Efficacy of the Shotblocker in Reducing Pain Associated with Intramuscular Injections
Lisa Drago, Brigitte Baumann, April Douglass-Bright, Maame Yaa Yiadom, Akwasi Amponsah and Sabina Singh
UMDNJ-RWJMS at CAMDEN, St. Christopher's Hospital for Children, Drexel University College of Medicine
Objectives
To determine the efficacy of the Shotblocker (SB) in reducing pain associated with intramuscular (IM) injections in children.
Methods
A prospective randomized controlled trial was conducted October 2005–November 2006. A convenience sample of children aged 2 months to 17 years who presented to the emergency department or an outpatient clinic for an IM injection were randomized to either the conventional care (CC) group (standard IM injection without pain relief) or the SB group. The SB is a plastic disk that surrounds the injection site and stimulates the skin via multiple blunt contact points, theoretically blocking the flow of pain signals to the brain. A standardized data form recorded demographic data, injection types and site, and perceived pain scores using a 6 point Likert-type scale (parents and nurses) and the validated Wong-Baker FACES pain scale for children 36 months. Child pain assessments were transformed to numerical data (smiling = 0, sobbing = 6). Chi-square and Student's t test were used for the analysis.
Results
A total of 185 children were screened and 165 children were enrolled with 56% male, and a mean age of 45 months (95% CI = 36 to 53). The majority (92%) required a routine immunization, 4% a tetanus booster for an acute injury, and 4% a rabies immunization. The mean number of injections received by each child was 1.7. There were no differences in baseline characteristics between groups. Perceived pain scores by nurses were higher for the CC group 2.6 (95% CI = 2.3 to 2.9) vs. 1.8 (95% CI = 1.5 to 2.1), p < 0.001 as well as by parents: 2.6 (95% CI = 2.2 to 3) vs. 2.1 (95% CI = 1.7 to 2.4) p = 0.04. Children aged 36 months (n = 64) did not report a difference in pain scores using transformed Wong Baker pain scores 1.5 (95% CI = 0.8 to 2.1) (CC) vs. 1.3 (95% CI = 0.8 to 1.8) (SB), p = 0.6.
Conclusions
The SB appears to influence parental and nurse assessments of pediatric pain, but these differences were not maintained when children were assessed.
Is Parental Weight Estimation More Accurate Than Other Weight Estimation Methods for Children?
Kevin Nguyen, David Krieser, Debra Kerr, Damien Jolley, Megan Clooney and Anne-Maree Kelly
The University of Melbourne, Sunshine Hospital, Joseph Epstein Centre for Emergency Medicine Research at Western Health, Monash University
Objectives
Several different pediatric weight estimation methods have been described for use when direct weight measurement is not possible. They include the APLS formula, the UK-derived Argall formula, the Broselow tape and the Australian-derived ‘Best Guess’ formulae. A potential alternative is parental estimate. Our objective was to compare the various weight estimation methods and parental estimate to measured weight.
Methods
This prospective observational study was conducted in the Emergency Department of Sunshine Hospital, Australia. Children aged 1–11 years who presented to the ED between August 18, 2005 and February 25, 2006 were eligible for inclusion. Data collected included height, age, ethnicity, parent estimate of weight and measured weight. The outcome of interest was agreement between estimated weight and measured weight for each method. Data was analyzed by descriptive statistics and performance of each weight estimation method was compared using mean difference [MD], root mean square error [RMSE] and agreement within 10%.
Results
A total of 410 cases were included in this study. The median age was 4 years, there were more boys (54.4%) and the majority of cases were of White ethnicity (74.9%). The mean BMI of the sample was 17 kg/m2 and mean actual weight was 21.2 kg. Performance of the methods are shown in the Table. Parent estimate was the most accurate with 78% of parent estimates within 10% of measured weight. Parent estimates were consistently accurate across weight and age groups.
Conclusions
Parental estimation of weight is more accurate than all the weight estimation methods studied. When this is not available, the Broselow tape is the most accurate alternative method.
Accuracy of the Landmark and Palpation Techniques for Pediatric Femoral Vein Identification
James Woodson, Vivek Tayal, Manoj Pariyadath, Stephen Leathers and H. Norton
Carolinas Medical Center
Objectives
We hypothesized that the landmark and palpation technique to identify the femoral vein in comparison to sonographically identified femoral vein in non-critically ill pediatric patients would be inaccurate.
Methods
Prospective observational cohort study of pediatric femoral vein localization using palpation and traditional landmarks compared to ultrasound-identified femoral vein in pediatric patients less than 16 years old in the ED. Exclusion criteria included patients with infections overlying the femoral veins or those with major pelvic/femoral trauma within the past 3 months. Demographic information included age, gender, weight, height, and BMI. In each patient, the landmark and palpation technique were measured by a PGY3 EM resident or EM attending. Successful approximation was defined as a measurement within the diameter of femoral vein as measured by ultrasound.
Results
Thirty (30) patients were enrolled with a mean age of 4.2 yrs (SD 3.9 yrs, range 2 months-12.9 yrs) with mean BMI status of 20.1 kg/m2 (SD 4.2 range 14.0-32.7 kg/m2). The average femoral vein diameter was 6.9 mm (SD 2.0 range 3.2-10.6 mm) as measured by ultrasound. The palpation method was within the ultrasound measured diameter in (14/30) 46.6% of patients. The landmarks method was within the ultrasound measured diameter in (9/30) 30.0% of patients. The palpation approximation was outside the diameter vein in 16 patients with an average distance outside vein of 3.5 mm (95% CI = of 2.1 mm to 4.9 mm, median of 2.8 mm, SD 2.9 mm). The landmark approximation was outside the diameter of the vein in 21 patients with an average distance outside vein of 6.6 mm (95% CI = of 4.7 mm to 8.5 mm, median of 5.7 mm, SD 1.9 mm).
Conclusions
Based on an ultrasound-identified femoral vein as a standard, pediatric femoral vein localization with palpation and landmark techniques suffers from inaccuracy. The palpation method was within the diameter more often than the landmarks method and with smaller average error.
Efficacy and Impact of Intravenous Morphine before Surgical Consult in Children with Right Lower Quadrant Pain Suggestive of Appendicitis: A Randomized Controlled Trial
Benoit Bailey, Sylvie Bergeron, Jocelyn Gravel, Jean-François Bussières and Arie Bensoussan
CHU Ste-Justine
Background
The evidence supporting the use of analgesia in children with abdominal pain suggestive of appendicitis is limited.
Methods
All children between the age of 8 and 18 years presenting to a pediatric emergency department with a significant right lower quadrant abdominal pain and a presumptive diagnosis of appendicitis were eligible to be enrolled in a randomized double-blind placebo controlled trial the initial pain was at least 5/10 on a verbal numeric scale. Patients received either 0.1 mg/kg of morphine (maximum 5 mg) or placebo. The primary outcomes were: 1) the difference in pain using a visual analog scale at baseline and 30 minutes after the completion of the intervention, and 2) the time delay between arrival in the emergency department and the final surgical decision (surgery or discharge from surgery care).
Results
Ninety patients with a suspected diagnosis of appendicitis were randomized to received morphine or placebo. Of these, 58/87 (67%) had a final diagnosis of appendicitis. Both groups were similar in terms of demographic, history, physical findings, probability of appendicitis, and initial pain score. There was no difference in the decrease of pain between the morphine and placebo groups: 24 ± 23 mm and 20 ± 18 mm, respectively (D 4 mm [95% CI = –5 to 12]). There was also no difference in the time delay between arrival in the emergency department and the surgical decision: median of 269 minutes (95% CI = 240 to 355) for morphine, and of 307 minutes (95% CI = 239 to 415) for placebo (D –34 minutes [95% CI = 105 to 40]).
Conclusions
The use of morphine in children with right lower quadrant abdominal pain with a presumptive diagnosis of appendicitis did not delay the surgical decision. In our group of patients, however, morphine was not more effective than placebo in diminishing their pain.
Comparison of Four Pain Scales in Children with Acute Abdominal Pain in a Pediatric Emergency Department
Benoit Bailey, Sylvie Bergeron, Jocelyn Gravel and Raoul Daoust
CHU Ste-Justine, Hôpital du Sacré-Coeur
Background
Pain documentation is becoming more and more frequent in the emergency department. In children, many pain scales may be used. However, their interchangeability, especially in the evaluation of acute pain, is not well known. The objective of our study was to evaluate the agreements between the visual analog scale (VAS), the standardized color analog scale (CAS), the Wong-Baker Faces Pain Rating Scale (WBFPS), and a verbal numeric scale (VNS) in children with acute abdominal pain suggestive of appendicitis in a pediatric emergency department (PED).
Methods
Participants were children aged 8 to 18 years old presenting to a PED with abdominal pain suggestive of appendicitis recruited to participate in a randomized controlled trial evaluating the efficacy of morphine. Patients were initially asked to grade their pain on a plasticized CAS, a paper VAS, a paper WBFPS, and then with a VNS. Thirty minutes after morphine or placebo administration, the same assessment was repeated. All scales were then converted to a 0 to 100 mm; agreements between scores were evaluated using the intraclass correlation (ric) and the Bland-Altman method.
Results
A total of 87 children were included in the study, 58 of them with confirmed appendicitis. All pain scales were correlated between each other (ric between 0.88 and 0.97, p < 0.001). However, except for the VAS/CAS comparison, the limits of agreement between each other were all more than our a priori limit of acceptability of ±20 mm: VAS/CAS-18.6, 14.4; VAS/WBFPS-20.1, 33.7; VAS/VNS -30.2, 20.8; CAS/WBFPS -18.5, 36.3; CAS/VNS 26.9, 22.1; WBFPS/VNS -38.7, 15.7. Also, the measurements differed by more than 20 mm in more than 10% of the patients for all the scales comparison except for VAS/CAS.
Conclusions
Our study suggests that only the results from the VAS and the CAS are interchangeable in children with acute abdominal pain suggestive of appendicitis. In particular, the VNS is not interchangeable with the other evaluated scales.
Characteristics of Children with Headache Two Weeks after a Minor Head Injury
Benoit Bailey, Martin Osmond, Terry Klassen, Ian Stiell and Rhonda Correll
CHU Ste-Justine, University of Ottawa, University of Alberta
Objectives
To characterize the children that complain of headache two weeks after a minor head injury.
Methods
This prospective cohort study was part of the Canadian Assessment of Tomography for Childhood Head injury (CATCH) study which was conducted in 10 Canadian pediatric teaching hospitals in 2001-2005 and included consecutive children (0–16 years) who presented with a Glasgow Coma Scale (GCS) score of 13-15 and documented loss of consciousness, amnesia, disorientation, persistent vomiting, or irritability (children <2 years). Chi-square or Student's t-test was performed for each variable that could be associated with headache. Odd ratios (OR) and their 95% confidence interval are presented.
Results
A total of 3880 children were included. Of these, 3,132 (81%) were followed-up at 2 weeks. Of the 2,845 children for whom headache could be assessed, 158 (5.6%) had headache at 2 weeks: 120 mild, 33 moderate, and 5 severe. CT scan was performed in 90 (57%) children. The patients with headache were older than the ones without: 11.6 ± 3.4 vs. 9.8 ± 4.3 years (D 1.8, 95% CI = 1.1 to 2.5). Other variables associated with headache at 2 weeks include: mechanism of injury (involved motorized vehicle) (OR 2.1 [1.4, 3.2]), history of disorientation/confusion (OR 1.5 [1.1, 2.2]), amnesia of the event (OR 1.6 [1.1, 2.2]), initial GCS <15 (OR 2.0 [1.3, 3.2]), brain injury on CT scan (OR 2.4 [1.3, 4.3]), and hospital admission (OR 2.2 [1.4, 3.3]). Furthermore, patients with headache at 2 weeks were less likely to have returned to normal activities (OR 0.12 [0.08, 0.19]) and more likely to have memory loss or concentration problems (OR 15.6 [9.2, 26.5]) and to have seen a physician after their initial discharge (OR 2.6 [1.8, 3.5]).
Conclusions
Headache is relatively uncommon in children 2 weeks after a minor head injury. However, these children are less likely to have returned to normal activities and more likely to have memory loss or concentration problems and to have required a second medical visit.
Safety of the Modification of the Triage Level for Children 6 to 36 Months Old with Fever
Jocelyn Gravel and Sergio Manzano
Hôpital Sainte-Justine
Introduction
The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) was implemented in Canadian emergency departments (ED) in 2001. An item of the PaedCTAS stipulates that patients aged between 3 and 36 months with fever must be triaged as urgent. To maximize resources use, a modification has been applied in our institution since 2001. The protocol stipulates that children 6 to 36 months old with fever and no sign of toxicity could be triaged as semi-urgent.
Objectives
Evaluate whether children 6 to 36 months old with fever but no sign of toxicity and triaged as semi-urgent behave as the other patients triaged semi-urgent.
Methods
A retrospective cohort study evaluating all patients triaged in an urban tertiary pediatric hospital during a 6 month period was performed. Data were retrieved from the ED database (Staturg from Statdev). Hospitalization rate was compared for 4 groups: 1. children aged 3 to 36 months with fever triaged urgent, 2. children aged 3 to 36 months with fever triaged non-urgent (following the protocol), 3. all the patients triaged urgent, and 4. all the patients triaged semi-urgent.
Results
During the study period, there were 36,285 visits at the ED and 3,477 visits for children aged 3 to 36 months with fever. Of these, the nurses triaged 1,322 (38%) patients as urgent and 1,869 (54%) patients as semi-urgent. The proportion of hospitalization for children aged 3 to 36 months with fever triaged urgent was similar to the proportion of all the patients triaged urgent (13.1% vs. 13.4%) while the proportion of hospitalization for children aged 3 to 36 months with fever triaged semi-urgent was similar to the one of all the patients triaged semi-urgent (2.3% vs. 2.0%). No patients downgraded as semi-urgent were admitted to the intensive care unit.
Conclusions
Patients aged 6 to 36 months with fever and no sign of toxicity can be triaged as semi-urgent safely. This would modify the triage level of approximately 5% of the population visiting a pediatric ED.
CT Scan with IV Contrast Alone for Evaluation of Pediatric Appendicitis
Madelyn Garcia, George Drugas, Lynn Babcock-Cimpello, Jeff Bazarian, Erik Rueckman, Luann Teschmacher and Sohug Mookerjee
University of Rochester
Numerous CT protocols are used to diagnose pediatric appendicitis. A protocol using IV contrast alone (CT IV) examined whether elimination of PO contrast impacted CT diagnostic performance and time to imaging.
Objectives
1) Determine the performance of CT IV for diagnosing appendicitis in clinically equivocal cases. 2) Prospectively compare the performance of CT IV among radiologists of different training levels (attendings vs. residents). 3) Determine time saved in the ED by the elimination of oral contrast.
Methods
ED patients (3-18 years) with indeterminate abdominal pain were prospectively enrolled and imaged. CT interpretations were either appendicitis or no appendicitis/indeterminate. Final diagnoses were confirmed by pathology or phone follow-up. Test performance characteristics were determined and inter-observer agreement was calculated using kappa statistic. Study power was 89% to detect a 15% difference in sensitivity between readers ( = 0.05). Time to CT was compared to a retrospective cohort imaged using CT with IV and oral contrast.
Results
250 patients were enrolled (122 male, 128 female), mean age 12.7 years (range, 3.1-18.9). The incidence of appendicitis was 30.0% with a negative appendectomy rate of 13.8%. There was no significant difference between resident and attending performance: sensitivity (83% vs. 79), specificity (96% vs. 90%) and accuracy (92% vs. 90%). Resident and attending agreement on CT interpretation was high: weighted kappa = 0.72. Attendings read 26.8% of the scans as indeterminate compared to 17.8% for residents, with a NPV of 93% and 90% respectively. Mean time to CT was 4 hours, 0 minutes vs. 5 hours, 36 minutes for CT using oral and IV contrast (p < 0.0001).
Conclusions
CT IV is diagnostically reliable for excluding appendicitis in equivocal cases. CT IV saves over 1.5 hours per patient and performs well, independent of reader experience level, making it aptly suited for busy emergency departments.
Does Respiratory Rate, Height of Fever, or Oxygen Saturation Predict Pneumonia in Febrile Infants?
Leslie Simon, Keri Carstairs, Jackie Jones, Sherri Rudinsky and David Tanen
Naval Medical Center San Diego
Objectives
Determine the predictive value of respiratory rate (RR), temperature (Temp), oxygen saturation (O2 Sat) and initial Emergency Physician (EP) interpretation of chest radiograph (CXR) in febrile infants with pneumonia (PNA).
Methods
Chart review of a registry of febrile infants aged 24 months and younger presenting to the ED of a tertiary care military hospital between December 2002 and December 2003. Fever was defined as 100.4 for <3 months and 102.2 for 3-24 months.
Data abstracted: Age, Temp, RR, O2 Sat, and EP read of CXR. Final radiology review of the CXR was considered the gold standard for the dx of PNA. Four age groups were defined: 0-1 month, 1-3 months, 3-6 months, and 6-24 months. Mean Temp, RR and O2 Sat were compared using Student's t-tests.
Results
985 patients (55% male; Median Age: 12 m, 25/75 IQR: 8 m, 17 m) met entry criteria. 790 received CXR and 82 were diagnosed with PNA. Age distribution of PNA: 1 (1.2%) 0-1 month, 1 (1.2%) 1-3 months, 7 (8.5%) 3-6 months, and 73 (89%) 6-24 months. Comparing infants with PNA vs. those without PNA, no significant difference was detected in regards to age (13.9 ± 6.6 vs. 12.2 ± 6.3, p = 0.15), Temp (103.2 ± 1.2 vs. 103.3 ± 1.1, p = 0.96) or RR (37 ± 10 vs. 36 ± 11, p = 0.36). O2 Sat was found to be statistically different between groups (96.6% ± 2.5 vs. 97.7% ± 1.8, p < 0.001). Infants who did not undergo CXR demonstrated similar age, Temp, RR, and O2 Sat characteristics. Interestingly, 32 (37%) of the CXR read by radiologists as PNA were read as normal by EPs; 109 (15.4%) CXR read as normal by radiologist were read as PNA by EPs yielding a sensitivity for EP reads of 61% (95% CI = 50% to 71%) and specificity of 85% (95% CI = 82% to 87%).
Conclusions
Although O2 Sat was found to be lower in febrile infants with PNA, the difference does not appear clinically significant. RR and Temp were not found to be predictive of PNA in febrile infants. EPs differ significantly from radiologists in the interpretation of CXR in febrile infants.
Post-discharge Adverse Behavioral Events in Children Receiving Fentanyl/Midazolam Versus Ketamine in a Pediatric ED
Alisa McQueen, Robert Wright and Baruch Krauss
Children's Hospital and Harvard Medical School
Objectives
Compare post-discharge adverse behavioral events of three sedation regimens: ketamine with and without midazolam and fentanyl/midazolam (F/M).
Methods
Prospective observational study of post-discharge events with ketamine, ketamine/midazolam (K/M) or F/M in a pediatric ED. Families were contacted within 2 weeks of discharge and administered a validated 27-item Post-Hospital Behavior Questionnaire (PHBQ). PHBQ scores indicate more reported adverse behaviors. We used linear and logistic regression to model PHBQ scores and logistic regression to model vomiting risk. PHBQ scores were divided to quintiles and the highest quintile compared to the lower 4 quintiles. Age, procedure, length of procedure, and gender were entered as independent variables to adjust for confounding.
Results
A total of 480 children were enrolled and 447 children (mean age 7.3 ± 4.5 yrs) received sedation and were successfully contacted. 83 received F/M, 286 ketamine without midazolam, and 78 K/M. In the unadjusted analysis, there were no differences in PHBQ score among the F/M group (2.3 ± 3.3) the K/M group (2.0 ± 2.7) or ketamine alone group (2.4 ± 3.9) by one way ANOVA. In the regression models, higher PHBQ summary scores were not associated with receiving F/M (beta = 0.6, p = 0.4; logistic model OR 2.6, 95% CI = 0.9 to 7.4) or ketamine alone (beta = 0.4, p = 0.5; logistic model OR 1.6, 95% CI = 0.7 to 3.9) when using K/M as the referent group. Higher total doses of ketamine (beta = 0.6, p = 0.025) or fentanyl (beta = 1.3, p < 0.0001) were associated with increased PHBQ scores. The use of ketamine without midazolam was associated with an increased risk of vomiting (OR 1.8, 95% CI = 1.01 to 3.1).
Conclusions
There were no differences in behavioral scores between F/M and ketamine. Higher total doses of ketamine or fentanyl were associated with increased adverse behavioral scores. The use of ketamine alone, without midazolam, was associated with an increased risk of vomiting post-discharge.
Clinical Predictors of Lyme Disease Among Pediatric Patients with Acute Monoarticular Arthritis
Amy Thompson and Richard Bachur
Children's Hospital Boston
Background
The diagnosis of Lyme arthritis requires serology results that are not available during an ED visit. Physicians must discriminate Lyme arthritis from septic or reactive arthritis to make treatment decisions.
Objectives
1. Define clinical characteristics of patients with acute monoarticular arthritis in a Lyme endemic area. 2. Identify clinical predictors of Lyme arthritis.
Methods
Retrospective study of patients aged <18 years presenting to an ED in Massachusetts over 7 years. Patients who had joint aspirations and Lyme serologies were identified. Lyme arthritis (LA) was defined by positive serology and negative joint culture. Septic arthritis (SA) was defined by 1) a pathogen from joint fluid or 2) bacteremia with >20,000 cells/ml. Patients with negative cultures and Lyme serology were considered reactive arthritis (RA).
Results
162 patients were studied with a median age of 6.5 yrs (IQR 4.4,10.7). 61 (38%) patients had LA, 15 (9%) had SA. See table on the following page.
Temp, WBC, ANC, WBC in joint fluid, and %PMNs in joint fluid are not useful in discriminating LA from SA. History of fever, ESR and CRP distinguish LA from SA; Fever history Odds Ratio (OR) 8.3 (95% CI = 1.7 to 50), ESR >60 OR 4.4 (1.3, 14), and CRP >10 OR 6.7 (1.6, 28). Combination of all 3 variables OR 30 (3,300).
Conclusions
Lyme arthritis shares clinical features of both septic and reactive arthritis. Comparing septic to Lyme arthritis, a combination of fever history, ESR >60 and CRP >10 defines a high risk group for septic arthritis.
What is the Impact of Advanced Life Support on the Management and Outcomes of Out-of-hospital Seizures in Children?
Martin Osmond, Ian Stiell, Lisa Nesbitt, Catherine Clement, Starla Campbell, Douglas Munkley, Lori Luinstra-Toohey, Justin Maloney, George Wells and Study Group
University of Ottawa, Greater Niagara General Hospital
Objectives
The Ontario Out-of-hospital Advanced Life Support (OPALS) Study is designed to evaluate EMS interventions for critically ill patients. The OPALS Pediatric Study tested the impact on children with out-of-hospital seizures of adding a full ALS program to existing BLS-D EMS systems.
Methods
This multicenter before-after controlled clinical trial was conducted in 17 communities and enrolled all children (<16 years old) with out-of-hospital generalized seizures who were seizing during EMS attendance during the 36-month BLS-D phase and the subsequent 36-month ALS phase. Paramedics were fully trained to ALS standards including endotracheal intubation and administration of IV drugs. Chi-square and Student's t-test analyses were performed.
Results
There were 417 children enrolled during the BLS-D (N = 183) and ALS (N = 234) phases. The groups were well matched for gender (52.5% male) but the BLS group was younger (mean age 4.2 vs. 5.6 years), had more febrile seizures (35.5% vs. 22.2%; p = 0.02) and less chronic non-febrile seizures (39.3% vs. 49.6%; p = 0.02). During the ALS phase, intubation was attempted for 5 children with 40% success; IV access was attempted for 123 (52.6%) children with 65% success; and anticonvulsants were given to 124 (53.0%) children (rectal diazepam 33.8%; IV diazepam 19.2%). No anticonvulsants were used during the BLS-D phase. From the BLS-D to the ALS phase, there was a decrease in number of patients still seizing on arrival to the ED (44.8% vs. 32.1, p = 0.008) and an increase in the use of bag valve mask ventilation (6.7% vs. 19.2%, p = 0.0002). There was no difference in any other outcome including hospital discharge (98.9% vs. 99.1%; p = 0.85), hospital admission (45.0% vs. 42.2%; p = 0.59), or ICU admission (16.9% vs. 11.6%; p = 0.34).
Conclusions
This first controlled trial to evaluate full ALS programs for out-of-hospital seizures in children shows a substantial number of children receiving out-of-hospital anticonvulsants and fewer children still seizing on arrival to the ED.
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An Assessment of Knowledge, and Beliefs of Pediatric Emergency Nurses Towards the use of Metered-dose Inhaler and Spacer (MDI+S) for the Treatment of Acute Asthma Before and 12 Months after a Practice Change
Martin Osmond, Dale Dalgleish, Kathryn Lawson, Tracy MacDonald, Tammy Clifford, Isabelle Gaboury, Rhonda Correll and Carrol Pitters
University of Ottawa
Objectives
To understand the knowledge, and beliefs of pediatric emergency nurses (ENs) towards the use of MDI+S instead of nebulizers (NEBS) for the treatment of acute mild-to-moderate asthma in the ED before and 12 months after a practice change.
Methods
We conducted a cross-sectional, standardized survey of all pediatric ENs in a tertiary care pediatric ED before (PRE-survey) and 12 months after (POST-survey) a change from NEBs to MDI+S for the treatment of all children with a mild to moderate asthma exacerbation in the ED. A modified version of Dillman's Survey Method was used. Analysis was performed using McNemar tests for categorical variables and Wilcoxin signed rank tests for ordinal variables.
Results
The response rate was 84.5% (49/58) PRE survey and 76.2% (48/63) POST survey with 30 ENs completing both a PRE and POST survey. Only 4% reported significant ED use of MDI+S in the PRE survey vs. 97.8% in the POST. Compared with the PRE survey ENs reported the following statistically significant changes in the POST survey: parents are less satisfied upon switching from NEBS to MDI+S (PRE = 28% vs. POST = 44%; p = 0.04); there are fewer side effects with MDI+S compared with NEBS (PRE = 10% vs. POST = 47%; p = 0.005); and treatment with MDI+S takes more nursing time than NEBS (PRE = 65%, POST = 89%; p = 0.04). On the POST survey, 66% felt parents were disappointed in the switch to MDI+S, however, 63% felt that the ED stay was not prolonged with MDI+S, 77% felt MDI+S was easier for young children to use and 93% felt that the chance to observe and use MDI+S in the ED would benefit the patients at home.
Conclusions
After 12 months of using MDI+S in the ED, many ENs believe that this technique takes more nursing time, and that parents are disappointed with the change. However, they also report less side effects, easier administration of medication in young children, and educational benefits. This information should help inform other EDs considering a change in practice.
Effect of Having Children in the Household of Adult Emergency Department Smokers: Motivation to Quit
Angela Mills, Karin Rhodes, Christopher Follansbee, Frances Shofer, Melanie Prusakowski and Steven Bernstein
University of Pennsylvania, Montefiore Medical Center
Objectives
Environmental tobacco smoke (ETS) is a leading cause of morbidity for children. We hypothesized that adult parenting smokers in the ED have a higher interest in quitting than adult smokers without children and may be more amenable to tobacco cessation counseling.
Methods
A cross-sectional study of adult smokers in 8 US academic EDs. Structured data collection included demographics, clinical information, number of smokers and children, household rules around smoking, and tobacco-related assessment tools. Standard comparative statistics were performed.
Results
A total of 1168 smokers were enrolled, of whom 441 (37.8%) had at least one child (range 1-11 children) in their household for a total of 973 children. Compared to smokers without household children, smokers with household children were younger (mean age 37.4 vs. 42.8 years), more female (58.5% vs. 39.3%), more nonwhite (44.3% vs. 27.5%), and less uninsured (25.5% vs. 36.5%) (all p < 0.006). The two groups did not differ in level of nicotine addiction (median Fagerstrom Test for Nicotine Dependence score 4 vs. 4, p = 0.31). Smokers with children were slightly more interested in quitting (mean Ladder of Contemplation score 4.8 vs. 5.1, p = 0.02). Using 10-point rating scales known as the Importance, Readiness, and Confidence Rulers, smokers with household children felt it was more important to quit smoking than smokers without (median scores 9 vs. 8, p = 0.01), and felt more confident in their ability to quit (median scores 7 vs. 6, p = 0.004), but did not feel more ready (median scores 7 vs. 6, p = 0.23). Of note, 45% of smokers with children did not allow smoking inside the home, vs. 30% of smokers without children (p < 0.001).
Conclusions
Adult ED smokers with household children are interested in quitting and are taking steps to limit their children's ETS exposure. Asking adult ED smokers if there are children in the household may provide a means to enhance motivation to quit.
Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma
Marc Gorelick, Shireen Atabaki, John Hoyle, Peter Dayan, James Holmes, Richard Holubkov, David Monroe, James Callahan and Nathan Kuppermann
Medical College of Wisconsin, Children's National Medical Center, deVos Children's Hospital, Morgan Stanley Children's Hospital of New York, UC Davis School of Medicine, University of Utah, Howard County General Hospital, Children's Hospital of Philadelphia
Objectives
To determine the interobserver agreement in the assessment of historical and physical examination findings of children undergoing emergency department (ED) evaluation for blunt head trauma.
Methods
Prospective cohort study of children under 18 years evaluated for blunt head trauma at one of 25 EDs in PECARN. Patients were excluded if injury occurred >24 hours prior to evaluation, if neuroimaging was obtained at another hospital prior to evaluation, or if the patient had a clinically trivial mechanism of injury. Two attending or fellow emergency physicians (EP) independently completed a standardized clinical assessment on a templated data form. Assessments were performed within 60 minutes of each other, and prior to any neuroimaging (if obtained). Agreement between the two observers beyond that expected by chance was calculated for each clinical variable, using the kappa () statistic for categorical variables and weighted kappa for ordinal variables. Variables with a lower 95% confidence limit (LCL) for > 0.4 were considered to have acceptable agreement.
Results
1516 pairs of observations were obtained (dizziness, amnesia and headache were not assessed in up to 738 children considered pre- or non-verbal). Acceptable agreement was achieved in 21 of the 28 variables studied (75%). Mechanism of injury had = 0.87. For 10 subjective symptoms, ranged from 0.47 (dizziness) to 0.93 (presence of vomiting); only dizziness had 95% LCL < 0.4. Of the 17 physical exam findings, ranged from 0.18 (agitated) to 0.89 (GCS). 95% LCL for was <0.4 for bulging fontanelle, other signs of altered mental status, and quality of scalp hematoma if present.
Conclusions
Both subjective and objective clinical variables in children with blunt head trauma can be assessed by different observers with acceptable agreement, making these variables suitable candidates for clinical decision rules.
Blunt Head Trauma in the Pediatric Emergency Care Applied Research Network (PECARN)
Nathan Kuppermann, James Holmes, Peter Dayan, John Hoyle, Shireen Atabaki, J. Dean, Richard Holubkov and PECARN
University of California, Davis, Morgan Stanley Children's Hospital of N.Y., DeVos Children's Hospital, Children's National Medical Center, University of Utah, PECARN
Objectives
To describe the spectrum of head trauma in a pediatric emergency medicine network. For children with minor head trauma, we sought to derive a decision rule to identify patients at very low and high risk for traumatic brain injuries (TBI).
Methods
We prospectively enrolled children <18 years with blunt head trauma at 25 EDs in PECARN from 6/04 to 5/06. Patients with trivial mechanisms were excluded. Head CTs were obtained at the clinician's discretion. Clinical assessment was recorded onto a data form prior to CT results. Patients discharged home were contacted by phone, and medical records of hospitalized patients were reviewed. In patients with minor head trauma (i.e., GCS score 14-15), a decision rule is being developed (using recursive partitioning, with variables with a priori likelihood of association with TBI and with at least moderate interobserver agreement) to identify children at very low and high risk of TBI. Site monitoring and an independent data center insured data quality.
Results
Of 35,140 children enrolled, 62% were boys, and mean age was 6.6 years (SD 5.6). Common mechanisms of injury included falls (48.1%), occupant in motor vehicle crashes (9.1%), ran into stationary objects (8.5%), object struck head (8.4%), sports (7.3%), assaults (7.3%), pedestrians (3.3%) or bicyclists (1.2%) struck by automobiles, and bicycle crashes (3.5%). 96.8% had GCS of 14 (3.1%) or 15 (93.7%). The CTs were obtained in 36.8% (site-specific range: 9.7%-71.1%), and were positive in 11.2% (30% of these were isolated skull fractures). Neurosurgery was performed on 0.5%, and 0.1% died from TBI. For patients with GCS 14-15, a decision rule for TBI will be reported at the meeting.
Conclusions
Blunt head trauma is common in PECARN EDs. Patients are more commonly male, and falls are the dominant mechanism. Most patients have minor head trauma, and CT use is highly variable. A decision rule to identify patients at very low and high risk of TBI may result in more efficient CT use.
Bag-Valve-Mask Performance Limitations Due to Improper Setup and Use
James O'Neill, Charry Scott, Peter Wludyka and Robert Luten
University of Florida at Jacksonville, University of North Florida
Objectives
Pediatric bag-valve-masks (BVM) have potential performance issues when they are improperly set up and used. These performance issues are compounded when a child with high compliance lungs receives BVM ventilation. This study was designed to demonstrate the effects of improper setup and use in a simulated lung model of a cross-section of commonly used infant BVM devices.
Methods
Five commonly used BVMs were tested on an infant test lung. Pressure and volume measurements were recorded with the pediatric resuscitators under normal, middle and high lung compliances as would be found in various disease states. The four possible combinations of the pop-off valve and manometer port in the open and closed positions were tested. Breaths per minute and lung resistance were standardized. The resulting multifactor study consisted of n = 180 runs.
Results
SAS 9.1 was used to analyze the data. Total volume was significantly affected by manufacturer, manometer, rate, and compliance (p < 0.001 for each factor). Pressure was a significant co-variate (p < 0.0001). Popoff was not significant (p = 0.086). Across each of the different manufacturers, and independently of compliance, an open manometer port (improper setup) led to significant decreases in volume delivered. Total volume summary statistics (mean ± SD) for the four combinations of manometer and pop-off valve are ON:ON (94.4 ± 27.6), ON:OFF (77.1 ± 24.5), OFF:ON (53.3 ± 25.1), and OFF: OFF (50.3 ± 25.1). Using Tukey-Kramer comparisons all pair-wise differences except OFF:ON versus OFF:OFF were significantly different with 5% simultaneous level of significance; that is, the effect of popoff setting when manometer was OFF was not significant.
Conclusions
This study demonstrates the negative impact of an improperly set up BVM on the delivery of desired lung volumes. Details of BVM design and function and malfunction are discussed.
Middle and High School Students Education Regarding the Dangers of Anabolic Steroids
Jean Dymott, Heidi Suffoletto and John Leddy
State University of New York at Buffalo
Background
Anabolic steroid use by well-known professional athletes has occurred across a wide range of sports. Due to a significant amount of media attention to these athletes, student-athletes have been exposed to the idea that steroid use is prevalent among high-level athletes. At the time of this study, it is not clear if steroid side effects are known to these students.
Objectives
To assess middle and high school students' knowledge of the effects, both intended and unintended, of anabolic steroid use.
Methods
Athletic directors in 13 western New York middle and high schools distributed anonymous surveys to a sample of their students, both athletes and non-athletes, yielding 2,328 surveys eligible for analysis. One-page surveys included demographic information and two open-ended questions assessing knowledge of steroid side effects. All survey data was recorded using Microsoft Excel and analyzed by a statistician.
Results
Eighty-five percent say they have been made aware of risks of taking steroids, however only 79% could give any example on the open-ended question concerning risks. In addition, 48% gave only one risk in their answer. Thirty-three percent were unsure how likely these side effects were to occur. Self-reporting of having "tried" steroids was 0.7% for females and 3.3% for males, consistent with previous studies.
Conclusions
Our data suggest a minimal knowledge of steroid side effects among middle and high school-aged students. Our study is the first to use open-ended questions assessing steroid side effect knowledge. This provides new insight, as answer prompts are not used in the questions. Of the answers given, many were quite vague. From this study, we have learned that there is tremendous potential to educate student-athletes to the potential dangers of anabolic steroid use. Emergency medicine affords unique educational opportunities for the subspecialty of sports medicine during emergency department encounters with these students.
The Emergency Severity Index (Version 4): Reliability in Pediatric Patients
Yamini Durani, Deena Brecher, Daniel Walmsley, Magdy Attia and John Loiselle
Alfred I. duPont Hospital for Children
Background
The Emergency Severity Index version 4 (ESI vs.4) is a triage system, which has demonstrated reliability in adult populations, however it has not been extensively studied in pediatrics. This updated version of ESI is the first to include fever criteria specific to pediatric patients.
Objectives
The goal of this study is to measure the reliability of the ESI vs.4 in the pediatric population by comparing agreement rates between pediatric emergency (PEM) physicians and pediatric triage (PT) nurses.
Methods
In this prospective cohort study PEM physicians and PT nurses participated in an ESI vs. 4 standardized training session. Participants completed a survey consisting of 20 written pediatric case scenarios, which required them to assign a triage category to each case. Case scenarios and standardized responses were obtained from the ESI vs. 4 training materials. Agreement rates within each group compared to the standard response were measured and kappa statistic was calculated to determine intragroup and intergroup reliability.
Results
Ten physicians and 10 nurses completed the study, yielding 400 observations. The group had a mean of 11.2 (±7.8) years of experience in pediatrics and nurses had a mean of 6.7 (±9.5) years of experience in triage. On a likert scale only 5% of study participants were uncomfortable with ESI vs. 4 after training session. Sixty percent preferred ESI vs. 4 to our institution's current 4 level triage system. The agreement rates among physicians and nurses with the standardized responses to case scenarios were 86% and 84%, respectively. The kappa for physicians was 0.7 and for nurses was 0.6. Mean (±SD) scores for number of correct responses for PEM physicians and PT nurses was not significantly different (p = 0.55). The intergroup kappa was 0.71.
Conclusions
The ESI vs. 4 is a reliable tool for triage assessments in pediatric patients when utilized by experienced PT nurses. The ESI vs. 4 is a triage system with high agreement between physicians and nurses.
National Trends in ED Antibiotic Prescribing for Children with Acute Otitis Media 1996–2004
Thomas Fischer, Adam Singer, Christopher Lee and Henry Thode, Jr.
Stony Brook University
Objectives
Withholding antibiotics in non-toxic children with acute otitis media (AOM) is now recommended in order to reduce anti-bacterial resistance rates. Using the National Hospital Ambulatory Medical Care Survey (NHAMCS), we describe the national trends for prescribing antibiotics in children with AOM presenting to EDs in the US over the last decade. We hypothesized that the rates of prescribing antibiotics would decline over time.
Methods
Retrospective study of NHAMCS databases, a national sampling of ED visits, for the years 1996 through 2004 were used to identify trends in ED prescription of antibiotics to children ages 2-12 years with AOM. The National Drug Code Directory Drug Classes were used to identify type of antibiotic prescribed. Frequency and type of antibiotic prescription patterns over time were evaluated.
Results
There were 1.1 million and 0.8 million ED visits for AOM during the first and last years of the study. Children ages 2-12 accounted for about 40% of all ED visits for AOM, with another 40% in the <2 year age group and 20% in the greater than 12 years of age group. Fifty-four percent and 50% of the patients with AOM were prescribed antibiotics during the first and last year of the study. There was no significant change in the proportion prescribed antibiotics over time. The rates of use of antibiotics for AOM were similar in all three age groups. Types of antibiotic prescribed were similar over the study period; approximately 2/3 of the patients received prescriptions for penicillin and another 15% received erythromycins, and 12% cephalosporin.
Conclusions
There was no significant decrease in the percentage of children with AOM that were prescribed antibiotics in the ED between 1996 and 2004. There was also no change in the patterns of prescribing antibiotics.
Effect of Rapid Assessment Times on Length of Stay in a Pediatric Emergency Department
Usha Sethuraman, Nirupama Kannikeswaran, Prashant Mahajan, Mohsen Saidinejad, Elizabeth Duffy, Scott Compton, Shuli Yu and Stephen Knazik
Children's Hospital of Michigan, Wayne State University
Background
Prolonged wait times in the emergency department (ED) have been associated with patient dissatisfaction. To improve patient throughput time and satisfaction, a rapid patient assessment program called "29 minute" ED initiative was instituted at our Children's Hospital at the end of 2004, which guaranteed that the patient will be seen by a physician within 29 minutes of arrival to the ED.
Objectives
The main objective of this study was to evaluate the impact of this initiative on the total length of stay (LOS) in the ED as part of a pilot analysis.
Methods
Retrospective chart analysis of randomly selected visits (randomized to different ED times, days and seasons) before (2004) and after (2005) the initiative was conducted. We compared variables such as door to doctor time (time of first physician contact with the patient), LOS (both overall and adjusted for the different triage categories with triage 1 being most severe and triage 3 being least) and admission rates between the two groups. Means were compared using Student's t-tests while categorical variables were compared using chi-square tests.
Results
Data on 149 visits (2004) and 150 visits (2005) were compared. The door to doctor time was significantly reduced after institution of the program (0.46 ± 0.75 hrs (2005) vs. 0.89 ± 0.76 hrs (2004), CI = 0.26 to 0.61) but this reduction was significant only for triage category 3 (0.44 ± 0.56 hrs (2005) vs. 0.94 ± 0.70 hrs (2004), CI = 0.31 to 0.69). There was no change in LOS (2.19 ± 1.74 hrs (2005) vs. 2.57 ± 1.64 hrs (2004), CI = 0.0008 to 0.77). Admission rates were not affected after the program was initiated (11.5% (2005) vs.11.4% (2004), OR 1.01, CI = 0.49 to 2.0).
Conclusions
The rapid assessment time guarantee did not change the overall LOS in our ED. The impact of this program was mainly on the door to doctor time in lower acuity patients. Since the majority of our ED patients belong to triage category 3, we believe that this reduction in door to doctor time may improve patient satisfaction.
Bladder Ultrasound Increases Catheterization Success in Pediatric Patients
Brigitte Baumann, Kathryn McCans, Sarah Stahmer, Mary Leonard, Justine Shults and William Holmes
University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School at Camden, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, VA Medical Center
Objectives
To determine whether ultrasound-guided catheterization (USGC) by trained pediatric emergency department (ED) nurses improves the success rate of first-attempt transurethral bladder catheterization.
Methods
A prospective, randomized controlled trial was conducted in an urban pediatric ED. Children 36 months requiring diagnostic urine samples were randomized into one of two arms: conventional (non-imaged) catheterization (CC) versus USGC. Children were excluded if they were critically ill, had genitourinary abnormalities, an indwelling catheter, or were toilet trained. Catheterization was postponed in the CC group if there was evidence that the child had recently urinated and in the USGC group if the transverse bladder diameter was <2 cm. Demographic data, number of catheterizations required for success (2.5 cm3 urine), specimen adequacy, and collection times were recorded.
Results
Of the 93 enrolled subjects, the mean age was 9.6 months, 61% were female and the majority (80%) required a urine specimen for a fever/sepsis workup. Forty-five children underwent CC and 48 underwent USGC; there were no differences in baseline characteristics between groups. First-attempt success rates were highest in the ultrasound arm: 67% (CC) versus 92% (USGC), p = 0.003. Of the 19 failures, only one caregiver allowed a repeat catheterization (CC arm), which also failed. Correlation between sonographic bladder volume measurements and total urine volume was excellent (r = 0.76; p < 0.001). Both urinalysis and culture were less likely to be completed on specimens from the CC (91%) than from the USGC arm (100%), p = 0.04. Time to obtain urine in the CC group, however, was less than half that of the USGC arm (12 versus 28 minutes, respectively; p < 0.001).
Conclusions
Although there is a time delay in obtaining an adequate sample, USGCs by trained pediatric ED nurses generated a significant improvement over CC in first-attempt successes and in obtaining an adequate urine sample.
Multicenter Controlled Clinical Trial to Evaluate the Impact of Advanced Life Support on Children with Out-of-hospital Respiratory Distress
Martin Osmond, Ian Stiell, Lisa Nesbitt, Catherine Clement, Starla Campbell, Douglas Munkley, Lori Luinstra-Toohey, Justin Maloney, George Wells and Study Group
University of Ottawa, Greater Niagara General Hospital
Objectives
There is little published evidence regarding the optimal EMS management of pediatric respiratory distress. Our study evaluated the impact of advanced life support (ALS) EMS programs on pediatric respiratory patient outcomes.
Methods
This multicenter before-after controlled clinical trial was conducted in 17 communities as part of the Ontario Out-of-hospital Advanced Life Support (OPALS) Study, which evaluates the impact of EMS programs for multiple conditions. During the before phase, care was provided at the BLS-D level. During the after phase, ALS providers administered nebulized and IV drugs and performed endotracheal intubation. Data were collected from ambulance reports, centralized dispatch data, and in-hospital records. Chi-square and Student's t-test analyses were performed.
Results
The 1,257 patients enrolled during the two 24-month BLS and ALS phases were well matched for clinical and demographic features and had these characteristics: mean age 4.9 (0-15), male 56.1%, mean RR 31, chronic asthma 35.2%, chronic respiratory medications 34.5%. Bag valve mask ventilation was provided to 10 (1.6%) in the BLS phase and 9 (1.4%) in the ALS phase (p = 0.74). During the ALS phase, patients received these EMS interventions: nebulized salbutamol 39.6%, IV epinephrine 0.9%, intubation 1 (0.16%), IV access attempted 33 (5.1%), IV successful 24 (3.7%). There was no significant reduction from the BLS to the ALS phase in overall mortality (0.5% vs. 0.2%; p = 0.30) or admission to hospital (26.0% vs. 22.2%; p = 0.16). There was however a significant difference from the BLS to the ALS phase in admission to ICU (3.3% vs. 1.4%; p = 0.046).
Conclusions
This large controlled trial of children with respiratory distress shows that the addition of a system-wide EMS ALS program did not significantly improve patient survival or hospital admission but may decrease ICU admission. Few children transported with respiratory distress received assisted ventilation or advanced airway maneuvers.
Evaluation of a Rapid Nucleic Acid Hybridization Test in Detecting Group A Streptococcal Pharyngitis and Comparison to Throat Culture in a Pediatric Emergency Department
Caroline Ouellet, Benoit Bailey, Carole Scrivo and Céline Laferrière
CHU Ste-Justine
Background
The sensitivity of rapid antigen detection test based on latex agglutination or ELISA varies and may be poor in some cases. Newer rapid streptococcal tests using nucleic acid hybridization appear promising.
Objectives
To compare the validity of the Gen-Probe Group A Streptococcus Direct Test (GADST) to the throat culture in detecting Group A streptococcal pharyngitis in a pediatric emergency department (PED).
Methods
Children (<18 years) presenting to the PED of a tertiary care hospital were eligible to be included in the study if a throat culture was deemed clinically required for pharyngitis from 03/05 to 07/05 and from 10/05 to 06/06. Two throat swabs were collected simultaneously; one for culture and the other for GADST. In case of discrepancy, a Todd-Hewitt broth was performed and the result of this was considered the accurate result. Sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR–) and their 95% confidence interval were calculated.
Results
A total of 399 children aged 6.3 ± 5.0 years were included. Clinical symptoms and signs were: sore throat (73%), fever (65%), exudate (33%), adenopathy (51%), and absence of cough (50%). The rate of positive throat culture was 39%. For all children, Sn of GADST in our study was 92% (87, 96); Sp 75% (69, 80); PPV 71% (64, 77); NPV 94% (89, 96); LR+ 3.71 (2.97, 4.64) and LR– 0.10 (0.06, 0.18). After distribution of discordant results, the Sn of the GADST was 99% (96, 99), Sp 83% (78, 88), PPV 81% (75, 86), NPV 99.5% (95% CI = 97.0 to 99.9), LR+ 6.04 (4.48, 8.15), and LR– 0.008 (0.001, 0.055).
Conclusions
GADST in our study did not perform as well as anticipated. The numbers of false positives preclude us to recommend its use instead of the throat culture within our population. This confirms the need to evaluate the performance of a new diagnostic test in one's setting before adopting it.
Cosmetic Outcomes of Absorbable Versus Nonabsorbable Sutures in Pediatric Facial Lacerations
Raemma Luck, Robert Flood, Dalit Eyal, John Saludades and John Gaughan
Temple University Children's Medical Center, Temple University School of Medicine
Objectives
Recent studies, mostly in adults, suggest that lacerations repaired with absorbable and non-absorbable sutures have similar cosmetic outcomes. We sought to compare the long-term cosmetic outcomes of absorbable versus non-absorbable sutures for facial lacerations in children using a non-inferiority design; and to compare the complication rates and parental satisfaction between the two suture groups.
Methods
Healthy patients, 1-18 years in age, presenting to a pediatric ED with facial lacerations, 1-5 cm in length, were randomized to repair using fast-absorbing catgut (FAC) or Nylon (NYL) suture. Patients were excluded if the laceration could be repaired with a tissue adhesive, had irregular boarders, caused by mammalian bites, were significantly contaminated, or were >8 hours old. Patients were followed up at 5-7 days and at 3 months. Three blinded observers, using a previously validated cosmetic Visual Analogue Scale (VAS) with <15 mm considered to be the minimal clinically important difference (MCID), rated photographs taken of the wound at 3 months. Parents also rated the wound using the VAS and completed a satisfaction survey.
Results
Of the 88 patients initially enrolled, 47 patients completed the study: 23 in the FAC and 24 in the NYL. There were no significant differences in patient demographics and wound characteristics in the two groups. The observers' mean VAS for FAC was 92.3 (CI = 89.1 to 95.4) and for NYL was 93.7 (CI = 91.4 to 96.0), with a mean difference of 1.4 (CI = –5.31 to 8.15), less than the MCID of 15 mm. Mean Parental VAS score for FAC was 86.3 (CI = 78.4 to 94.1) and for NYL was 91.2 (CI = 86.9 to 95.4), with a mean difference of 4.9 (CI = 2.41 to 7.41). There were no significant differences in the rates of infection, wound dehiscence, keloid formation, and parental satisfaction.
Conclusions
Use of FAC may be a viable alternative to non-absorbable suture in the repair of facial lacerations in children and may obviate the need for a second visit for suture removal.
Sonographic Evaluation of Positioning for Lumbar Puncture in Infants
Beth Cadigan, Robert Jones, Rita Cydulka and Sandra Werner
Albany Medical Center, Metrohealth
Objectives
Tight flexed positioning during lumbar puncture has been observed to compromise the respiratory status of infants. We used ultrasound to investigate whether the flexing of infants is anatomically necessary for the performance of lumbar puncture, and whether the standard flexed recumbent position significantly widened the space between the lumbar spinous processes.
Methods
This was a prospective controlled study. A convenience sample of twenty-one healthy infants under a month of age were scanned in two positions (prone in a spine neutral position, and lateral recumbent with their knees bent into their chest and their neck flexed). In each position a 5-10 MHz linear array transducer was used to scan midline along the lumbar spinous processes in the sagittal plane. The distance between the spinous processes were then measured near the ligamentum flavum using the ultrasound machine's electronic calipers.
Results
In the spine neutral position the distance between the lumbar spinous processes was wide enough to accommodate a 22-gauge spinal needle (diameter 0.072 cm) for all interspaces. Results show that mean lumbar interspinous space widths increased significantly with flexed positioning p < 0.0001 for all interspace. The L5-S1 interspace was only measured in 17 subjects due to difficulty in obtaining clear measurements at this level with the edges of the spinous processes being poorly defined.
Caregiver and Healthcare Provider Satisfaction with Ultrasound-Guided Pediatric Bladder Catheterization
Brigitte Baumann, Kathryn McCans, Sarah Stahmer, Mary Leonard, Justine Shults and William Holmes
UMDNJ-RWJMS at Camden, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia VA Medical Center
Background
Conventional (non-imaged) bladder catheterization has lower first attempt success rates (67-72%) when compared to ultrasound (US)-guided catheterization (92-100%), yet US-guided catheterization takes nearly twice as long.
Objectives
Given the advantage and disadvantages of these two methods, we assessed caregiver and healthcare provider perceptions of and satisfaction with conventional and US-guided bladder catheterization performed in a pediatric ED.
Methods
Caregivers and healthcare providers of children enrolled in a prospective, randomized controlled trial examining the success rates of conventional versus US-guided catheterization completed standardized questionnaires. Each child's caregiver, nurse and physician noted their perceptions of the procedure as well as their satisfaction and future preferences using a 7 point Likert scale. Chi 2 and t tests were used.
Results
Of the 93 caregivers, 45 had children randomized to the conventional arm and 48 to the US arm. Nine physicians and 3 nurses participated, with a total response rate of 100%. Both caregiver groups had similar previous catheterization experience; none had children who had previous US-guided catheterization(s). Conventional group caregivers rated their children's discomfort higher than those of the US group (4.4 vs. 3.4) p = 0.02, and were less satisfied than those of the US group (4.5 vs. 6.4) p < 0.001. Nurses' satisfaction with catheterization in the conventional group was lower than in the US group (3.0 vs. 5.5) as were physicians (4.3 vs. 5.7) p < 0.001. Nurses were less likely to use conventional catheterization in future attempts (2.7 vs. 5.5) as were physicians (2.5 vs. 6.0) p < 0.001.
Conclusions
Conventional group caregivers noted higher mean child discomfort scores than the ultrasound group caregivers. Both caregivers and healthcare providers expressed greater satisfaction with ultrasound and were more likely to prefer this imaging modality with future catheterization attempts.
Inter-rater Reliability of Transcutaneous Doppler Ultrasound Measurements of Cardiac Output and Stroke Volume in the Pediatric Emergency Department
Gail Stewart, H. Bryant Nguyen, Tommy Kim, Joshua Jauregui, Sean Hayes, Stephen Corbett and William Wittlake
Loma Linda University Medical Center
Introduction
Cardiac output (CO) and stroke volume (SV) are often measured in children using transthoracic echocardiography. As the role for early, aggressive fluid resuscitation in pediatric shock expands; a more practical means of measuring cardiac function in the ED would be attractive.
Objectives
To evaluate the inter-rater reliability of a transcutaneous Doppler ultrasound (TDUS) technique to measure CO and SV in pediatric ED patients.
Methods
An 8-month prospective observational study was conducted on a convenience sample of patients <18 years old (range 2 weeks to 17 years), presenting to the pediatric ED. Six raters were trained to use the TDUS (USCOM Ltd, Australia). 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 (97) patients were enrolled with mean age 9.7 ± 5.2 years. Major diagnostic categories included infection (22%), trauma (20%) and gastrointestinal disorder (17%). The range in CO was 0.9-11.0 L/min, SV was 5.1-152.0 mL/min2. There was significant correlation between two rater measurements of CO (r2 = 0.69, 95% confidence intervals of 0.76-0.89, p < 0.0001) and SV (r2 = 0.80, 95% confidence intervals of 0.85-0.93, p < 0.0001). Bland-Altman analysis of CO measurements between two raters showed bias of -0.05, SD of bias = 1.18, and 95% limits of agreement -2.37 to 2.27 L/min. SV showed bias of 10.78, SD of bias 14.41, and 95% limits of agreement -27.46 to 29.01 mL/min2. The mean difference in CO and SV between raters was 16.44 ± 17.82 and 16.13 ± 13.44 percent, respectively.
Conclusions
TDUS demonstrates acceptable inter-rater agreement in measuring CO and SV in children. Further studies are warranted to evaluate its clinical utility in hemodynamic monitoring of the critically ill pediatric ED patients.
Lyme Disease as a Cause of Aseptic Meningitis in Children in a Lyme-Endemic Region
Maia Rutman, Aris Garro, Kari Simonsen, Jenifer Jaeger and Gregory Lockhart
Brown Medical School
Background
Lyme disease (LD) is the most common tick-borne infection in the USA, with an incidence in Rhode Island that is 10 times the national average. Meningitis is often the first recognized manifestation of LD and is difficult to distinguish from viral meningitis, yet requires treatment with IV antibiotics. Currently, the percentage of children presenting with aseptic meningitis due to LD is unknown.
Objectives
To prospectively study CSF antibody evidence of LD in children with aseptic meningitis.
Methods
Children aged 2-18 years presenting to a tertiary pediatric hospital in RI with signs of meningitis between 4/1/06 and 10/31/06 were prospectively enrolled. Subjects were eligible if CSF had 7 WBCs/µL. Subjects were excluded for antibiotic use within 14 days or bacteria on CSF Gram stain. After informed consent, results of CSF Lyme EIA, Western blot (WB) and/or PCR sent on remaining CSF were recorded. Subjects were divided into two groups: Cohort 1 included patients with clinical correlates of LD (erythema migrans and/or cranial neuropathy), Cohort 2 included those without signs of LD.
Results
67 children met inclusion criteria. 36 were enrolled (Cohort 1, n = 10; Cohort 2, n = 26), 10 were excluded for prior antibiotic use, and 21 were missed.
Conclusions
This is the first prospectively studied cohort of pediatric patients with Lyme meningitis. Clinicians should consider testing for LD in children presenting with aseptic meningitis in Lyme-endemic regions.
