Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma.

BACKGROUND: Recent studies have shown that the use of parenteral corticosteroids in the emergency department decreases the hospitalization rate for patients with acute asthma. We studied the efficacy of oral corticosteroids in the emergency department treatment of moderately ill children with acute asthma. METHODS: Emergency department patients aged 1 through 17 years whose chief complaint was acute asthma were assigned a pulmonary index, based on clinical evaluation. Those with a moderate exacerbation (pulmonary index = 9 through 13) received either 2 mg/kg of oral prednisone or placebo in a randomized, double-blind fashion. Patients in each group were then treated with an identical regimen of frequent aerosolized albuterol, for up to a maximum of 4 hours. RESULTS: Seventy-five patients were assessed. Overall, 11 (31%) of 36 in the prednisone group required hospitalization compared with 19 (49%) of 39 in the placebo group (P = .10). Among the sickest patients (initial pulmonary index > 10), 7 (32%) of 22 prednisone-treated patients required hospitalization compared with 13 (72%) of 18 placebo-treated patients (P < .05). Among patients who had a suboptimal response to initial beta 2-agonist therapy and who therefore would have been hospitalized had treatment been restricted to 2 hours, 9 (45%) of 20 in the prednisone group ultimately required hospitalization when duration of care was extended 2 additional hours compared with 15 (83%) of 18 in the placebo group (P < .05). In addition, prednisone-treated patients had a significantly greater improvement in median pulmonary index (5.0 vs 3.0, P < .001). CONCLUSIONS: These data demonstrate that oral prednisone, within 4 hours of its administration, reduced the need for hospitalization among a subset of children treated in the emergency department for acute asthma.

Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient.

OBJECTIVE: To assess the prevalence of laboratory abnormalities (complete blood cell count, electrolytes, blood urea nitrogen, creatinine, glucose, aspartate aminotransferase, alanine aminotransferase, amylase, lipase, urinalysis [U/A]) and the sensitivity and specificity of the physical examination (PE) and screening laboratory tests for identifying intra-abdominal injury (IAI) in moderately injured pediatric patients. DESIGN, PARTICIPANTS, AND SETTING: Phase I: Retrospective chart review of 285 consecutive level II (moderately injured) trauma patients seen at a children's hospital emergency department/pediatric trauma center. All patients were received directly from the scene and had the following data recorded: mechanism of injury, Glasgow coma score, trauma score, pediatric trauma score, systematically recorded PE findings, laboratory results, and injuries detected during hospitalization. Phase II: To confirm the sensitivity of the PE and U/A found in phase I, the model was applied to 91 additional trauma patients identified by International Classification of Diseases, 9th revision (ICD-9) codes as having IAI. INTERVENTION: None. RESULTS: Phase I: A total of 3939 tests were ordered for the 285 patients entered in phase I. Aspartate aminotransferase and alanine aminotransferase values were obtained in 59% of patients; glucose level was obtained in 78% of patients; complete blood cell count, U/A, and levels of electrolytes, blood urea nitrogen, creatinine, amylase, and lipase were obtained in more than 85% of patients. The overall prevalence of laboratory abnormalities was 5.7%. Fourteen patients (4.8%) were identified who had a total of 23 significant IAIs (9 pancreatic, 6 splenic, 5 renal, 3 hepatic). The PE combined with U/A showing more than five red blood cells per high-power field had a sensitivity of 100%, specificity of 64%, positive predictive value of 13%, and negative predictive value of 100% for the detection of IAI. The presence of laboratory abnormalities suggesting injury did not increase the sensitivity of the model and significantly decreased both specificity and positive predictive value. Phase II: The PE combined with U/A identified an abnormality in 89 (97.8%) of 91 cases (95% confidence interval = 94.8% to 100%). CONCLUSIONS: In the moderately injured pediatric trauma patient, (1) there is a low prevalence of laboratory abnormalities; (2) the PE combined with U/A is a highly sensitive screen for IAI; and (3) in patients with a normal PE of the abdomen and a normal U/A, laboratory testing seldom identifies unsuspected IAI.

Noncompliance with scheduled revisits to a pediatric emergency department.

OBJECTIVES: To determine the incidence of, the risk factors associated with, and the consequences of noncompliance (NC) with a scheduled revisit to a pediatric emergency department (ED). DESIGN: A prospective, inceptive cohort study. SETTING: An urban pediatric ED. PATIENTS: A sample of 179 children. INTERVENTIONS: Interviews of parents and physicians. RESULTS: Overall, 91 (51%) of the parents were noncompliant, and just 21% were noncompliant because "the child was better." Of the 124 patients who ED physicians believed were "certain to return," 57 (46%) were noncompliant. Six factors were associated with NC: (1) the parent believed that the child was not severely ill (relative risk [RR], 2.92; 95% confidence interval [CI], 1.31-6.49); (2) the parent was judged to be unable to recognize a clinical deterioration of the child (RR, 1.95; 95% CI, 1.55-2.45); (3) the parent did not own a car (RR, 1.77; 95% CI, 1.23-2.54); (4) the parent was younger than 21 years (RR, 1.48; 95% CI, 1.12-1.95); (5) no laboratory testing was performed during the initial ED visit (RR, 1.36; 95% CI, 1.03-1.80); and (6) the parent was judged "not certain" to return (RR, 1.34; 95% CI, 1.01-1.78). CONCLUSIONS: The high rate and the lack of predictability of NC with a scheduled revisit to an ED should influence patient disposition decisions. The factors associated with NC in this study may serve as a model for identifying parents who are at a high risk of NC and as a foundation for interventions designed to improve compliance.

Cerebral and coronary embolization of a valvular tumor.

Stroke and myocardial infarction are not commonly seen in children; the occurrence of both conditions in the same well child is unusual. Undifferentiated cardiac tumors are rarely encountered in the pediatric population. We present a case of stroke and myocardial infarction as a consequence of an undifferentiated valvular tumor in a previously healthy child. This case emphasizes the critical importance of serial clinical examinations as part of a complete stroke workup. It suggests the need for additional research on the use of thrombolytic therapy for pediatric cerebral and myocardial infarction and stresses individualization of cardiac tumor treatment plans.

Adenosine in the termination of albuterol-induced supraventricular tachycardia.

Five percent of children in the United States have asthma. Status asthmaticus is one of the most common conditions for which children seek care in a pediatric emergency department. beta 2-Agonists such as albuterol are the mainstay of emergency therapy for such children. We present a case of a 4-year-old boy who experienced supraventricular tachycardia (SVT) following albuterol therapy. This is believed to be the first report of adenosine being successfully used to treat a child with albuterol-induced SVT. We also briefly review the recognition and management of SVT in children and the pharmacokinetics of and indications for adenosine.

Patient self-management of acute asthma: adherence to national guidelines a decade later.

BACKGROUND AND OBJECTIVES: Children in the emergency department (ED) with acute asthma were enrolled to assess the impact of asthma on their activities of daily living and evaluate their access to care and preventive strategies, determine the proportion who adhered to the National Heart, Lung, and Blood Institute (NHLBI) guidelines for proper steps to take at home during an acute asthma exacerbation, and compare adherence rates for those with persistent and mild intermittent asthma. DESIGN AND METHODS: Children 2 to 18 years old who presented to the Children's Hospital of Philadelphia's ED with acute asthma exacerbations were enrolled prospectively. Parents and patients completed the 108-item Asthma Exacerbation Response Questionnaire with a focus on determining the home management steps they took both at the onset of the asthma exacerbation and just before coming to the ED. RESULTS: Among the 433 children studied, 76% had at least 1 doctor visit, 75% had at least 1 ED visit, and 43% had at least 1 hospitalization for asthma in the preceding 12 months. Overall, 64% had persistent asthma by NHLBI criteria, yet just 4% were cared for by an allergist or pulmonologist, 38% took daily anti-inflammatory therapy, and 18% received a daily inhaled corticosteroid. Also, 48% did not use a holding chamber with their metered-dose inhalers, and 66% did not use their peak flow meters. Regarding exacerbation response, 71% did not have a written action plan, and 89% did not maintain a symptom diary. Both at the onset of wheezing and just before coming to the ED, administration of a beta2-agonist was the only step that the majority of children performed. One-third or fewer followed the other steps recommended by the NHLBI, including using a peak flow meter, beginning oral corticosteroids, calling or going to see the doctor, or going to the ED. Children with persistent asthma were not more adherent to the guidelines than those with mild intermittent disease. CONCLUSIONS: Asthma has a significant adverse effect on the lives of these children. The NHLBI guidelines, first published a decade ago, were designed to reduce asthma's increasing morbidity and mortality, but this study uncovered a high rate of nonadherence with many aspects of the guidelines, including preventive strategies and home management of an exacerbation.

Pain of local anesthetics: rate of administration and buffering.

STUDY OBJECTIVE: To determine the impact of administration rate and buffering on the pain associated with subcutaneous infiltration of lidocaine. METHODS: Forty-two adult volunteers employed at a tertiary care center participated in this prospective, single-blinded study. Each subject received four lidocaine injections prepared and administered as follows: slow, buffered (SB); slow, unbuffered (SU); rapid, buffered (RB); rapid, unbuffered (RU). Buffering was accomplished by mixing 1% lidocaine with 8.4% sodium bicarbonate in a 9:1 ratio. Slow administration was 30 seconds and rapid was 5 seconds. Needle size (27-gauge), injection depth (.25 inch), lidocaine volume (1.0 mL), and temperature (room) were the same for each of the four injections. In all four conditions, the needle remained in the forearm for 30 seconds, to ensure blinding. The main outcome measure was the mean pain score for each condition, as recorded on a 10-cm visual analog scale. RESULTS: The lowest pain scores (mean +/- SE) were recorded for the SU and SB conditions at 1.49 +/- 29 and 1.48 +/- 26, respectively, and they were significantly lower than the scores for RB (2.34 +/- 28; P < .01) or RU (3.11 +/- 33; P < .001). Each of the slow conditions was reported to be the "least painful" of the four significantly more often than either rapid condition. CONCLUSION: This is the largest blinded study to assess administration rate and the pain of a local anesthetic. We found that administration rate had a greater impact on the perceived pain of lidocaine infiltration than did buffering.

Utility of laboratory testing for infants with seizures.

OBJECTIVES: Study objectives were to 1) determine the frequency with which laboratory studies are obtained, 2) determine the proportion of results that are clinically significantly abnormal, and 3) define the clinical characteristics of those with abnormal results, among infants with nonfebrile seizures (NFSz). METHODS: A retrospective consecutive cohort study of infants < or = 12 months old presenting to the ED of a tertiary care, children's hospital following a seizure. A 2-year review was performed. Serum chemistry results were classified as "normal," "outside of the normal range," or "clinically significantly abnormal." RESULTS: Sixty-seven of 134 (50%) with a NFSz were tested compared to 19/80 (24%) with a febrile seizure (FSz, P < 0.001). Nine (5 with hyponatremia and 4 with hypocalcemia) of the 67 (13%) tested NFSz infants had a clinically significant abnormality, as did 9 of 21 (43%) NFSz infants who seized in the ED compared to 0/46 (0%) without ED seizure activity (P < 0.0001). Hypothermia (T < 36.5 degrees C) and age less than 1 month were common characteristics of infants with clinically significant abnormalities. CONCLUSIONS: This is one of the only studies to have assessed the utility of laboratory testing for infants with seizures. Abnormal serum chemistries accounted for a greater proportion of seizures among this cohort compared to that reported previously for older children. Laboratory testing is recommended for NFSz infants who 1) are actively seizing in the ED, 2) have a temperature below 36.5 degrees C, or 3) are less than 1 month of age.

Ecthyma gangrenosum as a manifestation of Pseudomonas sepsis in a previously healthy child.

We present a case of Pseudomonas aeruginosa sepsis heralded by ecthyma gangrenosum in a previously healthy 15-month-old child. Pseudomonas infection and its uncommon skin manifestation are rarely encountered in an immunocompetent child. This case highlights the critical importance of identifying ecthyma gangrenosum to institute optimal antimicrobial therapy.

Nebulized dexamethasone versus oral prednisone in the emergency treatment of asthmatic children.

STUDY OBJECTIVE: To compare nebulized dexamethasone with oral prednisone in the treatment of children with asthma. DESIGN: A randomized, double-blind, double-placebo study. SETTING: An urban pediatric emergency department. PARTICIPANTS: Patients aged 1 to 17 years with acute asthma. INTERVENTIONS: Patients with moderate asthma exacerbation received frequent aerosolized albuterol and either 1.5 mg/kg of nebulized dexamethasone or 2 mg/kg of oral prednisone. RESULTS: A total of 111 children was evaluated; 21% of those treated with dexamethasone required hospitalization, compared with 31% of those treated with prednisone (P = .26). A significantly greater proportion of dexamethasone-treated children were discharged home within 2 hours (23% versus 7%, P = .02). In the dexamethasone group, 8% who received the drug by mouthpiece were hospitalized compared with 33% who received it by face mask (P = .06). Fewer children treated with dexamethasone vomited (0% versus 15%, P = .001) and fewer relapsed within 48 hours of ED discharge (0% versus 16%, P = .008). CONCLUSION: Nebulized dexamethasone was as effective as oral prednisone in the ED treatment of moderately ill children with acute asthma and was associated with more rapid clinical improvement, more reliable drug delivery, and fewer relapses.

A randomized trial of magnesium in the emergency department treatment of children with asthma.

STUDY OBJECTIVE: Magnesium sulfate has been shown to benefit asthmatic children and adults with poor responses to initial beta(2)-agonist therapy in the emergency department. We sought to determine whether the routine early administration of high-dose magnesium would benefit moderate to severely ill children with acute asthma. METHODS: This was a randomized, double-blind, placebo-controlled trial of 54 children 1 to 18 years of age who presented to the ED of a tertiary care children's hospital with a moderate to severe asthma exacerbation. After receiving a nebulized albuterol treatment (0.15 mg/kg) and methylprednisolone (1 mg/kg), patients were randomly assigned to receive either 75 mg/kg of magnesium sulfate (maximum 2.5 g) or placebo. Thereafter, all patients were treated with frequent nebulized albuterol following a structured protocol. The main outcome was degree of improvement as assessed by Pulmonary Index scores over 120 minutes. Secondary outcomes included hospitalization rates and time required to meet discharge criteria. RESULTS: The mean change in Pulmonary Index score from baseline to 120 minutes was 2.83 for the magnesium group compared with 2.66 for the placebo group (95% confidence interval -1. 24 to 1.60). Eleven (46%) of 24 magnesium-treated patients were hospitalized compared with 16 (53%) of 30 in the placebo group (95% confidence interval -19% to 34%). There were no statistically significant differences between the groups with respect to time required to meet discharge criteria. CONCLUSION: The routine administration of high-dose magnesium to moderate to severely ill children with asthma, as an adjunct to initial treatment with albuterol and corticosteroids, was not efficacious.

Oral versus intravenous corticosteroids in children hospitalized with asthma.

BACKGROUND: Previous studies have demonstrated that in the emergency treatment of an asthma exacerbation, corticosteroids used in conjunction with beta-agonists result in lower hospitalization rates for children and adults. Furthermore, orally administered corticosteroids have been found to be effective in the treatment of outpatients with asthma. However, similar data in inpatients is lacking. OBJECTIVE: The purpose of this study was to determine the efficacy of oral prednisone versus intravenous methylprednisolone in equivalent doses for the treatment of an acute asthma exacerbation in hospitalized children. METHODS: We conducted a randomized, double-blind, double-placebo study comparing oral prednisone at 2 mg/kg/dose (maximum 120 mg/dose) twice daily versus intravenous methylprednisolone at 1 mg/kg/dose (maximum 60 mg/dose) four times daily in a group of patients 2 through 18 years of age hospitalized for an acute asthma exacerbation. All patients were assessed by a clinical asthma score 3 times a day. The main study outcome was length of hospitalization; total length of stay and time elapsed before beta-agonists could be administered at 6-hour intervals. Duration of supplemental oxygen administration and peak flow measurements were secondary outcome measures. RESULTS: Sixty-six patients were evaluated. Children in the prednisone group had a mean length of stay of 70 hours compared with 78 hours for the methylprednisolone group (P =.52). Children in the prednisone group were successfully weaned to beta-agonists in 6-hour intervals after 59 hours compared with 68 hours for the methylprednisolone group (P =.47). Patients receiving prednisone required supplemental oxygen for 30 hours compared with 52 hours for the methylprednisolone group (P =.04). CONCLUSION: There was no difference in length of hospital stay between asthmatic patients receiving oral prednisone and those receiving intravenous methylprednisolone. Because hospitalization charges are approximately 10 times greater for intravenous methylprednisolone compared with oral prednisone, the use of oral prednisone to treat inpatients with acute asthma would result in substantial savings.