The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department.

This prospective cohort study evaluated the effectiveness and safety of a selective discharge policy for patients treated with racemic epinephrine (RE) and intramuscular (IM) dexamethasone (DEX) in the emergency department (ED). Children younger than 13 years of age presenting to the ED with croup who were treated with RE and IM DEX and discharged home were enrolled in the study. Patients were discharged home if they were free of intercostal retractions and stridor at rest, following a 2 h observation period. Telephone follow up determined whether further medical attention for croup was required within 48 h of discharge from the ED. Eighty-two patients were enrolled in the study over a one year period. Six of these patients (7%) required follow up for croup within 48 h of discharge and 2 (2%) required admission. We conclude that a subset of patients with croup treated with RE and IM DEX in the ED can be safely discharged home.

Topical anesthesia.

OBJECTIVE: To consider topical anesthetic options available to primary care physicians, indications for their use, and efficacy and safety of these agents as supported by the literature. QUALITY OF EVIDENCE: Five randomized controlled trials were retrieved that compared various topical anesthetics as well as topical anesthetics versus infiltrative anesthesia. MAIN FINDINGS: A combination of lidocaine, epinephrine, and tetracaine (LET) is currently the topical anesthetic of choice for repair of simple lacerations involving the faces and scalps of children. A promising new topical preparation is bupivacaine and epinephrine, but its efficacy must be studied in larger populations before widespread use can be advocated. Using EMLA (eutectic mixture of local anesthetics) for repair of extremity lacerations requires further study and cannot yet be recommended. Continued use of topical tetracaine, adrenaline, and cocaine (TAC) is not supported in the literature, because of its greater expense, its status as a restricted narcotic, its potential for toxicity, and better availability of an equally efficacious alternative, LET. CONCLUSIONS: Children's simple facial and scalp lacerations can be safely repaired using topical LET gel. Physicians must adhere to recommendations to avoid mucous membrane contact and ensure appropriate dosing with these agents. Bupivacaine-epinephrine topical preparation is a promising analgesic agent that warrants further study.

Walk-in clinics: implications for family practice.

To understand better the reasons for the growth in popularity of walk-in clinics in Canada we surveyed 321 patients with a regular physician in Toronto who attended a walk-in clinic in the same city over a 16-day period in February 1988. They were asked their reason for attending the clinic, their perception of the urgency of their problem, their choices as alternatives to walk-in clinics and their satisfaction and concerns with the type of care received at the clinic. The three most common reasons for attending the clinic were convenient location (in 33% of the cases), inability to see their regular physician soon enough (in 16%) and no appointment needed (in 13%). Most (80%) of the patients felt that they needed medical attention within 24 hours after the onset of their problem. Most (83%) of the respondents would have sought medical attention at another walk-in clinic, from their regular physician or at an emergency department had the clinic been closed. Only 36% and 18% of the patients respectively responded that their regular physician worked evenings or weekends. Most of the visits to the clinic were outside regular weekday business hours. The level of satisfaction with the service received at the clinic was high. The extended hours and no-appointment philosophy of walk-in clinics, coupled with family physicians' reluctance to work evenings and weekends, have made such clinics an attractive option for patients with primary care problems that they believe require prompt attention.