Emergency Medicine

Goods for Guns--the use of a gun buyback as an injury prevention/community education tool

Margaret McGuire et al. — Tue, 10 Apr 2012 11:22:17 PDT

BACKGROUND: US children aged between 5 years and 14 years have a rate of gun-related homicide 17 times higher and a rate of gun-related suicide and unintentional firearm injury 10 times higher than other developed countries. Gun buyback programs have been criticized as ineffective interventions in decreasing violence. The Injury Free Coalition for Kids-Worcester (IFCK-W) Goods for Guns buyback is a multipronged approach to address these concerns and to reduce the number of firearms in the community.

METHODS: The IFCK-W buyback program is funded by corporate sponsors, grants, and individual donations. Citizens are instructed to transport guns, ammunition, and weapons safely to police headquarters on two Saturdays in December. Participants are guaranteed anonymity by the District Attorney's office and receive gift certificates for operable guns. Trained volunteers administer an anonymous survey to willing participants. Individuals who disclose having unsafely stored guns remaining at home receive educational counseling and trigger locks. Guns and ammunition are destroyed at a later time in a gun crushing ceremony.

RESULTS: Since 2002, 1,861 guns (444 rifle/shotgun, 738 pistol/revolver, and 679 automatic/semiautomatic) have been collected at a cost of $99,250 (average, $53/gun). Seven hundred ten people have surrendered firearms, 534 surveys have been administered, and ≈ 75 trigger locks have been distributed per year.

CONCLUSIONS: IFCK-W Goods for Guns is a relatively inexpensive injury prevention model program that removes unwanted firearms from homes, raises community awareness about gun safety, and provides high-risk individuals with trigger locks and educational counseling.

Sickle Cell Disease

Barbara M. Walsh — Fri, 16 Mar 2012 07:47:11 PDT

Pediatric Respiratory Emergencies : Upper Airway Obstruction and Infections

Mariann M. Manno — Fri, 09 Mar 2012 13:36:02 PST

Respiratory distress from upper airway obstruction is an unusual but potentially catastrophic emergency in young children. It may be caused by a number of different processes, alone or in combination, including an acute infectious process, a congenital anomaly, or a foreign body in the airway or esophagus. A working knowledge of the anomalies and diseases of the upper airway is of primary importance in pediatric emergency medicine. Classification of airway pathology can be based on the anatomic location, the patient's age, the urgency of the symptoms, and whether it is a congenital or acquired lesion or an infectious or noninfectious process. The starting point for any classification is an appreciation of the unique aspects of pediatric airway anatomy.

Injury and Violence

Daniel J. Rogers et al. — Fri, 09 Mar 2012 13:36:01 PST

Injury is the leading cause of death for persons 1–44 years and the 4th leading cause of death overall. Regardless of whether intentional or unintentional, injury is both predictable and preventable.

Being a Child in the Midst of Terrorism

Richard V. Aghababian et al. — Fri, 09 Mar 2012 13:36:00 PST

Terrorism—a planned, often politically motivated event designed to kill many innocent victims and inflict physical pain, psychological suffering, and fear on an entire community—is new to our Western culture, but not to children worldwide. Terrorism, violence, and disaster have involved children in the form of naturally occurring events; transportation accidents; exposure to war; social, ethnic and religious conflict; and as collateral damage in adult mass casualty incidents. Throughout childhood and adolescence, children are physically less capable and emotionally more vulnerable to the effects of terrorism. This fact may make children likely primary targets for terrorism in the future. Children are unique from the perspective of their anatomy, physiology, emotional development, and response to specific physical and psychological insults. These unique needs of children have rarely been considered in disaster planning. Civilian emergency physicians and Emergency Medical Services (EMS) systems have learned about mass casualty incidents through military models, focused on the needs of adult victims; consequently, they have limited personal clinical experience with pediatric disaster medicine. A terrorist attack with predominately pediatric casualties would have a tremendous and far-reaching impact on all child survivors, family members, and the community at large. All facets of the EMS system must be aware of this potential and be prepared to meet the special and divergent needs of children in the setting of a chemical, biological, radiation, or explosive event that involves large numbers of children. A paradigm shift that deals with unaddressed issues of treatment, equipment, triage, and training is a critical step in preparing to address the needs of children in the midst of terrorism.

Glowing in the dark: time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children

Andrew T. Burr et al. — Fri, 09 Mar 2012 12:24:40 PST

BACKGROUND/PURPOSE: Although ultrasound is often the preferred pediatric imaging study, many institutions lack ultrasound access at night; and computerized tomography (CT) becomes the only radiological method available for evaluation of appendicitis in children. The purpose of this study was to characterize patterns of daytime and nighttime use of ultrasound or CT for evaluation of pediatric appendicitis and to measure consequent differences in radiation exposure and cost.

METHODS: A retrospective chart review of patients evaluated for appendicitis from October 2004 to October 2009 (N = 535) was performed to evaluate daytime and nighttime use of ultrasound and CT for pediatric patients.

RESULTS: Average age was 10.2 years (range, 3-17 years). During the day, 6 times as many ultrasounds were performed as CTs (230 vs 35). At night, half as many ultrasounds were performed (50 vs 110). Average radiation dose per child during the day was significantly lower than at night (day, 0.52 mSv per patient; night, 2.75 mSv per patient). Average radiology costs were lower for daytime patients ($2491.06 day vs $4045.00 night; P < .05).

CONCLUSIONS: Dependence on CT at night results in higher average radiation exposure and cost. Twenty-four-hour ultrasound availability would decrease radiation exposure and cost of evaluation of children presenting with appendicitis.

Detection of occult pneumonia in a pediatric emergency department

Sonal Shah et al. — Fri, 09 Mar 2012 12:24:38 PST

BACKGROUND: Many children undergo chest radiography (CXR) in their evaluation of a febrile illness. Pneumonia without signs of respiratory distress or ausculatory findings has been previously described (termed occult pneumonia [OP]).

OBJECTIVE: The objectives of this study were to determine the incidence of OP among children who have CXR performed and to identify clinical predictors of OP.

METHODS: A prospective observational study of children undergoing CXR for possible pneumonia was conducted. Standardized data forms were completed before the CXR. Univariate analysis and recursive partitioning were used to identify predictors of OP.

RESULTS: Of 1866 patients enrolled, 308 had no evidence of respiratory distress or lower respiratory tract findings and were studied for OP. Twenty-one patients had radiographic OP (6.8%; 95% confidence interval [CI], 4.0%-10.6%). Age, height of fever, duration or quality of cough, and pulse oximetry were not associated with OP. A decision rule based on fever for 1 day or longer or with a combination of fever for less than 1 day but worsening cough identifies patients at greater risk for OP (likelihood ratio, 1.47; 95% CI, 1.21-1.77). No patient with fever for less than 1 day and without any cough or without worsening cough had pneumonia (likelihood ratio, 0.40; 95% CI, 0.19-0.84).

CONCLUSIONS: Occult pneumonia was identified in 1 of 15 patients undergoing CXR without respiratory distress or ausculatory findings. Obtaining a CXR for the detection of OP in children without cough and with fever for less than 1 day in duration should be discouraged.

Clinical predictors of pneumonia among children with wheezing

Bonnie L. Mathews et al. — Fri, 09 Mar 2012 12:24:37 PST

OBJECTIVE:

The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting.

METHODS:

A prospective cohort study was performed with children

RESULTS:

A total of 526 patients met the inclusion criteria; the median age was 1.9 years (interquartile range: 0.7-4.5 years), and 36% were hospitalized. A history of wheezing was present for 247 patients (47%). Twenty-six patients (4.9% [95% confidence interval [CI]: 3.3-7.3]) had radiographic pneumonia. History of fever at home (positive likelihood ratio [LR]: 1.39 [95% CI: 1.13-1.70]), history of abdominal pain (positive LR: 2.85 [95% CI: 1.08-7.54]), triage temperature of >or=38 degrees C (positive LR: 2.03 [95% CI: 1.34-3.07]), maximal temperature in the ED of >or=38 degrees C (positive LR: 1.92 [95% CI: 1.48-2.49]), and triage oxygen saturation of <92% (positive LR: 3.06 [95% CI: 1.15-8.16]) were associated with increased risk of pneumonia. Among afebrile children (temperature of <38 degrees C) with wheezing, the rate of pneumonia was very low (2.2% [95% CI: 1.0-4.7]).

CONCLUSIONS:

Radiographic pneumonia among children with wheezing is uncommon. Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged.

Effect of trainees on length of stay in the pediatric emergency department

Catherine A. James et al. — Fri, 09 Mar 2012 12:24:36 PST

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.

A prospective evaluation of the 1-hour decision point for admission versus discharge in acute asthma

Mark M. Wilson et al. — Fri, 09 Mar 2012 12:24:34 PST

Study objectives were to evaluate the 1-hour decision point for discharge or admission for acute asthma; to compare this decision point to the admission recommendations of the Expert Panel Report 2 (EPR-2) guidelines; to develop a model for predicting need for admission in acute asthma. The design used was a prospective preinterventional and postinterventional comparison. The setting was a university hospital emergency department. Participants included 50 patients seeking care for acute asthma. Patients received standard therapy and were randomized to receive albuterol by nebulizer or metered-dose inhaler with spacer every 20 minutes up to 2 hours. Symptoms, physical examination, spirometry, pulsus paradoxus, medication use, and outcome were evaluated. Based on clinical judgment, the attending physician decided to admit or discharge after 1 hour of therapy. Outcome was compared to the EPR-2 guidelines. Post hoc statistical analyses examined predictors of the need for admission from which a prediction model was developed. Maximal accuracy of the admit versus discharge decision occurred at 1 hour of therapy. Using FEV(1) alone as an outcome predictor yielded suboptimal performance. FEV(1) at 1 hour plus ability to lie flat without dyspnea were the best indicators of response and outcome. A model predictive of the need for admission was developed. It performed better (P =.0054) than the admission algorithm of the EPR-2 guidelines. The decision to admit or discharge acute asthmatics from the ED can be made at 1 hour of therapy. No absolute value of peak flow or FEV(1) reliably predicts need for hospital admission. The EPR-2 guideline thresholds for admission are barely adequate as outcome predictors. A clinical model is proposed that may allow more accurate outcome prediction.

Underuse of analgesia in very young pediatric patients with isolated painful injuries

John Alexander et al. — Fri, 09 Mar 2012 12:24:33 PST

STUDY OBJECTIVE: We sought to compare the use of analgesic agents in very young children with that in older children with isolated painful injuries.

METHODS: We performed a retrospective chart review of patients seen between 1999 and 2000 in a pediatric emergency department. Patients aged 6 months to 10 years who sustained isolated long bone fractures or second- and third-degree burns were included. Exclusion criteria included head injury, chest or abdominal trauma, and developmental delay or neurologic disorder. Research subjects were separated into 2 study groups: very young (ages 6 to 24 months) and school age (ages 6 to 10 years).

RESULTS: One hundred eighty research subjects met the inclusion and exclusion criteria: 96 in the very young group and 84 in the school age group. Research subjects in the very young group received no analgesic agents more often than school age research subjects for all injuries (64.6% versus 47.6%, respectively), all fractures (70.6% versus 48.8%, respectively), displaced fractures (55.0% versus 22.0%, respectively), and all burns (50.0% versus 25.0%, respectively). When analgesic agents were administered, very young patients were less likely to receive narcotics compared with school age patients. Analgesic dosing for both the very young and school age groups was similar and within established guidelines.

CONCLUSION: Children younger than 2 years of age receive disproportionately less analgesia than school age children, despite having obviously painful conditions. Emergency physicians should consider special issues involved in assessing and managing pain in very young children.

Coccygeal fracture, constipation, convulsion, and confusion: a case report of malignant hypertension in a child

Paul A. Zgurzynski et al. — Fri, 09 Mar 2012 12:24:31 PST

Malignant hypertension is an unusual but well described cause of seizures in pediatrics. It is a medical emergency that must be recognized and emergently treated to prevent morbidity and mortality. In contrast to adults, hypertension in children is usually secondary to an underlying disease process. We present a complex case of hypertensive encephalopathy with seizures as the initial presentation of a pelvic mass, describe the initial work-up and stabilization and present an overview of the literature. Review of the medical literature described only one similar presentation (1). Interestingly, acute symptoms in this patient may have been precipitated by use of an over-the-counter medication.