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Pediatric Emergency Department (pediatric + emergency_department)

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Medical Sciences	100%

Selected Abstracts

The Impact of a Brief Expectation Survey on Parental Satisfaction in the Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 12 2006
Christopher D. Spahr MD
Abstract Objectives To determine the effect of physician knowledge of parental expectations on satisfaction with emergency department (ED) care. Methods This was a prospective, controlled, interventional trial involving parents of children presenting to a children's hospital ED. Parents completed an expectation survey on arrival, which was either immediately placed back in the enrollment envelope (control) or shown to the physician caring for the child (intervention). The physician was instructed to initial the expectation survey to acknowledge receipt of the survey. Parents then completed a satisfaction survey at discharge. The primary outcomes were differences in satisfaction with physician review of the expectation survey, as measured by 1) parental ratings of overall care and 2) their willingness to recommend the ED to others. A third (baseline) group completed only a satisfaction survey at discharge. Results A total of 614 (66%) of the 930 enrolled parents completed the study. Intention-to-treat analysis did not show a significant increase in parental satisfaction ratings for either overall care or recommend the ED; however, only 42% of the intervention group surveys had documented physician review. When these initialed surveys were compared with the control group in a per-protocol analysis, there was a significant improvement in parental satisfaction. There were no differences between the control and baseline groups, indicating no effect of the expectation survey completion on satisfaction. Conclusions Physician knowledge of written parental expectations may improve parental satisfaction during an ED visit. Further work is needed to overcome the barriers to physician review of the expectation survey to maximize parent satisfaction. [source]

Screening for Adolescent Depression in a Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 5 2006
Emily Gale Scott MD
Abstract Objectives: To describe the prevalence of depressive symptoms in adolescents presenting to the emergency department (ED) and to describe their demographics and outcomes compared with adolescents endorsing low levels of depressive symptoms. Methods: The Beck Depression Inventory,2nd edition (BDI-II) was used to screen all patients 13,19 years of age who presented to the ED during the period of study. The BDI-II is a 21-item self-report instrument used to measure the presence and severity of depressive symptoms in adolescents and adults. Demographics and clinical outcomes of screening-program participants were abstracted by chart review. Patients were categorized into one of four severity categories (minimal, mild, moderate, or severe) and one of three presenting complaint categories (medical, trauma, mental health). Results: Four hundred eighty-seven patients were approached, and 351(72%) completed the screening protocol. Participants endorsed minimal (n= 192, 55%), mild (n= 52, 15%), moderate (n= 41, 11%), or severe depressive symptoms (n= 66, 19%). Those with moderate or severe depressive symptoms were more likely to be hospitalized. Of patients completing the BDI-II, 72% with psychiatric, 12% with traumatic, and 19% with medical chief complaints endorsed either moderate or severe depressive symptoms. Conclusions: Depressive symptoms are prevalent in this screening sample, regardless of presenting complaint. A substantial proportion of patients with nonpsychiatric chief complaints endorsed moderate or severe depressive symptoms. A screening program might allow earlier identification and referral of patients at risk for depression. [source]

Utilization of the Ottawa Ankle Rules by Nurses in a Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 2 2002
Anna Karpas MD
Objectives: To determine the ability of pediatric emergency department (ED) nurses to accurately apply the Ottawa Ankle Rules (OAR) and to evaluate whether the rate of negative ankle radiographs can be reduced by incorporating the OAR into an existing collaborative practice protocol (CPP). Methods: The authors' ED currently uses a CPP in which patients with ankle pain, swelling, deformity, or decreased range of motion on primary nursing assessment undergo radiography prior to physician evaluation. A cross-sectional study was conducted between June and November 2000. Patients aged 5-19 years with an ankle injury who met at least one of the CPP criteria were eligible for enrollment. The OAR were applied by the primary nurse after initial assessment. Ankle radiographs were ordered for all enrolled patients. The interobserver variability between nurses was evaluated on a random sample. Results: One hundred ninety subjects were enrolled in the study. The OAR were correctly interpreted by nurses in 98.4% of subjects. Agreement on the interobserver reliability sample was 100%. Of the 185 subjects, 31 (16.8%) had positive radiographs. Positive OAR results were noted in 30 of 31 subjects with positive radiographs. The sensitivity of the OAR was 97% (95% CI = 0.82 to 0.99) with a specificity of 25% (95% CI = 0.18 to 032). Use of the OAR would have reduced the radiography rate by 21%. Conclusions: Trained nurses can accurately apply and interpret the OAR. The incorporation of the OAR into the nursing assessment of children with acute ankle injuries may reduce the number of radiographs ordered. [source]

Markers of Overcrowding in a Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 2 2010
Antonia S. Stang MD
Abstract Objectives:, The objective of this study was to identify markers of overcrowding in pediatric emergency departments (PEDs) according to expert opinion and then to use statistical methods to further explore the underlying construct of overcrowding. Methods:, A cross-sectional survey of all PED directors (n = 12) and pediatric emergency medicine fellowship program directors (n = 10) across Canada was conducted to elicit expert opinion on relevant markers of emergency department (ED) crowding. The list of markers was reduced to those specific to the ED for which data could be extracted from one tertiary care PED from an existing computerized patient tracking system. Data representing 2,190 consecutive shifts and 138,361 patient visits were collected between April 2005 and March 2007. Common factor analysis (CFA) was used to determine the underlying factors that best represented overcrowding as determined by markers identified by experts in pediatric emergency medicine Results:, The main markers of overcrowding identified by the survey included measures of patient volume (25%), ED operational processes (55%), and delays in transferring patients to inpatient beds (13%). Data collected on 41 markers were retained for the CFA. The results of the CFA indicated that the largest portion of variation in the data (48%) was accounted for by markers describing patient volumes and flow through the ED. Measures of admission delays accounted for a smaller proportion of variability (9%). Conclusions:, The results suggest that for this tertiary PED, markers of ED operational processes and patient volume may be more relevant for determination of overcrowding than markers reflecting delays in transferring patients to inpatient beds. This study provides a foundation for further research on markers of overcrowding specific to the pediatric setting. ACADEMIC EMERGENCY MEDICINE 2010; 17:151,156 © 2010 by the Society for Academic Emergency Medicine [source]

The Implementation of Intranasal Fentanyl for Children in a Mixed Adult and Pediatric Emergency Department Reduces Time to Analgesic Administration

ACADEMIC EMERGENCY MEDICINE, Issue 2 2010
Anna Holdgate MBBS, FACEM
ACADEMIC EMERGENCY MEDICINE 2010; 17:1,4 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, The objective was to determine whether the introduction of intranasal (IN) fentanyl for children with acute pain would reduce the time to analgesic administration in a mixed adult and pediatric emergency department (ED). Methods:, A protocol for IN fentanyl (1.5 ,g/kg) for children age 1,15 years presenting with acute pain was introduced to the department. All children who received intravenous (IV) morphine in the 7 months prior to the introduction of the protocol and either IV morphine or IN fentanyl in the 7 months after the introduction of the protocol were identified from drug registers. Time to analgesic administration, time to see a doctor, and the ages of patients were compared between the periods before and after the introduction of IN fentanyl. Results:, Following implementation, 81 patients received IN fentanyl and 37 received IV morphine, compared to 63 patients receiving morphine in the previous 7 months. The median time to analgesic administration for IN fentanyl was significantly shorter than for morphine (32 minutes vs. 63 minutes, p = 0.001). Children receiving fentanyl were significantly younger than those receiving morphine (median = 8.5 years vs. 12 years, p < 0.001). Conclusions:, This study demonstrates that children treated with IN fentanyl received analgesic medication faster than those treated with IV morphine in a mixed ED. Younger children were more likely to receive opioid analgesia following the introduction of fentanyl. [source]

Detection of Maternal Alcohol Use Problems in the Pediatric Emergency Department

ALCOHOLISM, Issue 7 2006
Heather A. Flynn
Background: Maternal alcohol use problems may impact the health and well-being of children, but often remain unrecognized. Mothers of young children seldom seek outpatient care for themselves; thus, pediatric settings may present an opportunity for the detection of maternal alcohol use problems. This study examines the feasibility of screening for and prevalence of alcohol use problems in mothers of young children in the context of seeking pediatric emergency care. We also examined the relationship of maternal alcohol use problems with use of pediatric emergency care. Methods: A total of 361 English-speaking mothers of children aged 7 and younger completed screening measures during their child's emergency care visit. TWEAK was used to screen for alcohol use problems. The screening survey also included information on children's health status and health care use, demographics, and the Center for Epidemiological Studies Depression Scale. Results: Of the women approached, 90% agreed to complete the screening measure. On the basis of cutoff score of 2 or more, 7% of women had elevated TWEAK scores. Those women with a TWEAK score >2 reported greater use of the pediatric emergency department (PED) than women scoring below the cutoff. On the basis of multivariate analyses, significant predictors of recent PED use included the presence of child chronic illness, younger maternal age, and TWEAK score. Conclusions: Screening for alcohol use problems among mothers of young children using the TWEAK appears to be feasible in a busy PED setting. The PED setting is promising for identifying risk drinking among women who may be less likely to be otherwise detected and for whom alcohol use may be impacting child outcomes. [source]

Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young Adults in a Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 11 2009
Edward Bernstein MD
Abstract Objectives:, Marijuana was involved in 209,563 emergency department (ED) visits in 2006, according to the Drug Abuse Warning Network. Although screening and brief intervention (SBI) has been effective in changing drinking among ED patients in a number of studies, tests of marijuana SBI in a pediatric emergency department (PED) have not yet been reported. The aim of this pilot study was to test whether SBI is effective in reducing marijuana consumption among youth and young adults presenting to a PED with a diverse range of clinical entities. Methods:, A three-group randomized controlled preliminary trial was structured to test 1) differences between Intervention (Int) and standard Assessed Control (AC) groups in marijuana consumption, from baseline to 12 months, and 2) the feasibility of adding a Nonassessed Control (NAC) group to evaluate regression to the mean and assessment reactivity. Patients aged 14,21 years in an urban, academic PED were screened during 2006,2007, using standardized risk factor questions. Subjects were eligible if they used marijuana three or more times in the past 30 days, but were excluded for co-occurring high-risk alcohol use. Consented enrollees were randomized to NAC, AC, and Int groups in a two-stage process that permitted blinding to status during assessment and follow-up. NACs received a resource handout, written advice about marijuana use risks, and a 12-month follow-up appointment. ACs were assessed using standardized instruments and received resources, written advice, and 3- and 12-month follow-up appointments. The Int group received assessment, resources, written advice, 3- and 12-month appointments, a 20-minute structured conversation conducted by older peers, and a 10-day booster telephone call. A peer educator utilized a motivational style interview protocol adapted for adolescents to elicit daily life context and future goals, provide feedback, review pros and cons of marijuana use, assess readiness to change, evaluate strengths and assets, negotiate a contract for change, and make referrals to treatment and/or other resources. Measurements included demographic information; 30-day self-report of marijuana use; attempts to quit, cut back, or change conditions of use; and risk factor questions repeated at follow-up. Results:, Among 7,804 PED patients screened, 325 were eligible; 210 consented and enrolled (Int, n = 68; AC, n = 71; NAC, n = 71), with a 12-month follow-up rate of 71%. For the primary objective, we compared Int to AC. At 12 months, Int participants were more likely to be abstinent for the past 30 days than ACs (odds ratio [OR] for reported abstinence = 2.89, 95% confidence interval [CI] = 1.22 to 6.84, p < 0.014). The Int group had greater reduction in days used, baseline to 12 months, controlling for baseline (Int = ,7.1 vs. AC = ,1.8), were less likely to have been high among those who smoked (OR = 0.39, 95% CI = 0.17 to 0.89, p < 0.05), and were more likely to receive referrals. In a linear regression model controlling for baseline use, NACs smoked 4 fewer days per month than ACs, but consumption was not significantly different, suggesting no assessment reactivity effect. Conclusions:, A preliminary trial of SBI promoted marijuana abstinence and reduced consumption among PED patients aged 14,21 years. A no-contact condition for the NAC group over the year after enrollment was insufficient to capture enrollees for follow-up across a range of baseline acuity. [source]

An Interdisciplinary Initiative to Reduce Radiation Exposure: Evaluation of Appendicitis in a Pediatric Emergency Department With Clinical Assessment Supported by a Staged Ultrasound and Computed Tomography Pathway

ACADEMIC EMERGENCY MEDICINE, Issue 11 2009
Naresh Ramarajan MD
Abstract Objectives:, In the emergency department (ED), a significant amount of radiation exposure is due to computed tomography (CT) scans performed for the diagnosis of appendicitis. Children are at increased risk of developing cancer from low-dose radiation and it is therefore desirable to utilize CT only when appropriate. Ultrasonography (US) eliminates radiation but has sensitivity inferior to that of CT. We describe an interdisciplinary initiative to use a staged US and CT pathway to maximize diagnostic accuracy while minimizing radiation exposure. Methods:, This was a retrospective outcomes analysis of patients presenting after hours for suspected appendicitis at an academic children's hospital ED over a 6-year period. The pathway established US as the initial imaging modality. CT was recommended only if US was equivocal. Clinical and pathologic outcomes from ED diagnosis and disposition, histopathology and return visits, were correlated with the US and CT. ED diagnosis and disposition, pathology, and return visits were used to determine outcome. Results:, A total of 680 patients met the study criteria. A total of 407 patients (60%) followed the pathway. Two-hundred of these (49%) were managed definitively without CT. A total of 106 patients (26%) had a positive US for appendicitis; 94 (23%) had a negative US. A total of 207 patients had equivocal US with follow-up CT. A total of 144 patients went to the operating room (OR); 10 patients (7%) had negative appendectomies. One case of appendicitis was missed (<0.5%). The sensitivity, specificity, negative predictive value, and positive predictive values of our staged US-CT pathway were 99%, 91%, 99%, and 85%, respectively. A total of 228 of 680 patients (34%) had an equivocal US with no follow-up CT. Of these patients, 10 (4%) went to the OR with one negative appendectomy. A total of 218 patients (32%) were observed clinically without complications. Conclusions:, Half of the patients who were treated using this pathway were managed with definitive US alone with an acceptable negative appendectomy rate (7%) and a missed appendicitis rate of less than 0.5%. Visualization of a normal appendix (negative US) was sufficient to obviate the need for a CT in the authors' experience. Emergency physicians (EPs) used an equivocal US in conjunction with clinical assessment to care for one-third of study patients without a CT and with no known cases of missed appendicitis. These data suggest that by employing US first on all children needing diagnostic imaging for diagnosis of acute appendicitis, radiation exposure may be substantially decreased without a decrease in safety or efficacy. [source]

Effect of Trainees on Length of Stay in the Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 9 2009
Catherine James MD
Abstract Background:, Emergency departments (EDs) in teaching hospitals have competing goals of timely patient care and supervised trainee education. Previous investigations have indicated that trainees add time to the length of ED patient encounters. However, no studies have quantified the effect of trainees on pediatric ED length of stay (LOS). Objectives:, The objectives were to measure the effect of trainees on pediatric ED LOS by comparing LOS for patients managed by a pediatric emergency physician (PEP) alone to LOS for patients seen by a trainee and a precepting PEP (Trainee+PEP). A secondary objective was to identify factors other than provider type associated with LOS differences observed in teaching hospital pediatric EDs. Methods:, Data were extracted from a computerized ED tracking system in an urban tertiary care children's hospital with approximately 52,000 visits annually. All patients were seen by a PEP alone, an urgent care physician, or a trainee (a pediatric emergency medicine fellow; a pediatric, emergency medicine, or combined internal medicine/pediatrics resident; or a medical student) plus a precepting PEP. The primary comparison was the ratio of median LOS for the PEP group versus the Trainee+PEP group. Results:, There were 92,193 visits eligible for inclusion over a 2-year period. Median patient age was 5.75 years (interquartile range [IQR] = 21 months to 12.9 years). The PEP group managed 9,141 patients (10%), while the Trainee+PEP group treated 72,135 patients (78%). Overall LOS for an ED visit was 221 minutes. The median LOS was 192 minutes for PEP patients and 225 minutes for Trainee+PEP patients (difference of means = 17%, p < 0.001). Laboratory and imaging studies were associated with LOS increases of 111 and 74 minutes, respectively; both were performed more frequently in Trainee+PEP patients (44% vs. 33% for laboratory studies and 41% vs. 39% for imaging studies, both comparisons p < 0.001). When LOS was analyzed after adjusting for confounding factors including patient acuity, laboratory or radiologic testing, and trainee year, LOS for Trainee+PEP was higher by 17 minutes, or 9% (95% confidence interval [CI] = 6% to 12%, p < 0.001). When LOS was examined for four specific diagnoses (asthma, gastroenteritis, appendicitis, foot/ankle sprain), there were no significant differences in LOS between the PEP and Trainee+PEP groups. Conclusions:, In the pediatric ED of a teaching hospital, ED LOS is on average 9% higher in patients seen by trainees. In an era of increasing efforts to accelerate throughput while training future providers, these findings provide an important metric for the delivery of pediatric emergency care. [source]

Prospective Validation of the Pediatric Appendicitis Score in a Canadian Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 7 2009
Maala Bhatt MD
Abstract Objectives:, Clinical scoring systems attempt to improve the diagnostic accuracy of pediatric appendicitis. The Pediatric Appendicitis Score (PAS) was the first score created specifically for children and showed excellent performance in the derivation study when administered by pediatric surgeons. The objective was to validate the score in a nonreferred population by emergency physicians (EPs). Methods:, A convenience sample of children, 4,18 years old presenting to a pediatric emergency department (ED) with abdominal pain of less than 3 days' duration and in whom the treating physician suspected appendicitis, was prospectively evaluated. Children who were nonverbal, had a previous appendectomy, or had chronic abdominal pathology were excluded. Score components (right lower quadrant and hop tenderness, anorexia, pyrexia, emesis, pain migration, leukocytosis, and neutrophilia) were collected on standardized forms by EPs who were blinded to the scoring system. Interobserver assessments were completed when possible. Appendicitis was defined as appendectomy with positive histology. Outcomes were ascertained by review of the pathology reports from the surgery specimens for children undergoing surgery and by telephone follow-up for children who were discharged home. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. The overall performance of the score was assessed by a receiver operator characteristic (ROC) curve. Results:, Of the enrolled children who met inclusion criteria (n = 246), 83 (34%) had pathology-proven appendicitis. Using the single cut-point suggested in the derivation study (PAS 5) resulted in an unacceptably high number of false positives (37.6%). The score's performance improved when two cut-points were used. When children with a PAS of ,4 were discharged home without further investigations, the sensitivity was 97.6% with a NPV of 97.7%. When a PAS of ,8 determined the need for appendectomy, the score's specificity was 95.1% with a PPV of 85.2%. Using this strategy, the negative appendectomy rate would have been 8.8%, the missed appendicitis rate would have been 2.4%, and 41% of imaging investigations would have been avoided. Conclusions:, The PAS is a useful tool in the evaluation of children with possible appendicitis. Scores of ,4 help rule out appendicitis, while scores of ,8 help predict appendicitis. Patients with a PAS of 5,7 may need further radiologic evaluation. [source]

A Brief Motivational Interview in a Pediatric Emergency Department, Plus 10-day Telephone Follow-up, Increases Attempts to Quit Drinking Among Youth and Young Adults Who Screen Positive for Problematic Drinking

ACADEMIC EMERGENCY MEDICINE, Issue 8 2010
Judith Bernstein RNC
ACADEMIC EMERGENCY MEDICINE 2010; 17:890,902 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, Adolescents in their late teens and early 20s have the highest alcohol consumption in the United States; binge drinking peaks at age 21-25 years. Underage drinking is associated with many negative consequences, including academic problems and risk of intentional and unintentional injuries. This study tested the effectiveness of pediatric emergency department (PED) screening and brief intervention to reduce alcohol consumption and associated risks. Methods:, A three-group randomized assignment trial was structured to test differences between intervention (I) and standard assessed control (AC) groups in alcohol consumption and alcohol-related behaviors from baseline to 12 months and to compare the AC group with a minimally assessed control (MAC) group to adjust for the effect of assessment reactivity on control group behavior. Patients aged 14,21 years were eligible if they screened positive on the Alcohol Use Disorders Identification Test (AUDIT) or for binge drinking or high-risk behaviors. The MAC group received a resource handout, written advice about alcohol-related risks, and a 12-month follow-up appointment. Patients in the AC group were assessed using standardized instruments in addition to the MAC protocol. The I group received a peer-conducted motivational intervention, referral to community resources and treatment if indicated, and a 10-day booster in addition to assessment. Measurements included 30-day self-report of alcohol consumption and alcohol-related behaviors, screens for depression and posttraumatic stress disorder, and self-report of attempts to quit, cut back, or change conditions of use, all repeated at follow-up. Motor vehicle records and medical records were also analyzed for changes from baseline to 1-year follow-up. Results:, Among 7,807 PED patients screened, 1,202 were eligible; 853 enrolled (I, n = 283; AC, n = 284; MAC, n = 286), with a 12-month follow-up rate of 72%. At 12 months, more than half of enrollees in Reaching Adolescents for Prevention (RAP) attempted to cut back on drinking, and over a third tried to quit. A significantly larger proportion of the I group made efforts to quit drinking and to be careful about situations when drinking compared to AC enrollees, and there was a numerically but not significantly greater likelihood (p = 0.065) among the I group for efforts to cut back on drinking. At 3 months, the likelihood of the I group making attempts to cut back was almost triple that of ACs. For efforts to quit, it was double, and for trying to be careful about situations when drinking, there was a 72% increase in the odds ratio (OR) for the I group. Three-month results for attempts were sustained at 12 months for quit attempts and efforts to be careful. Consumption declined in both groups from baseline to 3 months to 12 months, but there were no significant between-group differences in alcohol-related consequences at 12 months or in alcohol-related risk behaviors. We found a pattern suggestive of assessment reactivity in only one variable at 12 months: the attempt to cut back (73.3% for the I group vs. 64.9% among the AC group and 54.8% among the MAC group). Conclusions:, Brief motivational intervention resulted in significant efforts to change behavior (quit drinking and be careful about situations while drinking) but did not alter between-group consumption or consequences. [source]

Bedside Ultrasound Diagnosis of Clavicle Fractures in the Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 7 2010
Keith P. Cross MD
ACADEMIC EMERGENCY MEDICINE 2010; 17:687,693 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, Clavicle fractures are among the most common orthopedic injuries in children. Diagnosis typically involves radiographs, which expose children to radiation and may consume significant time and resources. Our objective was to determine if bedside emergency department (ED) ultrasound (US) is an accurate alternative to radiography. Methods:, This was a prospective study of bedside US for diagnosing clavicle fractures. A convenience sample of children ages 1,18 years with shoulder injuries requiring radiographs was enrolled. Bedside US imaging and an unblinded interpretation were completed by a pediatric emergency physician (EP) prior to radiographs. A second interpreter, a pediatric EP attending physician with extensive US experience, determined a final interpretation of the US images at a later date. This final interpretation was blinded to both clinical and radiography outcomes. The reference standard was an attending radiologist's interpretation of radiographs. The primary outcome was the accuracy of the blinded US interpretation for detecting clavicle fractures compared to the reference standard. Secondary outcome measures included the interrater reliability of the unblinded bedside and the blinded physicians' interpretations and the FACES pain scores (range, 0,5) for US and radiograph imaging. Results:, One-hundred patients were included in the study, of whom 43 had clavicle fractures by radiography. The final US interpretation had 95% sensitivity (95% confidence interval [CI] = 83% to 99%) and 96% specificity (95% CI = 87% to 99%), and overall accuracy was 96%, with 96 congruent readings. Positive and negative predictive values (PPVs and NPVs, respectively) were 95% (95% CI = 83% to 99%) and 96% (95% CI = 87% to 99%), respectively. Interrater reliability (kappa) was 0.74 (95% CI = 0.60 to 0.88). FACES pain scores were available for the 86 subjects who were at least 5 years old. Pain scores were similar during US and radiography. Conclusions:, Compared to radiographs, bedside US can accurately diagnose pediatric clavicle fractures. US causes no more discomfort than radiography when detecting clavicle fractures. Given US's advantage of no radiation, pediatric EPs should consider this application. [source]

The Role of Exhaled Nitric Oxide in Evaluation of Acute Asthma in a Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 1 2009
Maria Y. Kwok MD
Abstract Objectives:, Fractional excretion of nitric oxide (FENO) has been used as a noninvasive marker to assess and manage chronic asthma in adults and children. The aim of this study was to determine the feasibility of obtaining FENO concentrations in children treated in the emergency department (ED) for acute asthma exacerbation and to examine the association between FENO concentrations and other measures of acute asthma severity. Methods:, This was a cross-sectional study of a convenience sample of children 2,18 years old who were seen in an urban ED for acute asthma exacerbation. Using a tidal breathing method with real-time display, the authors measured FENO concentrations before and 1 hour after the administration of corticosteroids and at discharge from the ED. Outcome measures included pulmonary index score (PIS), hospital admission, and short-term outcomes (e.g., missed days of school). Results:, A total of 133 subjects were enrolled. Sixty-eight percent (95% confidence interval [CI] = 60% to 76%) of the subjects provided adequate breaths for FENO measurement. There was no difference in the median initial FENO concentration among subjects, regardless of the severity of their acute asthma. Most subjects showed no change in their FENO concentrations from the start to the end of treatment. FENO concentrations were not significantly associated with other short-term outcomes. Conclusions:, Measurement of FENO is difficult for a large proportion of children with acute asthma exacerbation. FENO concentration during an asthma exacerbation does not correlate with other measures of acute severity and has limited utility in the ED management of acute asthma in children. [source]

Impact of Disaster Drills on Patient Flow in a Pediatric Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 6 2008
Nathan Timm MD
Abstract Objectives:, Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-accredited hospitals must conduct disaster drills twice a year, with one incorporating a mass casualty incident to the emergency department (ED). The authors found no studies describing the potential negative impact on the quality of care real patients in the ED receive during these drills. The objective was to determine the impact that mass casualty drills have on the timeliness of care for nondisaster patients in a pediatric ED. Methods:, Since 2001, nine disaster drills involving mass casualties to the ED were conducted at the authors' institution. The authors studied 5-, 10-, and 24-hour blocks of time surrounding these events and defined quality measures as the timeliness of care in terms of length of stay (LOS) in ED, time-to-triage, and time-to-physician. Drill dates were compared with control dates (the same weekday on the following week). Paired t-tests were used to compare outcomes of interest between drill and control days. Results:, Nine drill days and nine control days were studied. There was no statistically significant difference between drill dates and control dates in average time-to-triage and time-to-emergency physician and average ED LOS. Admitted patients spent less time in the ED during drill dates. Conclusions:, Disaster drills at this institution do not appear to significantly affect the timeliness of care to nondisaster drill ED patients. Attention should be paid to the quality of care "real" patients receive to ensure that their care is not jeopardized during an artificial stress to the system during a disaster drill. [source]

Lack of Agreement in Pediatric Emergency Department Discharge Diagnoses from Clinical and Administrative Data Sources

ACADEMIC EMERGENCY MEDICINE, Issue 7 2007
MSCE, Marc H. Gorelick MD
Background:Diagnosis information from existing data sources is used commonly for epidemiologic, administrative, and research purposes. The quality of such data for emergency department (ED) visits is unknown. Objectives:To determine the agreement on final diagnoses between two sources, electronic administrative sources and manually abstracted medical records, for pediatric ED visits, in a multicenter network. Methods:This was a cross sectional study at 19 EDs nationwide. The authors obtained data from two sources at each ED during a three-month period in 2003: administrative sources for all visits and abstracted records for randomly selected visits during ten days over the study period. Records were matched using unique identifiers and probabilistic linkage. The authors recorded up to three diagnoses from each abstracted medical record and up to ten for the administrative data source. Diagnoses were grouped into 104 groups using a modification of the Clinical Classification System. Results:A total of 8,860 abstracted records had at least one valid diagnosis code (with a total of 12,895 diagnoses) and were successfully matched to records in the administrative source. Overall, 67% (95% confidence interval = 66% to 68%) of diagnoses from the administrative and abstracted sources were within the same diagnosis group. Agreement varied by site, ranging from 54% to 77%. Agreement varied substantially by diagnosis group; there was no difference by method of linkage. Clustering clinically similar diagnosis groups improved agreement between administrative and abstracted data sources. Conclusions:ED diagnoses retrieved from electronic administrative sources and manual chart review frequently disagree, even if similar diagnosis codes are grouped. Agreement varies by institution and by diagnosis. Further work is needed to improve the accuracy of diagnosis coding; development of a grouping system specific to pediatric emergency care may be beneficial. [source]

Barriers to Metered-dose Inhaler/spacer Use in Canadian Pediatric Emergency Departments: A National Survey

ACADEMIC EMERGENCY MEDICINE, Issue 11 2007
Martin H. Osmond MDCM
Background Metered-dose inhalers and spacers (MDI+S) are at least as effective as nebulizers for treating children with mild to moderate asthma exacerbations. Despite advantages in terms of efficacy, side effects, and ease of use, MDI+S are not used in many North American pediatric emergency departments (PEDs). Objectives To survey emergency physicians, emergency nurses, and respirologists in Canadian pediatric teaching hospitals regarding their practices, beliefs, and barriers to change with respect to bronchodilator delivery. Methods This was a cross-sectional, mailed survey of all emergency physicians, all respirologists, and a random sample of emergency nurses at ten Canadian PEDs. Results A total of 291 of 349 health care professionals (83%) responded. Twenty-one percent of emergency physicians use MDI+S in the PED (largely concentrated at two "user sites"). A majority at nonuser sites, and virtually all professionals at user sites, responded that MDI+S are at least as effective as nebulizers, switching to MDI+S is justified by existing research, patient outcomes would be equal or better, and they have the required knowledge and skills to use MDI+S in the emergency department. The largest perceived barriers to MDI+S implementation include concerns regarding safety and costs, related to feasibility of providing and sterilizing spacers, and parental expectations for nebulizers. Other barriers included staff beliefs regarding the effectiveness of MDI+S, changes in nursing workload, and lack of a physician champion for change. Conclusions MDI+S are infrequently used to treat patients with acute asthma in Canadian PEDs, despite the fact that most emergency staff believe they are effective. Important barriers to using MDI+S have been identified in this study and should be used to guide future implementation strategies. [source]

Procedural Pain Management Patterns in Academic Pediatric Emergency Departments

ACADEMIC EMERGENCY MEDICINE, Issue 5 2007
Rishi Bhargava MD
ObjectivesTo describe the current state of the art for pain and sedation management for five common pediatric emergency department (ED) procedure scenarios. MethodsFellowship directors of U.S. EDs with a pediatric emergency medicine fellowship training program were surveyed by mail and asked to choose the one most commonly used pain or sedation management option for five clinical scenarios: facial laceration repair, cranial computed tomography in a toddler, closed fracture reduction, neonatal lumbar puncture, and intravenous catheter insertion. Results were analyzed by using descriptive statistics, and the differences between high and low volume departments were compared by using a chi-square test. ResultsThirty-eight of 51 fellowship programs responded (75%). The majority of respondents were fellowship directors (76%). Topical anesthetics were most commonly reported as used for a simple facial laceration (84%), whereas ketamine sedation was most popular for fracture reduction (86%). Pain management for the other scenarios was more variable. More than half of the respondents (53%) would not sedate at all for cranial computed tomography, and only 38% reported use of pharmacologic pain management for intravenous catheter insertion. The majority (74%) reported use of anesthetic (topical or injected local) for neonatal lumbar puncture. High volume departments were more likely to use pain management for intravenous catheter insertions. ConclusionsPain and sedation management methods for pediatric procedures continue to evolve. Despite gains, there is still room for improvement, particularly regarding intravenous catheter insertions. [source]

Cutaneous Community-associated Methicillin-resistant Staphylococcus aureus among All Skin and Soft-tissue Infections in Two Geographically Distant Pediatric Emergency Departments

ACADEMIC EMERGENCY MEDICINE, Issue 1 2007
Molly B. Hasty MD
Abstract Objectives To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California. Methods Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0,686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities. Results Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA,positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensitivities at both institutions were similar. Conclusions The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings. [source]

Effect of Point-of-care Influenza Testing on Management of Febrile Children

ACADEMIC EMERGENCY MEDICINE, Issue 12 2006
Srikant B. Iyer MD
Abstract Objectives To determine the effect of point-of-care testing (POCT) for influenza on the physician management of febrile children who are at risk for serious bacterial illness (SBI) on the basis of age and temperature and who are presenting to a pediatric emergency department (ED) during an influenza outbreak. Methods Patients 2,3 months of age with temperature of ,38°C and patients 3,24 months of age with temperature of ,39°C who were presenting to a pediatric ED during an influenza outbreak were enrolled into a prospective, quasi-randomized, controlled trial. Influenza testing was performed on enrolled patients by either the POCT or the standard-testing (ST) methods. The two groups were compared in terms of laboratory testing, chest radiography, antibiotic use, visit-associated costs, pediatric ED lengths of stay, inpatient admission, and return visits to the pediatric ED. Similar analyses also were performed on the resulting subgroups of patients on the basis of method of testing (POCT or ST) and test result (positive or negative). Results Of 767 eligible patients, 700 (91%) completed the study. No significant differences were demonstrated between the POCT and ST groups with respect to laboratory tests ordered, chest radiographs obtained, antibiotic administration, inpatient admission, return visits to the pediatric ED, lengths of stay, or visit-associated costs. In the subgroup analysis, the adjusted odds ratios (ORs) for blood culture in influenza test,positive to ,negative patients were 0.59 and 0.71 in the POCT and ST groups, respectively (p = 0.088). The adjusted ORs for urine culture in influenza test,positive to ,negative patients were 0.46 and 0.67 in the POCT and ST groups, respectively (p = 0.005). Conclusions When using a strategy of performing influenza testing on all patients at risk for SBI who presented to a pediatric ED during an influenza outbreak, the method of testing (POCT or ST) did not appear to significantly alter physician management, cost, or length of stay in the pediatric ED. However, if the interaction of the method of testing and the test result (positive or negative) were considered, a positive POCT for influenza was associated with a significant reduction in orders for urinalyses and urine cultures. [source]

Emergency Department Treatment of Viral Gastritis Using Intravenous Ondansetron or Dexamethasone in Children

ACADEMIC EMERGENCY MEDICINE, Issue 10 2006
Christine M. Stork PharmD
Abstract Objectives To compare the efficacy of intravenous ondansetron or dexamethasone compared with intravenous fluid therapy alone in children presenting to the emergency department with refractory vomiting from viral gastritis who had failed attempts at oral hydration. Methods This double-blind, randomized, controlled trial was performed in a tertiary care pediatric emergency department. Children aged 6 months to 12 years presenting with more than three episodes of vomiting in the past 24 hours, mild/moderate dehydration, and failed oral hydration were included. Patients with other medical causes were excluded. Subjects were randomized to dexamethasone 1 mg/kg (15 mg maximum), ondansetron 0.15 mg/kg, or placebo (normal saline [NS], 10 mL). All subjects also received intravenous NS at 10,20 mL/kg/hr. Oral fluid tolerance was evaluated at two and four hours. Those not tolerating oral fluids at four hours were admitted. Discharged patients were evaluated at 24 and 72 hours for vomiting and repeat health care visits. The primary study outcome was hospitalization rates between the groups. Data were analyzed using chi-square test, Kruskal,Wallis test, Mantel,Haenszel test, and analysis of variance, with p < 0.05 considered significant. Results A total of 166 subjects were enrolled; data for analysis were available for 44 NS-treated patients, 46 ondansetron-treated patients, and 47 dexamethasone-treated patients. Hospital admission occurred in nine patients (20.5%) receiving placebo (NS alone), two patients (4.4%) receiving ondansetron, and seven patients (14.9%) receiving dexamethasone, with ondansetron significantly different from placebo (p = 0.02). Similarly, at two hours, more ondansetron-treated patients (39 [86.6%]) tolerated oral hydration than NS-treated patients (29 [67.4%]; relative risk, 1.28; 95% confidence interval = 1.02 to 1.68). There were no differences in number of mean episodes of vomiting or repeat visits to health care at 24 and 72 hours in the ondansetron, dexamethasone, or NS groups. Conclusions In children with dehydration secondary to vomiting from acute viral gastritis, ondansetron with intravenous rehydration improves tolerance of oral fluids after two hours and reduces the hospital admission rate when compared with intravenous rehydration with or without dexamethasone. [source]

A System for Grouping Presenting Complaints: The Pediatric Emergency Reason for Visit Clusters

ACADEMIC EMERGENCY MEDICINE, Issue 8 2005
MSCE, Marc H. Gorelick MD
Abstract Objectives: To develop a set of chief complaint groupings for pediatric emergency department (ED) visits that is comprehensive, parsimonious, clinically sensible, and evidence-based. Methods: Investigators derived candidate chief complaint clusters and ranked them a priori into three perceived severity categories. Pediatric visits were extracted from the National Hospital Ambulatory Medical Care Survey (NHAMCS); data for years 1998 and 2000 (n= 13,186) were used for derivation and data for year 1999 (n= 5,365) were used for validation. Visits were assigned to clusters based on the recorded complaints; clusters were combined to ensure adequate numbers for analysis (minimum n= 20), and the clusters were reviewed for clinical sensibility. Resource utilization was categorized in three levels: routine (examination only), ED treatment (tests or therapy in the ED but not admitted), and admission. Area under the receiver-operating characteristic (ROC) curve (AUC) was used to demonstrate the discriminative ability of the clusters in predicting resource use. Results: There were 463 unique complaints in the derivation database; 95 (20%) had a single associated visit. Fifty-two clusters were generated; only 2.4% of complaints were classified as other. The eight most common clusters encompassed 52% of the visits. The top five were fever (11%), extremity pain/injury, vomiting, cough, and trauma (unspecified). Complaint clusters were associated with actual resource utilization: for routine care, the AUC was 0.73 (0.74 in the validation set), and for admission, the AUC was 0.77 (0.74 in the validation set). Both resource utilization and triage classification increased with increased expert severity ranking (test for trend, p < 0.001). Conclusions: The proposed Pediatric Emergency Reason for Visit Cluster (PERC) system is a comprehensive yet parsimonious, clinically sensible means of categorizing pediatric ED complaints. The PERC system's association with measures of acuity and resource utilization makes it a potentially useful tool in epidemiologic and health services research. [source]

Influenza A in Young Children with Suspected Respiratory Syncytial Virus Infection

ACADEMIC EMERGENCY MEDICINE, Issue 12 2003
Marla J. Friedman DO
Objectives: To determine the prevalence of influenza A in young children suspected of having respiratory syncytial virus (RSV) infection and to compare the clinical presentation of these patients with those who have proven RSV infection. Methods: Children younger than or at 36 months of age who presented to a pediatric emergency department (ED) with suspected RSV infection during the influenza A season of 2001,2002 were eligible. Eligible children had an RSV antigen test ordered as part of their initial clinical management. A consecutive sample of children was enrolled for prospective observational analysis. The main outcome measure was the prevalence of influenza A in young children with suspected RSV infection. The secondary outcome measure was a comparison of the clinical presentations, of the two groups. Results: During the study period, 420 patients presented for evaluation of respiratory illness. RSV tests were ordered on 251 patients. Of 197 eligible patients, 124 (63%) tested positive for RSV and 33 (17%) for influenza A. Influenza A patients were more likely to have temperatures at or above 39°C than RSV patients (36% vs. 15%; p = 0.01). RSV patients were more tachypneic (54 vs. 43 breaths/minute; p < 0.0001) and more often had wheezing (90% vs. 8%; p < 0.0001). Twenty influenza patients (61%) were hospitalized. Conclusions: This study found a high prevalence of influenza A in young children suspected of having RSV infection. Clinicians should consider influenza A in young febrile children presenting with respiratory illnesses. [source]

Utilization of the Ottawa Ankle Rules by Nurses in a Pediatric Emergency Department

Improving Child Protection in the Emergency Department: A Systematic Review of Professional Interventions for Health Care Providers

ACADEMIC EMERGENCY MEDICINE, Issue 2 2010
Amanda S. Newton PhD
Abstract Objectives:, This systematic review evaluated the effectiveness of professional and organizational interventions aimed at improving medical processes, such as documentation or clinical assessments by health care providers, in the care of pediatric emergency department (ED) patients where abuse was suspected. Methods:, A search of electronic databases, references, key journals, and conference proceedings was conducted and primary authors were contacted. Studies whose purpose was to evaluate a strategy aimed at improving ED clinical care of suspected abuse were included. Study methodologic quality was assessed by two independent reviewers. One reviewer extracted the data, and a second checked for completeness and accuracy. Results:, Six studies met the inclusion criteria: one randomized controlled trial (RCT), one quasi-RCT, and four observational studies. Study quality ranged from modest (observational studies) to good (trials). Variation in study interventions and outcomes limited between-study comparisons. The quasi-RCT supported self-instructional education kits as a means to improve physician knowledge for both physical abuse (mean ± standard deviation [SD] pretest score = 13.12 ± 2.36; mean ± SD posttest score = 18.16 ± 1.64) and sexual abuse (mean ± SD pretest score = 10.81 ± 3.20; mean ± SD posttest score = 18.45 ± 1.79). Modest-quality observational studies evaluated reminder systems for physician documentation with similar results across studies. Compared to standard practice, chart checklists paired with an educational program increased physician consideration of nonaccidental burns in burn cases (59% increase), documentation of time of injury (36% increase), and documentation of consistency (53% increase) and compatibility (55% increase) of reported histories. Decisional flow charts for suspected physical abuse also increased documentation of nonaccidental physical injury (69.5% increase; p < 0.0001) and had a similar significant effect as checklists on increasing documentation of history consistency and compatibility (69.5 and 70.0% increases, respectively; p < 0.0001) when compared to standard practice. No improvements were noted in these studies for documentation of consultations or current status with child protective services. The introduction of a specialized team and crisis center to standardize practice had little effect on physician documentation, but did increase documentation of child protective services involvement (22.7% increase; p < 0.005) and discharge status (23.7% increase; p < 0.02). Referral to social services increased in one study following the introduction of a chart checklist (8.6% increase; p = 0.018). A recently conducted multisite RCT did not support observational findings, reporting no significant effect of educational sessions and/or a chart checklist on ED practices. Conclusions:, The small number of studies identified in this review highlights the need for future quality studies that address care of a vulnerable clinical population. While moderate-quality observational studies suggest that education and reminder systems increase clinical knowledge and documentation, these findings are not supported by a multisite randomized trial. The limited theoretical base for conceptualizing change in health care providers and the influence of the ED environment on clinical practice are limitations to this current evidence base. ACADEMIC EMERGENCY MEDICINE 2010; 17:117,125 © 2010 by the Society for Academic Emergency Medicine [source]

Emergency Management of Pediatric Skin and Soft Tissue Infections in the Community-associated Methicillin-resistant Staphylococcus aureus Era

ACADEMIC EMERGENCY MEDICINE, Issue 2 2010
Rakesh D. Mistry MD
Abstract Objectives:, Skin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections. Methods:, This was a cross-sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list-serv. Enrollment occurred via the list-serv over a 3-month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed. Results:, In total, 366 of 606 (60.3%) list-serv members responded. The mean (± standard deviation [SD]) duration of practice was 13.6 (±7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim-sulfa (27.0%), and first-generation cephalosporins (22.7%); methicillin-sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA-MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim-sulfamethoxazole (TMP-Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA-MRSA,inactive agents. All PEPs suspected CA-MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA-MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA-MRSA prevalence for even common infections. Conclusions:, Practice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated. ACADEMIC EMERGENCY MEDICINE 2010; 17:187,193 © 2010 by the Society for Academic Emergency Medicine [source]

The Implementation of Intranasal Fentanyl for Children in a Mixed Adult and Pediatric Emergency Department Reduces Time to Analgesic Administration

Detection of Maternal Alcohol Use Problems in the Pediatric Emergency Department

The Significance of Marijuana Use Among Alcohol-using Adolescent Emergency Department Patients

ACADEMIC EMERGENCY MEDICINE, Issue 1 2010
Thomas H. Chun MD
Abstract Objectives:, The objective was to determine if adolescents presenting to a pediatric emergency department (PED) for an alcohol-related event requiring medical care differ in terms of substance use, behavioral and mental health problems, peer relationships, and parental monitoring based on their history of marijuana use. Methods:, This was a cross-sectional comparison of adolescents 13,17 years old, with evidence of recent alcohol use, presenting to a PED with a self-reported history of marijuana use. Assessment tools included the Adolescent Drinking Inventory, Adolescent Drinking Questionnaire, Young Adult Drinking and Driving Questionnaire, Center for Epidemiologic Studies Depression Scale, Behavioral Assessment System for Children, and Peer Substance Use and Tolerance of Substance Use Scale. Results:, Compared to adolescents using alcohol only (AO), adolescents who use alcohol and marijuana (A+M) have higher rates of smoking (F = 23.62) and binge drinking (F = 11.56), consume more drinks per sitting (F = 9.03), have more externalizing behavior problems (F = 12.53), and report both greater peer tolerance of substance use (F = 12.99) and lower parental monitoring (F = 7.12). Conclusions:, Adolescents who use A+M report greater substance use and more risk factors for substance abuse than AO-using adolescents. Screening for a history of marijuana use may be important when treating adolescents presenting with an alcohol-related event. A+M co-use may identify a high-risk population, which may have important implications for ED clinicians in the care of these patients, providing parental guidance, and planning follow-up care. ACADEMIC EMERGENCY MEDICINE 2010; 17:63,71 © 2010 by the Society for Academic Emergency Medicine [source]

Serious Bacterial Infection in Recently Immunized Young Febrile Infants

ACADEMIC EMERGENCY MEDICINE, Issue 12 2009
Margaret Wolff MD
Abstract Objective:, The objective of this study was to investigate the prevalence of serious bacterial infection (SBI) in febrile infants without a source aged 6,12 weeks who have received immunizations in the preceding 72 hours. Methods:, The authors conducted a medical record review of infants aged 6,12 weeks with a fever of ,38.0°C presenting to the pediatric emergency department (ED) over 88 months. Infants were classified either as having received immunizations within the 72 hours preceding the ED visit (recent immunization [RI]) or as not having received immunizations during this time period (no recent immunization [NRI]). Primary outcome of an SBI was based on culture results; only patients with a minimum of blood and urine cultures were studied. Results:, A total of 1,978 febrile infants were studied, of whom 213 (10.8%) had received RIs. The overall prevalence of definite SBI was 6.6% (95% confidence interval [CI] = 5.5 to 7.7). The prevalence of definite SBI in NRI infants was 7.0% (95% CI = 5.9 to 8.3) compared to 2.8% (95% CI = 0.6 to 5.1) in the RI infants. The prevalence of definite SBI in febrile infants vaccinated in the preceding 24 hours decreased to 0.6% (95% CI = 0 to 1.9). The prevalence of definite SBI in febrile infants vaccinated greater than 24 hours prior to presentation was 8.9% (95 CI = 1.5 to 16.4). The relative risk of SBI with RI was 0.41 (95% CI = 0.19 to 0.90). All SBIs in the RI infants were urinary tract infections (UTI). Conclusions:, Among febrile infants, the prevalence of SBI is less in the initial 24 hours following immunizations. However, there is still a substantial risk of UTI. Therefore, urine testing should be considered in febrile infants who present within 24 hours of immunization. Infants who present greater than 24 hours after immunizations with fever should be managed similarly to infants without RIs. [source]

Post dural puncture headache in a pediatric patient with idiopathic intracranial hypertension

PEDIATRIC ANESTHESIA, Issue 9 2005
OLUBUKOLA O. NAFIU MD FRCA
Summary We describe the occurrence of postdural puncture headache (PPDH) in an adolescent with idiopathic intracranial hypertension (IIH) and its successful management with an epidural blood patch. PPDH is a very rare occurrence in patients with intracranial hypertension and is described as a paradoxical situation in the literature. There are only two previous case reports (in adults) of the possible association. A 15-year-old obese patient with a diagnosis of IIH had an uneventful diagnostic spinal tap using a 22G Quincke needle in the pediatric emergency department but returned 24 h later with PPDH. After a failed trial of conservative management, she had an uneventful but curative epidural blood patch with 15 ml of autologous venous blood and was able to return to school the day after the blood patch. Follow-up review by her neuro-ophthalmologist shows resolution of her headaches, considerable improvement in her visual field defect and resolution of papilledema. This is the first report of PPDH and its successful management with an epidural blood patch in a pediatric patient with IIH. [source]