Finger counting: an alternative method for estimating pediatric weights.

OBJECTIVES: We compared the accuracy of a conceptually simple pediatric weight estimation technique, the finger counting method, with other commonly used methods. METHODS: We prospectively collected cross-sectional data on a convenience sample of 207 children aged 1 to 9 presenting to our pediatric emergency department. Bland-Altman plots were constructed to compare the finger counting method to the Broselow tape method, parental estimate, the Luscombe formula, and the advanced pediatric life support (APLS) formula. Proportions within 10% and 20% of measured weight were compared. RESULTS: Mean difference and range of agreement in kilograms for Bland-Altman plots were as follows: -1.8 (95% confidence interval [CI], -2.3 to -1.3) and 15.4 (95% CI, 13.6-17.2) for the finger counting method; -1.4 (95% CI, -2.0 to -0.9) and 15.8 (95% CI, 13.9-17.6) for the Broselow method; -0.02 (95% CI, -0.53 to 0.49) and 14.8 (95% CI, 13-16.6) for parental estimate; 0.2 (95% CI, -0.33 to 0.72) and 15.3 (95% CI, 13.5-17.2) for the Luscombe formula; and -3.8 (95% CI, -4.4 to -3.2) and 17.2 (95% CI, 15.2-19.2) for the APLS formula. The finger counting method estimated weights within 10% in 59% of children (95% CI, 52%-65%) and within 20% in 87% of children (95% CI, 81%-91%). Proportions within 10% were similar for all methods, except the APLS method, which was lower. CONCLUSIONS: The finger counting method is an acceptable alternative to the Broselow method for weight estimation in children aged 1 to 9 years. It outperforms the traditional APLS method but underestimates weights compared with parental estimate and the Luscombe formula.

Pediatric procedural sedation with propofol using a higher initial bolus dose.

OBJECTIVES: We sought to describe the doses of propofol used for sedation in our pediatric emergency department, along with the range of procedures performed under propofol sedation. We also planned to describe clinically important physiologic changes seen and physician satisfaction with propofol at the doses observed. METHODS: This was a prospective observational case series. Physicians completed a data collection form after the propofol sedation. The physicians were asked to report physiologic changes that occurred during sedation and rate their satisfaction with propofol as a sedation agent on a 100-mm visual analog scale. RESULTS: Eight hundred eighty-six sedation events were reported. The median initial dose of propofol given was 2.0 mg/kg and the median total dose was 3.6 mg/kg. Propofol was used for a wide range of procedures. The most common physiologic change was desaturation/hypoxia (desaturation to <90% in 7.2%). No deaths, unplanned intubations, or surgical airway placements were reported. Treating physicians reported a median satisfaction score of 97 mm. CONCLUSIONS: A 2-mg/kg initial bolus dose of propofol for pediatric sedation was well tolerated and useful for a wide range of procedures. Physicians should expect to find a high level of satisfaction with this dose.

Changes in community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infections presenting to the pediatric emergency department: comparing 2003 to 2008.

OBJECTIVES: This study aimed to compare the differences in the type and location of skin infections, organisms cultured, and antibiotic resistance patterns presenting to the same pediatric emergency department from 2003 to 2008 with specific focus on community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections. METHODS: We performed a retrospective chart review of children younger than 18 years who presented to the pediatric emergency department with a skin or soft tissue infection from January 1 to December 31, 2008, and compared these data to a similar data set collected at the same institution from January 1 to December 31, 2003. RESULTS: From 2003 to 2008, the proportion of abscesses among all skin or soft tissue infections increased from 14% (95% confidence interval [CI], 8.4%-21.2%) to 65% (95% CI, 58.4%-70.6%). Cultures positive for MRSA increased from 21% (95% CI, 14.3%-29.0%) in 2003 to 42% (95% CI, 35.2%-47.8%) in 2008 (z score = -3.98, P < 0.001). Similar to 2003, all MRSA culture-positive abscesses were sensitive to trimethoprim-sulfamethoxazole and vancomycin in 2008. The most common anatomic location for MRSA abscesses in 2003 and 2008 was the buttocks, with a wider variation of anatomic sites in 2008 to include head/neck, trunk, and extremities. CONCLUSIONS: The prevalence of CA-MRSA skin infections, specifically abscesses, has significantly increased at our institution from 2003 to 2008. The antibiotic resistance patterns have not significantly changed. The most common anatomic location for CA-MRSA abscesses continues to be the buttocks, but more children are presenting with multiple abscesses in a wider variety of anatomic locations.

Citations to Web pages in scientific articles: the permanence of archived references.

STUDY OBJECTIVE: We validate the use of archiving Internet references by comparing the accessibility of published uniform resource locators (URLs) with corresponding archived URLs over time. METHODS: We scanned the "Articles in Press" section in Annals of Emergency Medicine from March 2009 through June 2010 for Internet references in research articles. If an Internet reference produced the authors' expected content, the Web page was archived with WebCite (http://www.webcitation.org). Because the archived Web page does not change, we compared it with the original URL to determine whether the original Web page had changed. We attempted to access each original URL and archived Web site URL at 3-month intervals from the time of online publication during an 18-month study period. Once a URL no longer existed or failed to contain the original authors' expected content, it was excluded from further study. The number of original URLs and archived URLs that remained accessible over time was totaled and compared. RESULTS: A total of 121 articles were reviewed and 144 Internet references were found within 55 articles. Of the original URLs, 15% (21/144; 95% confidence interval [CI] 9% to 21%) were inaccessible at publication. During the 18-month observation period, there was no loss of archived URLs (apart from the 4% [5/123; 95% CI 2% to 9%] that could not be archived), whereas 35% (49/139) of the original URLs were lost (46% loss; 95% CI 33% to 61% by the Kaplan-Meier method; difference between curves P<.0001, log rank test). CONCLUSION: Archiving a referenced Web page at publication can help preserve the authors' expected information.

Etiology of septic arthritis in children: an update for the new millennium.

OBJECTIVE: We sought to describe the causative organisms and joints involved in cases of pediatric septic arthritis in the post-Haemophilus influenzae type B and post-pneumococcal vaccine age and in the age of increasing infection with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). METHODS: This was a retrospective chart review of all children younger than 13 years presenting to our tertiary care pediatric emergency department between January 1, 2003, and December 31, 2007, with the diagnosis of septic arthritis. We reviewed the results of synovial fluid Gram stain and synovial fluid and blood culture. We defined septic arthritis as any of these 3 tests being positive for a known pathogen. We report patient characteristics, joint(s) involved, and organisms identified in these cases. RESULTS: We describe 13 cases of septic arthritis. Fifteen joints were involved. The most common joint involved was the hip (6/15) followed by the elbow (3/15), knee (2/15), and ankle (2/15). The most common organism involved was methicillin-sensitive S aureus (6/13), followed by CA-MRSA (2/13) and Streptococcus pneumoniae (2/13). CONCLUSION: Our results support continued concern for involvement of the hip and knee in cases of pediatric septic arthritis and consideration of other joints such as the elbow. Our data also suggest that empiric antibiotic coverage for CA-MRSA is indicated in cases of pediatric septic arthritis, as well as continued coverage for methicillin-sensitive S aureus and S pneumoniae.

Ketamine-associated vomiting: is it dose-related?

OBJECTIVE: Vomiting is a common adverse event after emergency department ketamine sedation in children. We sought to determine if the rate of vomiting is dose related to intravenous ketamine. METHODS: Treating physicians administered intravenous ketamine to children requiring sedation for a procedure in a pediatric emergency department using doses of their discretion in this prospective observational study. We compared initial and total ketamine doses between children with and without vomiting directly and after controlling for age and coadministered drugs using multiple logistic regression analysis. RESULTS: A wide range of initial (0.2 to 2.4 mg/kg) and total (0.3 to 23.8 mg/kg) ketamine doses were administered in the 1039 sedations studied. Vomiting occurred in 74 (7%) overall. Initial and total ketamine dose distributions were similar in children with and without vomiting (medians 1.6 vs 1.6 mg/kg and 2.2 vs 2.1 mg/kg, respectively). Our multivariate analysis found no significant association between emesis and initial dose; however, it did reveal an association with total dose that was explained by a minority (3.5%) of children who received high cumulative doses (>7 mg/kg). The rate of emesis was 7.0% when the total ketamine dose was 7 mg/kg or less and 11.1% when greater than 7 mg/kg. CONCLUSIONS: Within a wide range of intravenous doses, ketamine-associated vomiting is not related to either the initial loading dose or the total dose--except for a modest increase for those receiving high cumulative doses (>7 mg/kg).

Accessibility of Internet references in Annals of Emergency Medicine: is it time to require archiving?

STUDY OBJECTIVE: We seek to evaluate the accessibility of all Internet references appearing in Annals of Emergency Medicine from 2000, 2003, and 2005. Secondary objectives are to determine whether the number of Internet references is increasing and to describe how Internet references are inaccessible. METHODS: We visually scanned all articles for references made in the printed version of Annals of Emergency Medicine for 2000, 2003, and 2005. We identified the Internet references and grouped them into 11 categories according to the results of entering the uniform resource locator (URL) into the Internet browser. RESULTS: We identified 15,745 references published in Annals of Emergency Medicine. The proportion of Internet references increased from 1% of the total references in 2000 to 5.4% in 2005. Internet references were not readily accessible for 40 of 51 Internet references in 2000 (78%; 95% confidence interval [CI] 65% to 88%), 161 of 286 Internet references in 2003 (56%; 95% CI 50% to 62%), and 111 of 249 Internet references in 2005 (45%; 95% CI 39% to 51%). Inaccessibility was most commonly manifested by URLs that no longer link to active Web sites (172 of 312 inaccessible Internet references [55%]; 95% CI 50% to 61%) and URLs that linked to generic home pages where the authors' referenced material could not be found (115 of 312 inaccessible Internet references [37%]; 95% CI 32% to 42%). CONCLUSION: In Annals of Emergency Medicine, older Internet references appear to be less accessible than newer references. Internet reference archiving is one solution to preserving this information for future readers.

Replacement of Dislodged Gastrostomy Tubes After Stoma Dilation in the Pediatric Emergency Department.

INTRODUCTION: A dislodged gastrostomy tube (GT) is a common complaint that requires evaluation in the pediatric emergency department (ED) and, on occasion, will require stoma dilation to successfully replace the GT. The objective of this study was to describe the frequency that stoma dilation is required, the success rate of replacement, complications encountered, and the techniques used to confirm placement of the GT after dilation. METHODS: We conducted a retrospective medical record review of children 0-18 years who presented to the pediatric ED from February 2013 through February 2015 with a dislodged GT that required stoma dilation by pediatric emergency physicians with serially increasing Foley catheter sizes prior to successful placement of the GT. RESULTS: We reviewed a total of 302 encounters in 215 patients, with 97 (32%) of the encounters requiring stoma dilation prior to replacing a GT. The median amount of dilation was 2 French between the initial Foley catheter size and the final GT size. There was a single complication of a mal-positioned balloon that was identified at the index visit. No delayed complications were encountered. We performed confirmation of placement in all patients. The two most common forms of confirmation were aspiration of gastric contents (56/97 [58%]) followed by contrast radiograph in 39 (40%). CONCLUSION: The practice of serial dilation of a gastrostomy stoma site to allow successful replacement of a gastrostomy tube in pediatric patients who present to the ED with a dislodged gastrostomy tube is generally successful and without increased complication. All patients received at least one form of confirmation for appropriate GT placement with the most common being aspiration of gastric contents.

The flipped classroom: a modality for mixed asynchronous and synchronous learning in a residency program.

INTRODUCTION: A "flipped classroom" educational model exchanges the traditional format of a classroom lecture and homework problem set. We piloted two flipped classroom sessions in our emergency medicine (EM) residency didactic schedule. We aimed to learn about resident and faculty impressions of the sessions, in order to develop them as a regular component of our residency curriculum. METHODS: We evaluated residents' impression of the asynchronous video component and synchronous classroom component using four Likert items. We used open-ended questions to inquire about resident and faculty impressions of the advantages and disadvantages of the format. RESULTS: For the Likert items evaluating the video lectures, 33/35 residents (94%, 95% CI 80%-99%) responded that the video lecture added to their knowledge about the topic, and 33/35 residents felt that watching the video was a valuable use of their time. For items evaluating the flipped classroom format, 36/38 residents (95%, 95% CI 82%-99%) preferred the format to a traditional lecture on the topic, and 38/38 residents (100%, 95% CI 89%-100%) felt that the small group session was effective in helping them learn about the topic. Most residents preferred to see the format monthly in our curriculum and chose an ideal group size of 5.5 (first session) and 7 (second session). Residents cited the interactivity of the sessions and access to experts as advantages of the format. Faculty felt the ability to assess residents' understanding of concepts and provide feedback were advantages. CONCLUSION: Our flipped classroom model was positively received by EM residents. Residents preferred a small group size and favored frequent use of the format in our curriculum. The flipped classroom represents one modality that programs may use to incorporate a mixture of asynchronous and interactive synchronous learning and provide additional opportunities to evaluate residents.

Bilious vomiting does not rule out infantile hypertrophic pyloric stenosis.

OBJECTIVE: To describe the incidence of bilious vomiting in infants with infantile hypertrophic pyloric stenosis that presented to a pediatric emergency department. METHODS: A retrospective medical record review included all infants who presented to our level 1 pediatric emergency department from January 1, 2005, through December 31, 2009, who were diagnosed intraoperatively with infantile hypertrophic pyloric stenosis. Emesis was determined to be bilious if the vomit was described as "green," "containing bile," or "bilious." RESULTS: The authors identified 354 infants with infantile hypertrophic pyloric stenosis. The median age was 4 weeks 6 days (range = 11 days to 13 weeks). Bilious emesis was encountered in 1.4% (5/354; 95% confidence interval = 0.5% to 3.2%). The pyloric thickness measurements on ultrasound were significantly smaller in those with bilious emesis compared with those without bilious emesis (z score = 2.64; P = .014). CONCLUSION: Bilious emesis was the presenting symptom in a small proportion of infants with infantile hypertrophic pyloric stenosis.

Test characteristics of urinalysis to predict urologic injury in children.

OBJECTIVE: To use receiver operator characteristic curve methodology to determine the test characteristics of microscopic hematuria for identifying urologic injuries in children who underwent computed tomography (CT) of the abdomen and pelvis as part of a trauma evaluation. METHODS: We performed a retrospective medical record review of all children from 0 to 12 years of age who presented to our pediatric emergency department within a Level 1 trauma center, had an abdominal and pelvic CT and a microscopic urinalysis as part of an initial evaluation for trauma. Urologic injury was defined as any injury to the kidneys, ureters or bladder. We defined hematuria from the microscopic urinalysis and reported by the clinical laboratory as the exact number of red blood cells per high power field (RBC/hpf). RESULTS: Of the 502 children in the study group, 17 (3%; 95% CI [2%-5.4%]) had evidence of urologic injury on the abdominal or pelvic CT. Microscopic urinalysis for those children with urologic injury ranged from 0 to15,544 RBC/hpf. The remaining 485 children without urologic injury had a range of hematuria from 0 to 20,596 RBC/hpf. A receiver operating characteristic curve was generated and the area under the curve is 0.796 (95% CI [0.666-0.925]). CONCLUSION: If the abdominal and pelvic CT is used as the criterion standard for identifying urologic trauma, the microscopic urinalysis has moderate discriminatory power to predict urologic injury.