Risks associated with alcohol-positive status among adolescents in the emergency department: a matched case-control study.

OBJECTIVE: The purpose of this study was to examine alcohol use, alcohol-related problems, other risk-taking behaviors, and parental monitoring in adolescents who tested positive for alcohol in an emergency department. STUDY DESIGN: A matched case-control design was implemented for adolescents presenting to a pediatric emergency department who were screened for alcohol use. An alcohol-positive sample (N = 150) was compared with a matched alcohol-negative sample (N = 150) for alcohol use, alcohol problems, depression, smoking, risk-taking behavior, and parental monitoring. RESULTS: The alcohol-positive group reported significantly higher drinking frequency, drinking problems, prior alcohol-related injuries, and episodes of driving after drinking and riding with a drinking driver than the alcohol-negative adolescents. The same pattern was true for depressed mood, reckless behaviors, poor grades in school, and daily smoking. The parents of alcohol-positive teens reported their teens had come home intoxicated more often than parents of alcohol-negative teens. There were no differences between parent groups in monitoring of teens. CONCLUSION: Adolescents who test positive for alcohol in an emergency department are a high-risk group who meet the criteria for indicated prevention. Screening for alcohol abuse is recommended.

Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department.

This study evaluated the use of a brief motivational interview (MI) to reduce alcohol-related consequences and use among adolescents treated in an emergency room (ER) following an alcohol-related event. Patients aged 18 to 19 years (N = 94) were randomly assigned to receive either MI or standard care (SC). Assessment and intervention were conducted in the ER during or after the patient's treatment. Follow-up assessments showed that patients who received the MI had a significantly lower incidence of drinking and driving, traffic violations, alcohol-related injuries, and alcohol-related problems than patients who received SC. Both conditions showed reduced alcohol consumption. The harm-reduction focus of the MI was evident in that MI reduced negative outcomes related to drinking, beyond what was produced by the precipitating event plus SC alone.

Methemoglobinemia: etiology, pharmacology, and clinical management.

Methemoglobin (MHb) may arise from a variety of etiologies including genetic, dietary, idiopathic, and toxicologic sources. Symptoms vary from mild headache to coma/death and may not correlate with measured MHb concentrations. Toxin-induced MHb may be complicated by the drug's effect on other organ systems such as the liver or lungs. The existence of underlying heart, lung, or blood disease may exacerbate the toxicity of MHb. The diagnosis may be complicated by the effect of MHb on arterial blood gas and pulse oximeter oxygen saturation results. In addition, other dyshemoglobins may be confused with MHb. Treatment with methylene blue can be complicated by the presence of underlying enzyme deficiencies, including glucose-6-phosphate dehydrogenase deficiency. Experimental antidotes for MHb may provide alternative treatments in the future, but require further study.

Intravenous catheter blood cultures: utility and contamination.

OBJECTIVE: In pediatrics, blood cultures (BCs) are often drawn as intravenous (IV) catheters are placed. This routine minimizes the number of painful and often difficult punctures a child must undergo but results in the discarding of multiple BC bottles when these cultures are later determined to be unnecessary. If the contamination rate of BCs drawn through an indwelling IV did not exceed the contamination rate of BCs drawn at the time of IV placement, BCs could be drawn from the IV without subjecting the patient to another venipuncture. This study was done to compare the contamination rates of BCs drawn by these two methods. Additionally, we sought to determine if the collection of two BCs enhances pathogen recovery. METHODS: Prospective comparison of contamination and bacteremia rates of BCs drawn by two different methods: the first BC was drawn at the time of IV line placement and the second BC was drawn from the previously placed IV at a later time. Setting. Urban pediatric emergency department with an annual census of 40 000. PARTICIPANTS: One thousand five hundred sixty-four patients between the ages of 3 days and 22.1 years. The median age was 2.2 years. Sixty-four patients were excluded because we were unable to draw the second BC. Forty-six percent of eligible patients (n = 690) were girls. RESULTS: Fifty-seven (1.9%) of 3000 grew contaminants: 27 in the first and 30 in the second BC for contamination rates of 1.8% and 2.0%. Thirty-eight (1.3%) of 3000 BCs grew pathogens: 24 represent 12 patients with growth in two out of two cultures and 14 represent 14 patients with growth in one out of two cultures. Pathogen rates were 1.1% (16/1500) with one BC per patient and 1.7% (22/1500) with two BCs per patient. CONCLUSIONS: There is no difference in the contamination rates of two BCs drawn from the same site at two different times. The collection of two BCs per patient may enhance pathogen recovery.

Effect of metoclopramide dose on preventing emesis after oral administration of N-acetylcysteine for acetaminophen overdose.

OBJECTIVE: To determine the effect of the metoclopramide dose on the prevention of vomiting of N-acetylcysteine in acetaminophen overdose. METHODS: Patients with acetaminophen ingestions receiving metoclopramide prior to emergency department administration of N-acetylcysteine were included. Emergency Department and poison center records were reviewed for administration of metoclopramide pre-N-acetylcysteine and incidence of subsequent vomiting. The treatment group was defined as patients receiving high-dose metoclopramide (20-50 mg intravenously) prior to the loading dose of N-acetylcysteine. Controls were patients receiving standard-dose (< 20 mg intravenously) metoclopramide prior to loading dose of N-acetylcysteine. Outcome was vomiting within 60 minutes of N-acetylcysteine administration. RESULTS: Twelve of 19 patients (63%) receiving standard-dose metoclopramide vomited N-acetylcysteine. Only 5 of 23 patients (22%) receiving high-dose metoclopramide vomited N-acetylcysteine (crude odds ratio: 6.2; 95% CI [1.3-30.3]). After controlling for confounding in the logistic regression model, the effect of high-dose metoclopramide in preventing vomiting of N-acetylcysteine remained significant (adjusted odds ratio: 17.0; 95% CI [2.6-110.0]). CONCLUSION: This study supports the efficacy of high-dose metoclopramide to prevent emesis after the oral loading dose of N-acetylcysteine.

Detection of alcohol use in adolescent patients in the emergency department.

OBJECTIVES: To examine 3 methods of detecting alcohol use among adolescent patients visiting a Level-1 regional trauma center. METHODS: Part 1 was a retrospective review of laboratory records and (13- to 19-year-old) patient medical records over the 1-year period from August 1993 to July 1994. Part 2 was a review of ICD-9 discharge diagnoses for the same age range during the same 1-year period. Part 3 involved prospective saliva alcohol testing of injured patients aged 13-17 years old. RESULTS: Part 1: A total of 522 blood tests were conducted and 160 (30.6%) were positive for alcohol. More than one-third of the alcohol-positive sample had alcohol ingestion as the only reason for their visits, i.e., they were uninjured. The alcohol-positive group was more likely to be male and older. Part 2: A total of 99 alcohol-related discharge diagnoses were given to adolescent patients. Alcohol abuse was the most common diagnosis. With the 2 methods of detection combined, 186 patients were identified. Part 3: A total of 119 saliva alcohol tests were conducted. One patient tested positive but had been identified while in triage as having used alcohol. CONCLUSION: In this study population, approximately one-third of adolescent patients tested for alcohol as part of routine clinical care were alcohol-positive but were not necessarily given an alcohol-related diagnosis. Thus, studies determining rates of alcohol-positive adolescents treated in EDs should use multiple methods of detection. Universal testing does not appear to be warranted for all injured adolescent patients.

Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study.

This study tested the feasibility and efficacy of a brief smoking intervention for adolescents in a hospital setting. Forty adolescent patients were randomized to receive either brief advice or a motivational interview, a nonconfrontational therapeutic intervention. Feasibility of brief smoking interventions with teen patients was supported by high rates of recruitment, retention, and quit attempts, and long periods of continuous abstinence. Although between-groups differences on smoking measures were not significant at 3-month follow-up, an effect size of h = .28 was noted. The sample showed significant decreases in smoking dependence and number of days smoked. Baseline stage of change, smoking rate, and depression were significant prospective predictors of smoking outcome. Implications for smoking intervention research with adolescents are discussed.

Frozen oral hydration as an alternative to conventional enteral fluids.

BACKGROUND: Oral hydration therapy is effective in dehydration, but is often bypassed or may fail. OBJECTIVE: To compare the tolerance (amount accepted minus amount vomited) of a frozen solution (FS) (Revital-ICE, PTS Labs, Deerfield, Ill) with the conventional glucose electrolyte solution (CS). DESIGN: Prospective, controlled crossover trial. SETTING: Pediatric emergency department. PARTICIPANTS: A convenience sample of 91 children with enteritis, 6 months to 13 years of age, with mild or moderate dehydration. INTERVENTION: Children were offered either FS or CS. Each group was offered 10 mL/kg of either product during a 90-minute trial period, in 3 equal aliquots, and was monitored for the quantities consumed and vomited. Complete treatment failures (absolute refusal) were crossed over to the alternate product and intake was recorded. MAIN OUTCOME MEASURES: Tolerance of the full 10 mL/kg of the original product offered and, for treatment failures, the percentage who tolerated the alternate product. RESULTS: Of the patients who initially received FS, 23 (55%) tolerated the full amount offered, compared with 5 (11%) in the CS group (P < .001). Of the 57% who completely refused CS, after crossover, 20% tolerated the full amount of FS and 33% tolerated between 5 and 9 mL/kg of FS and were discharged from the hospital. The original treatment failures for FS (12%) were crossed over to CS; none tolerated more than 5 mL/kg CONCLUSIONS: Children with mild or moderate dehydration are more likely to tolerate FS than CS. Conventional solution failures crossed over to FS had a greater tolerance rate than the reverse.

Enhancement of lithium elimination by multiple-dose sodium polystyrene sulfonate.

OBJECTIVE: To determine whether multiple doses of sodium polystyrene sulfonate (SPS) enhance the elimination of IV-administered lithium (Li). METHODS: The study was a placebo-controlled, investigator-unblinded, murine trial of multiple doses of SPS on serum Li concentrations. Seventy-five male CD-1 mice were given IV pretreatment with LiCl (125 mg/ kg) followed by gavage treatments with SPS (5 g/kg/dose) 20, 40, 90, 150, and 210 minutes after LiCl (experimental group) or deionized water at equivalent times (control group). Subgroups of each treatment group were sacrificed at 1, 2, 4, and 6 hours after LiCl administration and blood was collected for Li analysis. RESULTS: Statistical analyses indicated that the SPS group had lower serum Li concentrations overall than did the control animals. This difference was apparent at the 2-, 4-, and 6-hour time points. CONCLUSION: In this murine model, repetitive doses of orogastric SPS enhanced the elimination of parenterally administered Li.

Sodium polystyrene sulfonate treatment for lithium toxicity: effects on serum potassium concentrations.

OBJECTIVE: To examine the effects of sodium polystyrene sulfonate (SPS) on serum potassium (K) concentrations in mice pretreated with parenteral lithium (Li). METHODS: A placebo-controlled murine model trial of SPS therapy following IV Li was performed. Sixty male CD-1 mice weighing 18-22 g were administered either IV LiCl (125 mg/kg) or a control solution (normal saline). Half of the mice in each of these groups were then given orogastric water 20, 40, 90, 150, and 210 minutes after LiCl or normal saline; the other half received SPS (5 g/kg/dose) at equivalent times. Subgroups of each of these four groups were sacrificed at one, two, and six hours after pretreatment and the serum was analyzed for K concentration. Serum K concentrations for the various groups were compared with analysis of variance and Newman-Keuls tests for the comparison of multiple means. RESULTS: A statistically significant reduction of serum K concentrations occurred in the animals that received SPS treatment following either IV saline or LiCl solutions. The degree of K reduction that resulted from the combination of LiCl and SPS treatment (35% reduction at six hours, compared with the placebo-treated controls) was larger than that which resulted from either IV Li with oral water (15% reduction) or IV saline with oral SPS (20% reduction). CONCLUSIONS: These findings suggest that development of hypokalemia may represent a potential limitation in the use of SPS in the treatment for Li toxicity.

The relationship between oxygen saturation and the clinical assessment of acutely wheezing infants and children.

The objective of this study was to determine the relationship between oxygen saturation (Sao2) and traditional clinical assessment measures in infants and young children presenting as outpatients with acute wheezing. To accomplish this, Sao2 before and after medication was compared in a post hoc analysis with the clinical response to treatment (respiratory rate and a standardized index of respiratory distress) in children who participated in a randomized, placebo controlled medication trial. The study was done in a pediatric emergency department and outpatient clinic, and the participants were 74, full-term previously well infants and young children, aged 1 to 36 months (mean age 16.1 months), presenting with acute wheezing and participating in the randomized trial. The results showed that Sao2 was found to be inversely correlated with both respiratory rate (r = -0.29, P < or = 0.05) and an index of respiratory distress (r = -0.36, P < or = 0.01) prior to medication but not afterward. There was no significant difference in Sao2 when infants, who had a clinical response to treatment based on a priori criteria, were compared to nonresponders (mean difference per patient: responders = 0.86% vs nonresponders = 0.79%, P = 0.51). This was due to a large amount of individual variability in postmedication Sao2 in both groups. We conclude that, before therapy, there are only weak correlations between SaO2 and both respiratory rate and an index of respiratory distress in acutely wheezing infants and children. After therapy, young children can appear clinically improved but measured oxygen saturation may be variable and not correlated with traditional clinical assessment measures.

Effect of delayed treatment with sodium polystyrene sulfonate on serum lithium concentrations in mice.

OBJECTIVES: To determine the efficacy of sodium polystyrene sulfonate (SPS) in lowering serum lithium (Li) concentrations. Specifically, to determine the effects of both different doses of SPS and different times to treatment with SPS on serum Li levels. METHODS: The study was a controlled, single-dose murine trial of SPS on serum Li levels. Male CD-1 mice (n = 525) were given orogastric LiCl and then divided into three main treatment groups: group SPS received a single orogastric administration of SPS in a dose of 5 gm/kg body weight at either 0, 15, 30, 45, or 90 minutes after LiCl; group half-SPS received a single orogastric administration of SPS in a dose of 2.5 gm/kg body weight at times equivalent to those of group SPS; and the control group received orogastric deionized water in a volume equivalent to that of group SPS at 0, 15, 30, 45, or 90 minutes after LiCl. Subgroups of seven to ten mice in each of the four treatment groups were sacrificed at one, two, four, and eight hours after administration of LiCl, and their blood was analyzed for Li concentration. RESULTS: 1) Single doses of SPS significantly lowered serum Li concentrations; 2) this effect was dose-related; 3) the delays in administration of SPS used in this study did not significantly reduce its ability to lower serum Li concentrations; and 4) even when administered after peak serum Li concentrations had been achieved, a single dose of SPS was effective in lowering serum Li levels. CONCLUSIONS: SPS may be efficacious in the treatment for Li toxicity under certain circumstances, even when there is delay to treatment. Additional study is warranted to further characterize the ability of SPS to alter Li kinetics.

Use of urinary gram stain for detection of urinary tract infection in infants.

STUDY OBJECTIVE: To determine whether Gram stain of urine is more sensitive than urinalysis in detecting urinary tract infection in infants. DESIGN: Prospective series. SETTING: Urban teaching hospital emergency department. PARTICIPANTS: Two hundred seven infants 6 months old or less, from whom a catheterized or suprapubically aspirated urine specimen was obtained for culture. INTERVENTIONS: Urinary Gram stain, culture, and urinalysis were performed. With culture results as the validating standard, the Gram stain sensitivity, specificity, and predictive values were compared with urinalysis, including leukocyte esterase, nitrite, pyuria, and bacteriuria. RESULTS: The prevalence of positive cultures was 8.7% (18 of 207). Gram stain had higher sensitivity than overall urinalysis (94% versus 67%, P < .05), higher specificity (92% versus 79%, P < .05), and higher positive predictive value (53% versus 23%, P < .05). CONCLUSION: Urinary Gram stain appears to be more reliable than urinalysis in detecting urinary tract infection in young infants.

Is continuity of care preserved in children who utilize the pediatric emergency department?

OBJECTIVE: Inner city families often use multiple sites for nonemergent medical care, including the pediatric emergency department. This practice raises concerns about continuity of care. The present study examined one aspect of continuity of care: Do children who receive care in a pediatric emergency department return to their primary care site so that appropriate follow up may be obtained? METHODS: Over a 4-week period two groups of neighborhood health center children were studied: Those who sought care at the pediatric emergency department and those who were "walk-ins" at the health centers. All visits during the 4-week study period which resulted in a recommendation for the child to be seen within 6 weeks at the health centers were included in the analysis. RESULTS: During the study period there were 87 patient visits to the pediatric emergency department with a documented physician instruction to be seen at their health center within 6 weeks. In 66 (76%) of the cases, the patient was seen at one of the health centers during the 6 weeks following the pediatric emergency department visit. There were 146 "walk-in" visits to the health centers with a documented physician instruction to be seen again at the health centers during the 6 weeks following the walk-in visit. In 111 (76%) of the cases, the patient was seen during the 6-week period. CONCLUSION: Our study shows that revisit rates were comparable for the two groups. We conclude that the rate of compliance with follow-up recommendations is similar for those who utilized the pediatric emergency department versus those who used the primary care site.

Are pediatric emergency medicine training programs meeting their goals and objectives? A self-assessment of individuals completing fellowship training in 1993.

The purpose of this study was to evaluate the overall training experience of those individuals completing fellowships in pediatric emergency medicine. Specific attention was given to the technical skills portion of training as set forth by the American Academy of Pediatrics Curriculum Committee on Pediatric Emergency Medicine. We surveyed those individuals completing their second year of fellowship training in pediatric emergency medicine. The questionnaire incorporated a self-assessment of the technical skills portion of the Subcommittee on Pediatric Emergency Medicine's most recent curriculum statement. It also contained several questions designed to evaluate the overall training experience. Eighty percent of respondents completing the self-assessment questionnaire rated their overall experience as favorable, whereas those who rated it unfavorable stressed a lack of training in research and teaching. Ninety-two percent of respondents felt they had a good clinical experience, but 80% expressed a need for further training in administration, 74% in research, and 46% in teaching. Although the majority claimed to be comfortable with most technical skills, several skills, including lifesaving procedures such as external pacing, peritoneal lavage, pericardiocentesis, shunt tap, airway foreign body removal, and needle cricothyrotomy, posed a significant degree of discomfort.

Isopropyl alcohol intoxication in a neonate through chronic dermal exposure: a complication of a culturally-based umbilical care practice.

A 21-day-old boy presented to our emergency department hypotonic, lethargic, and intermittently unresponsive to pain. A workup for ketoacidosis, sepsis, and central nervous system hemorrhage was negative. A urine drug screen collected eight hours after hospitalization showed 39 mg/dl of isopropyl alcohol and 76 mg/dl of acetone. The first serum drug analysis was not performed until 18 hours after admission, at a time when there had been clinical improvement. The isopropyl alcohol concentration was 8 mg/dl, and the acetone concentration was 203 mg/dl. Management was supportive, and the patient stabilized. He was discharged from the hospital in good health in three days. A further review of the history showed no evidence for an oral exposure to isopropyl alcohol. However, since leaving the maternity hospital the mother had been applying gauze pads or cotton balls soaked with isopropyl alcohol to the umbilicus with every diaper change. We conclude that the child suffered from an isopropyl alcohol intoxication that occurred by absorption through the umbilical area.