Variations in sedating uncooperative, stable children for post-traumatic head CT.

OBJECTIVE: To characterize variations among pediatric emergency physicians and their hospital facilities regarding sedation of the uncooperative, stable child for head CT following closed head injury. DESIGN: Mail survey with two follow-up mailings. PARTICIPANTS: Surveys were sent to all members of the Emergency Medicine Section of the American Academy of Pediatrics (AAP). RESULTS: Of 596 surveys sent, 431 (72%) were returned, with 304 (51%) usable responses. Respondents annually sedate over 17,500 children for post-traumatic head CT. Formal training to sedate children for head CT was noted by 73%. Published guidelines for sedation are followed by 74%; 10% were unaware of the existence of published guidelines for sedation. Twenty-six percent of the respondents were very or somewhat dissatisfied with their sedation-related practices. In response to three clinical scenarios involving sedation of 8-month-old, 3-year-old, and 6-year-old children for head CT, midazolam was the most commonly chosen drug. Over 20 different sedation strategies were selected for each scenario. CONCLUSIONS: Sedation practices for post-traumatic pediatric head CT vary widely, among both physicians and individual practitioners. Institutional and individual sedation-relation policies vary widely as well. Variation and dissatisfaction with sedation practices may reflect uncertainty regarding optimal sedation strategies. Further cost-effectiveness research is necessary.

Toxicology training of paramedic students in the United States.

A 16-item survey was mailed to the directors of 618 paramedic training programs in the United States to determine (1) the number of lecture hours devoted to toxicology topics and (2) how often paramedic training includes a rotation in a poison control center. The response rate was 82%. Toxicology accounts for approximately 2% of paramedic students' total training. Cardiovascular drug toxicity and hazardous materials are discussed for over 60 minutes by more than 50% of paramedic training programs. Four paramedic programs have no lecture time on cyclic antidepressant overdoses and one program has no lecture time on carbon monoxide poisoning. Eighty-one percent (377 of 467) have access to a regional poison control center; 11% (42 of 377) use the poison control center as a paramedic training site. Some US paramedic training programs spend insufficient time covering topics that have significant out-of-hospital morbidity. Although poison control centers are often available, they are underutilized for paramedic training.

Gatekeepers: a missed opportunity for safe transport.

OBJECTIVE: To assess whether contact with a health care provider or gatekeeper increases the use of an ambulance for patients with acute chest pain. METHODS: A convenience sample of adults > or =40 years of age presenting with a chief complaint of chest pain were interviewed by trained personnel regarding transport used to come to the ED. The study was performed at the ED of an urban university hospital. Patients with hemodynamic instability and those receiving thrombolytics or emergency angioplasty were excluded. Patients were asked about access to a primary health care provider and contact with a provider regarding this ED visit, including instructions given for transportation. RESULTS: Of the 450 interviewed patients, 42% arrived by ambulance. Those who had contact with a health care provider prior to the ED visit were less likely to come by ambulance than those without contact, 31% vs 51% (p < 0.001). Of the patients who had cardiac enzymes obtained to work up for their chest pain, 34% with health provider contact vs 57% without health provider contact arrived by ambulance (p < 0.001). Of those with acute myocardial infarction, 30% with health provider contact vs 66% without health provider contact came by ambulance (p < 0.03). Patients who recalled transport instructions from their providers tended to follow those instructions. The majority of patients who recalled no specific transport instructions arrived by personal automobile. CONCLUSION: Of patients presenting to an ED for evaluation of chest pain, those who made contact with a health care provider were less likely to arrive via ambulance.