Effect of ambient temperature on capillary refill in healthy children.

OBJECTIVES: To assess the effect of moderately decreased ambient temperature on capillary refill (CR) time in healthy children, and to measure the reliability of CR measurements between observers. DESIGN: Prospective interventional study with cross-over design. SETTING: Urban pediatric emergency department. PARTICIPANTS: 32 well-hydrated children aged 1 month to 12 years brought to the emergency department for care of minor illness or injury. INTERVENTIONS: Participants were assigned in random order to a 15-minute waiting period in each of two rooms, with and without air-conditioning (cool and warm rooms, respectively). At the end of each waiting period, fingertip CR was measured with a stopwatch, three times by each of one or more three trained observers. RESULTS: Mean CR time was 0.85 +/- 0.45 seconds in the warm room (mean ambient temperature (25.7 degrees C) vs 2.39 +/- 0.76 seconds in the cool room (mean temperature 19.4 degrees C). The mean overall difference in CR time between the two environments was 1.53 seconds (95% confidence interval [CI]: 1.31, 1.75; P < .001); the difference was significant regardless of age or sequence of exposure. 100% of patients were considered to have normal CR (less than 2 seconds) in the warm room, whereas only 31% were considered normal in the cool room. In the 16 patients with CR measured by three observers, interobserver reliability was fair, with an intraclass correlation coefficient of 0.70 (95% CI: 0.56, 0.85), and kappa of 0.54 (95% CI: 0.33, 0.73). CONCLUSIONS: Decreases in ambient temperature within a range found in typical office/emergency department settings may cause significant prolongation of CR time in children with normal circulatory status. There is marked interobserver variability in the measurement of CR even when performed by experienced observers. These findings suggest limitations to the use of CR in the assessment of ill or injured children.

Initial urinary catecholamine metabolite concentrations and prognosis in neuroblastoma.

Initial urinary catecholamine metabolite and amino acid excretion patterns were examined in 54 children with neuroblastoma. The relationships between prognosis and age at diagnosis, stage of disease, primary site, and histologic grade of tumor were similar in this population to those found in previous studies, but only age and stage were found to be independent prognostic variables. Prognosis in disseminated disease was found to correlate directly with the urinary vanilmandelic acid (VMA)/homovanillic acid (HVA) ratio but not with the absolute levels of HVA. The presence of the dopa metabolite, vanillactic acid, as well as increased amounts of cystathionine and/or low levels of VMA indicated poor prognosis. These results are consistent with the hypothesis that biochemically primitive neuroblastomas deficient in dopamine beta-hydroxylase are move virulent than their mature analogues which produce epinephrine, norepinephrine, and their metabolites.

Hidden spears: handlebars as injury hazards to children.

OBJECTIVES: To delineate the mechanism of serious bicycle handlebar-related injuries in children and make recommendations for preventive strategies. METHODS: Prospective cross-sectional surveillance system of seriously injured child bicyclists supplemented by in-depth, on-site crash investigation to delineate specific injury mechanisms. Interdisciplinary analyses involved engineers, clinicians, epidemiologists, and biostatisticians. SETTING: The emergency department and in-patient trauma service of an urban level one pediatric trauma center between October 1995 and September 1997. PARTICIPANTS: Patients under 18 years of age who were treated for serious bicycle-related injuries (Abbreviated Injury Scale scores of 2 or greater). RESULTS: The surveillance system identified two distinct circumstances for serious child bicyclist injury: 1) handlebar-related injuries associated with minor incidents (falls from bicycles) and 2) nonhandlebar-related injuries associated with severe incidents (bicycle-motor vehicle crashes). Crash investigations explored the minor incidents that resulted in serious handlebar-associated injuries. In the typical mechanism, as the child lost control of the bicycle and began to fall, the front wheel rotated into a plane perpendicular to the child's body. The child then landed on the end of the handlebar resulting in serious truncal injuries. CONCLUSIONS: A discordancy exists between the apparently minor circumstances and serious injuries sustained by child bicyclists who impact bicycle handlebars. Recognition of the mechanism of handlebar-related injuries might aid the practitioner in early diagnosis of serious abdominal injuries in child bicyclists. This injury mechanism may be avoided through bicycle redesign that would involve both limiting rotation of the front wheel and modifying the ends of handlebars. An integrated approach involving a surveillance system to identify an injury hazard supplemented by in-depth, on-site crash investigations effectively provided the detailed mechanism of injury needed to develop interventions.

Evaluation of a rapid screening filter test for urinary tract infection in children.

OBJECTIVE: Clinical evaluation of a rapid screening filter test for urinary tract infection (UTI), FiltraCheck-UTI, comparison to the urine dipstick and conventional urinalysis for test performance and cost effectiveness in children. SETTING: Pediatric emergency department at an urban children's hospital. METHODS: Cross-sectional concordance study of 1298 children age 2 days to 19 years (50% < or = 2 years) for whom a urine culture was ordered; screening tests run by trained laboratory personnel; cost per case detected calculated; retrospective chart review for clinical information. RESULTS: Prevalence of UTI was 7.1%. Urine obtained from children < or = 2 years by catheter (97%) as part of an evaluation of fever or sepsis (82%). FiltraCheck-UTI was comparable with microscopy for bacteriuria (P = 0.11), sensitivity of 85% (95% confidence interval, 76 to 91) and specificity of 72% (95% confidence interval, 70 to 75%) but it was difficult detect Gram-positive organisms by this method (P < 0.001). Its performance varied by definition of UTI. The urine dipstick had the best specificity and was the most cost-effective rapid test. CONCLUSIONS: FiltraCheck-UTI is more expensive and has more false positives than the urine dipstick in detecting UTI in children. The dipstick continues to be the best inexpensive alternative to microscopy, but it is probably not an adequate screen for when to send a urine culture in young children.

Clinical decision rule to identify febrile young girls at risk for urinary tract infection.

OBJECTIVE: To develop a clinical prediction rule to identify febrile young girls needing urine culture for evaluation of urinary tract infection (UTI). DESIGN: Prospective cohort study. SETTING: Urban children's hospital emergency department. PATIENTS: All girls younger than 2 years (N = 1469) presenting to the emergency department with fever (temperature > or =38.3 degrees C) and without an unequivocal source of fever during a 12-month period. MAIN OUTCOME MEASURES: The outcome of interest was UTI, defined as a catheterized urine culture with pure growth of 10(4) colonies/mL or greater. Candidate predictors included demographic, historical, and physical examination variables. Clinical prediction rules were developed using multiple logistic regression after screening variables for univariate association and reliability. RESULTS: The presence of 2 or more of the following 5 variables-less than 12 months old, white race, temperature of 39.0 degrees C or higher, fever for 2 days or more, and absence of another source of fever on examination-predicted UTI with a sensitivity of 0.95 (95% confidence interval, 0.85-0.99) and a specificity of 0.31 (95% confidence interval, 0.28-0.34). In the study population, with an overall prevalence of UTI of 4.3%, the positive predictive value of a score of 2 or more was 6.4% and the negative predictive value of a score of less than 2 was 0.8%. CONCLUSION: Using this clinical decision rule, a strategy of obtaining urine cultures from girls younger than 2 years with a score of 2 or more would lead to identification of 95% of children with UTI and elimination of 30% of unnecessary urine cultures.

Evaluation of head injury in a pediatric emergency department: pretrauma and posttrauma system.

OBJECTIVE: To determine if trauma center protocols affect the number of tests and consultations performed and the length of time spent in the emergency department or hospital. DESIGN: A retrospective review and comparison of treatment for children with isolated head injury admitted to the emergency department before trauma center designation (group 1, 1985), and 5 years after implementation of trauma center protocols (group 2, 1991). SETTING: Urban children's hospital, level I trauma center. RESULTS: One hundred sixty-five children met the enrollment criteria in 1985 and 162 met the criteria in 1991. Falls were the predominant mechanism of injury (55%) for both years. For patients with moderate injury (Glasgow Coma Scale score, 9-12) or severe injury (Glasgow Coma Scale score, <9), there was no difference in radiographic or laboratory evaluation. For patients with minimal head injury (Glasgow Coma Scale score, 15, no loss of consciousness, amnesia, seizure, focal neurologic findings, or persistent symptoms) and minor head injury (Glasgow Coma Scale score, >12, and loss of consciousness or amnesia), more radiologic and laboratory studies were done in 1991 that showed no clinically significant abnormalities. Patients with minimal head injury in group 2 were 14 times more likely to have cranial computed tomographic scans performed (95% confidence interval [CI], 3.4-67); 11 times more likely to have cervical spine radiographs (95% CI, 2.2-76.6); and 23 times more likely to have hepatic enzymes obtained (95% CI, 3-491). These differences persisted when analyzed by both the age of the patient and mechanism of injury. CONCLUSIONS: Application of trauma system protocols to isolated head injury patient evaluation results in increased use of laboratory and radiologic services. These practices have the potential to increase the cost of medical care without significantly improving outcome.

Lipopolysaccharide causes deficits in spatial learning in the watermaze but not in BDNF expression in the rat dentate gyrus.

We investigated the effects of a single injection and a daily injection of lipopolysaccharide (LPS) on spatial learning and brain-derived neurotrophic factor (BDNF) expression in the rat dentate gyrus. LPS is derived from the cell wall of Gram-negative bacteria and is a potent endotoxin that causes the release of cytokines such as interleukin-1 and tumour necrosis factor. LPS is thought to activate both the neuroimmune and neuroendocrine systems; it also blocks long-term potentiation in the hippocampus. Here, we examined the effects of LPS on a form of hippocampal-dependent learning-spatial learning in the water maze. Rats were injected with LPS intraperitoneally (100 microg/kg) and trained in the water maze. The first group of rats were injected on day 1 of training, 4 h prior to learning the water maze task. Groups 2 and 3 were injected daily, again 4 h prior to the water-maze task; group 2 with LPS and group 3 with saline. A number of behavioural variables were recorded by a computerised tracking system for each trial. The behavioural results showed a single injection of LPS (group 1) impaired escape latency in both the acquisition and retention phases of the study, whereas a daily injection of LPS did not significantly impair acquisition or retention. BDNF expression was analysed in the dentate gyrus of all animals. No significant differences in BDNF expression were found between the three groups.

Use of out-of-hospital interventions for the pediatric patient in an urban emergency medical services system.

OBJECTIVE: To determine appropriateness of out-of-hospital interventions by emergency medical services (EMS) personnel on children with respiratory illnesses. METHODS: A retrospective, cross-sectional study was performed on a random sample of 304 children transported by an urban EMS system during 1994. Data were abstracted from EMScan (a computerized database of all EMS dispatches) and the EMS narrative records. Appropriate utilization of interventions was determined by comparison with the standard EMS protocol for respiratory complaints in this system. An assessment of whether interventions were inappropriately underutilized or inappropriately overutilized was made. Effect of severity of illness, patient age, transport times, and use of medical command on the use of interventions was evaluated. RESULTS: Two hundred three patients (67%) were classified as having respiratory distress. Overall, 56% of the patients received appropriate interventions, 39% received one or two inappropriate interventions, and 5% received three or more inappropriate interventions. Rates of inappropriate utilization with 95% CI for each intervention were: oxygen 16% (95% CI = 12 to 20), assisted ventilation 2% (95% CI = 0.5 to 4), medication use 9% (95% CI = 6 to 13), vascular access 11% (95% CI = 7 to 14), phlebotomy 9% (95% CI = 6 to 13), and cardiac monitoring 18% (95% CI = 14 to 22). Oxygen and medications were underutilized (p < 0.005), whereas vascular access, cardiac monitoring, and phlebotomy were overutilized (p < 0.005). Online medical command (used in 9% of transports) improved appropriate use of vascular access [OR 8.3 (95% CI = 3 to 25) (p < 0.001)] and cardiac monitoring [OR = 3 (95% CI = 1 to 8) (p < 0.05)]. CONCLUSIONS: Emergency medical services personnel underutilized oxygen and medications and overutilized vascular access, phlebotomy, and cardiac monitoring in children with respiratory illness in this urban setting. Increasing patient age, transport times, and illness severity tend to increase the use of certain interventions, while contact with online medical direction seems to improve appropriate use of interventions.

Urinary tract infection in the pediatric patient.

Little attention has been focused on the identification of urinary tract infection (UTI) in young febrile children in the emergency department, despite recent information that suggests both a high prevalence and significant associated morbidity in this population. Most UTIs that lead to scarring or diminished kidney growth occur in children younger than age 4 years, especially babies in the first year of life. Overall, prevalence rates of UTI in febrile infants in the emergency department are approximately 3% to 5%, with higher rates for white girls, uncircumcised boys, and those without another potential source for fever. Prevalence and risk factors are given so that clinicians may identify those febrile children at particularly high or low risk of UTI for selective management. Culturing methods, urine screening tests, and culture interpretation are reviewed and management strategies based on these results are suggested.

Partners for child passenger safety: a unique child-specific crash surveillance system.

Insurance claims data were combined with telephone survey and on-site crash investigation data to create the first large scale, child-focused motor vehicle crash surveillance system in the US. Novel data management and transfer techniques were used to create a nearly real-time data collection system. In the first year of this on-going project, known as Partners for Child Passenger Safety, over 1200 children < or = 15 years of age per week were identified in crashes reported to State Farm Insurance Co. from 15 states and Washington, D.C. Partners for Child Passenger Safety is similar in its design and overall objectives to National Automotive Sampling System (NASS), the only other population-based crash surveillance system currently operating in the US.

Submersion injuries: drowning and near-drowning.

Submersion injuries are a major cause of morbidity and mortality in children and young adults. The Emergency Department physician should be familiar with the epidemiology, pathophysiology, modes of therapy, and prognostic indicators in order to provide optimum resuscitation to the near-drowning victim, correct referral, and counseling to their families.

Who can give a pediatric trauma history for children injured in bicycle crashes?

Emergency Departments are important sites for injury surveillance but the quality of data collected has not been evaluated. This prospective cohort study assessed the ability of various respondents to provide circumstantial information following pediatric bicyclist trauma. A semi-structured survey tool was administered in the Emergency Department of a Level One Pediatric Trauma Center for 448 child bicyclists. The injured child provided more complete information when compared to witnesses and Emergency Medical Services personnel. No one respondent type provided the complete history. To obtain thorough injury circumstantial information, multiple respondents should be interviewed utilizing a semi-structured questionnaire.

Teaching technical skills in pediatrics.

Technical skills are an important and difficult part of managing a very sick or injured child. However, technical procedures are more often learned from experience than practice. This article reviews a variety of technical skills and procedures commonly performed in a pediatric emergency department. Each technical procedure can be practiced using live or artificial model for simulation.

Near drowning: is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated?

OBJECTIVES: a) To report the neurologic outcome of a series of near-drowning victims treated with supportive management without aggressive cerebral resuscitation; and b) to identify patient characteristics that indicate prognosis and guide therapy at the scene, the Emergency Department, and in the intensive care unit (ICU). DESIGN: Retrospective review of all near-drowning patients requiring admission to the ICU over a 6-yr period (1/1/82 to 12/31/88). Hospital records were examined for the circumstances of submersion and rescue, patient condition on arrival in the Emergency Department and ICU, treatments, hospital course, and ultimate outcome. SETTING: Emergency departments of the referring hospital and ICU of Children's Hospital. PATIENTS: Forty-four pediatric submersion victims were treated with therapy limited to the support of vital functions. Three patients who met cold-water drowning criteria were excluded from the analysis for predictors of neurologic outcome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In our warm-water near-drowning patients, 56% survived neurologically intact, 32% survived in a persistent vegetative state, and the remaining 32% died. Unreactive pupils in the Emergency Department and a Glasgow Coma Score of < or = 5 on arrival to the ICU were the best independent predictors of poor neurologic outcome (odds ratio and 95% confidence intervals 374 [17 to 16,000] and 51 [5 to 2,200], respectively). However, no predictor was absolute and two nonhypothermic patients who arrived to the Emergency Department without vital signs, requiring cardiopulmonary resuscitation and cardiotonic medications, had full neurologic recovery. CONCLUSIONS: Our results cast further doubt on the utility of aggressive forms of cerebral monitoring and resuscitation and emphasize the need for initial full resuscitation in the Emergency Department.