Acute Management of Tension Pneumocephalus in a Pediatric Patient: A Case Report.

BACKGROUND: Tension pneumocephalus is a rare but life-threatening condition in which air gains entry into the cranium and exerts mass effect on the brain, resulting in increased intracranial pressure. It occurs most frequently secondary to head trauma, particularly to the orbits or sinuses. CASE REPORT: A 13-year-old male sustained facial trauma from a motor vehicle collision and was found to have tension pneumocephalus on computer tomography. The patient underwent immediate rapid sequence intubation without preceding positive pressure ventilation in the emergency department. At the time of his craniotomy, the tension pneumocephalus was found to have resolved and he went on to have a complete recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Any patient with facial or head trauma and pneumocephalus is at risk for the potential development of tension pneumocephalus. When present, we advocate that aggressive definitive airway management by rapid sequence intubation without preceding positive pressure ventilation and early surgical management should be prioritized.

Another angry adolescent: another boxer's fracture?

Hand injuries are a common chief complaint in the pediatric population presenting for emergency care. Adolescents, in particular, often present with trauma to their hands after punching objects. The most frequent result of this action is a fracture to one or more of their metacarpals, also known as a boxer's fracture. However, we present a case with this common mechanism that resulted in an uncommon injury, carpometacarpal joint dislocations.

Pediatric residents' ability to perform a lumbar puncture: evaluation of an educational intervention.

OBJECTIVE: To assess the baseline ability of pediatric residents to successfully perform a lumbar puncture (LP) and to evaluate the impact of an educational intervention on this skill in both a simulated and clinical environment. METHODS: An experimental group of first-year residents and a control group of second-year residents were enrolled in a prospective nonrandomized intervention study. Knowledge and skill at performing LPs were assessed using a written and a simulated LP test. The experimental group was tested at the start of their residency and then received the educational intervention. They were retested 6 months later. The control group did not receive the educational intervention and were tested at the start of their second year. The outcomes of clinical LPs performed by the 2 groups were also recorded. RESULTS: The experimental group showed significant improvement on both the written and the simulated LP test after the educational intervention. When compared with the control group, they performed the simulated LP significantly better as measured by the number of correctly performed steps. Both groups performed a low number of clinical LPs. CONCLUSIONS: After an educational intervention, pediatric first-year residents performed a simulated LP better than a group of second-year residents who had greater clinical LP experience. The low number of clinical LPs performed limits our ability to determine the educational intervention's impact in the clinical setting and reinforces the concern that recent changes to pediatric residencies may negatively impact residents' procedural experience.

Emergency department management of community-acquired methicillin-resistant Staphylococcus aureus.

Staphylococcus aureus is a known cause of a variety of illnesses that present to the emergency department, including skin and soft tissue infections, pneumonia, and sepsis. Managing these conditions has become more difficult with the emergence of bacterial strains in the community that are resistant to traditional first-line antibiotics. Emergency care providers need to be aware of the increased prevalence of these resistant bacteria, to understand the characteristics of the infections with which they are associated, and to know the effective antibiotic options for treating these bacterial infections in the emergency department patient population.

Approach to management of malignant hyperthermia-like syndrome in pediatric diabetes mellitus.

BACKGROUND: Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is usually associated with type 2 diabetes mellitus and is rare in children. However, a fatal malignant hyperthermia-like syndrome (MHLS) with rhabdomyolysis associated with new-onset diabetes mellitus and HHNS in adolescents has been described. DESIGN/METHODS: Case series. RESULTS: A 16-yr-old obese male (case A) and a 10-yr-old mid-pubertal nonobese female (case B) presented within a 6-month period with emesis, altered mental status, blood glucose >1600 mg/dL, and laboratory evidence of rhabdomyolysis. Case A developed fever after initiation of insulin therapy, along with refractory hypotension and multiorgan failure. He died 14 hrs after admission. Case B developed fever before insulin therapy, was treated with dantrolene, and made a full recovery. Metabolic workup showed evidence of short-chain acyl-CoA dehydrogenase (SCAD) deficiency. CONCLUSIONS: We report two cases of malignant hyperthermia-like syndrome associated with HHNS in adolescents. Their respective fluid management and clinical courses are described. Dantrolene therapy should be initiated immediately after this syndrome is recognized. We believe it is unlikely insulin is the sole trigger for MHLS. Case B is unique in that there was evidence of SCAD deficiency, a metabolic defect that we propose could lead to MHLS. We recommend that all patients with HHNS and MHLS be evaluated for an underlying metabolic disorder.