Safety and efficacy of rocuronium for controlled intubation with paralytics in the pediatric emergency department.

BACKGROUND: Controlled intubation in the pediatric emergency department (ED) requires a paralytic agent that is safe, efficacious, and of rapid onset. The safety of succinylcholine has been challenged, leading some clinicians to use vecuronium as an alternative. Rocuronium's onset is similar to that of succinylcholine. OBJECTIVE: To evaluate the safety and efficacy of rocuronium for controlled intubation with paralysis (CIP) in the pediatric ED. METHODS: A retrospective, observational study reviewed the records of patients less than 15 years of age, who received controlled intubation with paralytics at two Dallas EDs. The patients received either vecuronium or rocuronium. RESULTS: The study included 84 patients (vecuronium 19, rocuronium 65). Complications were similar between the two groups. Rocuronium had a shorter time from administration to intubation when compared to vecuronium (P < 0.05). CONCLUSION: Rocuronium is as safe and efficacious as vecuronium for CIP in the pediatric ED.

Acute flank pain: an unusual presentation of a spinal AVM.

The authors report the case of a 6-year-old boy with a spinal cord arteriovenous malformation (AVM) who presented with acute flank pain and a delayed onset of paraplegia. An early diagnosis of a spinal cord AVM was made difficult by the absence of neurological findings on initial evaluation. Included is a description of his clinical course, and the presentation of spinal AVMs to the emergency physician is discussed.

Noninvasive capnometry monitoring for respiratory status during pediatric seizures.

OBJECTIVE: To determine the reliability and clinical value of end-tidal CO2 by oral/nasal capnometry for monitoring pediatric patients presenting post ictal or with active seizures. DESIGN: Clinical, prospective, observational study. SETTING: University affiliated children's hospital. INTERVENTIONS: One hundred sixty-six patients (105 patients with active seizures, 61 post ictal patients) had end-tidal CO2 obtained by oral/nasal sidestream capnometry, and respiratory rates, oxygen saturation, and pulse rates recorded every 5 mins until 60 mins had elapsed. End-tidal CO2 values were compared with a capillary PCO2 and clinical observation. MEASUREMENTS AND MAIN RESULTS: The mean end-tidal CO2 reading was 43.0 +/- 11.8 torr [5.7 +/- 1.6 kPa] and the mean capillary PCO2 reading was 43.4 +/- 11.7 torr [5.7 +/- 1.6 kPa]. The correlation between end-tidal CO2 and capillary PCO2 was significant (r2 = .97; p < .0001). A relative average bias of 0.33 torr (0.04 kPa) with end-tidal CO2 lower than capillary PCO2 was established with 95% limits of agreement +/-4.2 torr (+/-0.6 kPa). Variability of difference scores was not related to range of mean scores (r2 = .00003), age (r2 = .0004), or respiratory rates (r2 = .0009). End-tidal CO2 (r2 = .22; p < .001) correlated better with respiratory rate changes when compared with oxygen saturation (r2 = .02; p = .01). CONCLUSIONS: Dependable end-tidal CO2 values can be obtained in pediatric seizure patients using an oral/nasal cannula capnometry circuit. Continuous end-tidal CO2 monitoring provides the clinician with a reliable assessment of pulmonary status that can assist with decisions to provide ventilatory support.

Upper airway obstruction caused by brown recluse spider envenomization of the neck.

A 7-year-old boy presented to the emergency department with progressive cervical soft tissue swelling and airway compromise due to envenomization by a brown recluse spider. This life-threatening complication is an extremely unusual presentation of brown recluse spider envenomization. Previous published reports have centered on the disfiguring localized tissue necrosis or life-threatening systemic reactions that occur secondary to the spider's venom.