Atlanto-occipital dislocation with retroclival hematoma in a pediatric patient presenting to the emergency department.

Atlanto-occipital dislocation is a rare, oftentimes fatal injury sustained from high-impact trauma. It is seen more often in children compared with adults. In the past decade, there are more pediatric survivors presenting to the emergency department for treatment. This case reviews the presentation, diagnosis, and treatment of a child who survived this injury.

Myasthenia gravis in an adolescent patient presenting to the pediatric emergency department.

Myasthenia gravis is a rare, chronic, autoimmune disorder characterized by postsynaptic dysfunction at the neuromuscular junction. The disease affects more females than males. We describe the case of a 17-year-old female adolescent with recurrent episodes of dysarthria and dysphagia and a history of aspiration pneumonia. A bedside edrophonium (Tensilon) test in our emergency department confirmed the diagnosis of myasthenia gravis.

Inter-rater reliability for noninvasive measurement of cardiac function in children.

INTRODUCTION: A transcutaneous ultrasound monitor has recently been developed which noninvasively and quickly measures cardiac output. Validity and reliability testing has been reported in adults. No reliability testing has been undertaken in the pediatric population. OBJECTIVE: Our objective was to evaluate the inter-rater reliability of a transcutaneous Doppler ultrasound technique to measure cardiac index (CI) and stroke volume index (SVI) in pediatric emergency department patients. METHODS: An 8-month prospective observational study was conducted on a convenience sample of emergency department patients younger than 18 years old. Five raters were trained to use an ultrasound cardiac output monitoring device. Two raters, blinded to each other's results, obtained independent measurements from the same patient within 15 minutes of each other. Inter-rater agreement was measured with the Pearson product correlation coefficient. Bland-Altman analysis demonstrated the extent of deviation from a line of agreement between raters. RESULTS: Ninety-seven patients were enrolled. Major diagnostic categories included infection, trauma, and gastrointestinal disorders. There was significant inter-rater correlation for CI (r = 0.76; 95% confidence interval, 0.66Y0.83; P G 0.0001) and SVI (r = 0.79; 95% confidence interval, 0.70Y0.86; P G 0.0001). Bland-Altman analysis of CI measurements between 2 raters showed bias of 0.06, SD of bias 1.00, and 95% limits of agreement j1.91 to 2.02 L/min/m2. Stroke volume index showed bias of j0.5, SD of bias 11.01, and 95% limits of agreement j22.08 to 21.08 mL/m2. CONCLUSIONS: Transcutaneous Doppler ultrasound technique demonstrates acceptable inter-rater agreement for measuring CI and SVI in children.

Test characteristics of parent's visual analog scale score in predicting ventriculoperitoneal shunt malfunction in the pediatric emergency department.

OBJECTIVES: Many parents of children with ventriculoperitoneal shunts present to the emergency department for evaluation of a possible shunt malfunction. No study to date has evaluated their ability to predict a shunt malfunction. Our study objective was to evaluate parents' accuracy for predicting a shunt malfunction in their child. We hypothesize that parents more experienced with prior shunt malfunctions are better able to predict subsequent malfunctions in their child. METHODS: We conducted a prospective, descriptive study on children younger than 18 years presenting to our tertiary care pediatric emergency department with a possible ventriculoperitoneal shunt malfunction. Parents rated the likelihood of a shunt malfunction using an unmarked 100-mm visual analog scale marked definitely malfunctioning at the high end. An experienced parent was defined as one who had previously experienced at least 3 shunt malfunctions in their child. RESULTS: We enrolled 85 parent-child dyads in our study. Twenty-four children were diagnosed with a malfunction. The predictive ability of parents to determine a shunt malfunction was found at a threshold visual analog scale score of 66 (sensitivity, 88.9%, and specificity, 62.2%). At a determined threshold value of 85 or more, experienced parents had a high specificity of 89.2% with a positive likelihood ratio of 5.1. Experienced parents showed an area under the curve of 0.7928 (95% confidence interval, 0.6037-0.9819); and inexperienced parents, 0.5611 (95% confidence interval, 0.3646-0.7576) (P = 0.096). CONCLUSIONS: Experienced parents are better able to predict a shunt malfunction in their child.

Albuterol nebulized in heliox in the initial ED treatment of pediatric asthma: a blinded, randomized controlled trial.

OBJECTIVE: A prospective blinded, randomized controlled trial was undertaken to compare the initial response of albuterol nebulized in heliox or control in the treatment of moderately severe asthma in children presenting to a pediatric ED. METHODS: Patients were randomized to receive heliox (n = 20) or control (n = 21). The primary outcome was to compare a modified dyspnea index score at 10 and 20 minutes after randomization. Secondary outcomes were to determine if heliox decreased admission rates or endotracheal intubation. RESULTS: There was no statistically significant difference found at 10 or 20 minutes after randomization with heliox (P = .169 and P = .062, respectively). No statistical difference in admission rate was found, and no patients required endotracheal intubation in either group. CONCLUSIONS: Our results demonstrate that albuterol nebulized with heliox offered no clinical benefit over standard therapy in the initial treatment of moderately severe asthma in the ED.

Perichondritis--a complication of high ear piercing.

Body piercing has become a fashionable trend in western culture. High ear piercing is common among the adolescent population and complications from this procedure although uncommon can be permanently disfiguring. We describe a case of perichondritis after high ear piercing in an adolescent male. A review of the history of body piercing, complications, risk factors, and treatment is presented.