anesthetized pediatric patients undergoing scheduled surgical procedures. The average age of patients was 5.1 years (range, 6 months to 15.2 years). Average duration of intubation attempts was 22.7 +/- 10.7 seconds, with a success rate on first attempt of 74%. Only minor complications occurred, and were limited to intubation attempts of greater than 45 seconds duration in four cases (6%), and patient oxygen saturation less than 90% in one case (2%). The study suggests that paramedics may be successfully incorporated into a hospital's clinical training program, and can receive closely supervised experience in pediatric endotracheal intubation without compromising patient care. Such training may increase the willingness of paramedics to attempt emergent prehospital endotracheal intubation of children, as well as increase their success with this potentially life-saving procedure.