Informed consent and parental choice of anesthesia and sedation for the repair of small lacerations in children.

This study investigated the issue of informed consent by surveying parent preferences for local anesthesia and sedation in the repair of small lacerations in their children in the emergency department (ED). Of the 45 ED patients with actual lacerations receiving a suture repair, 11 requested tetracaine-adrenaline-cocaine (TAC), 25 requested infiltrated lidocaine, and 9 were not given a choice (lidocaine administered because of wound proximity to a mucous membrane site). All 45 patients preferred nonsedation over sedation. In 44 of 45 patient cases, parents preferred to be included in the medical decision-making for their children. Of the 94 non-ED cases (interviewed in private offices) with a hypothetical chin laceration, 16 preferred TAC and 78 preferred infiltrated lidocaine. Sixty-seven of 94 preferred nonsedation over sedation. In 89 of 94 patient cases, parents preferred to be included in the medical decision-making for their children. Favorable points of continuous informed consent were presented, with risks, benefits, and alternatives disclosed. From the data presented, the following conclusions were drawn: (1) parents preferred infiltrated local anesthesia more commonly than topical local anesthesia; (2) parents preferred nonsedation over sedation under the clinical circumstances described; (3) parents overwhelmingly preferred to be included in the medical decisions affecting their children.

Stool appearance in intussusception: assessing the value of the term "currant jelly".

This study surveyed the stool appearance descriptions of 107 inpatient children with intussusception. Fifty-six patients presented with grossly bloody stools (passed spontaneously), 10 of which were determined on chart review to resemble currant jelly. Of the 51 patients without grossly bloody spontaneously passed stools, 35 patients had rectal examination results charted. Eight of these children had grossly bloody stools noted on rectal examination, 4 of which were determined on chart review to resemble currant jelly. While most of the grossly bloody stools were not consistent with pure currant jelly, the most common terms used in describing the grossly bloody stools were "bloody," "mucus," "red," and "diarrhea." Since stools truly resembling currant jelly account for a minority of the grossly bloody stools in intussusception, the term "currant jelly stools" should be assessed in the teaching of intussusception. Generic terms such as blood, mucus, burgundy, red, etc, are more objective and sensitive at identifying cases of intussusception. Junior physicians who are taught the classic presentation of intussusception with currant jelly stool should also be taught that intussusception should be considered in the differential diagnosis of children passing any type of bloody stool. As a result, physicians with limited experience will be more likely to appropriately consider the diagnosis of intussusception, permitting a more timely diagnosis and a better outcome.

Toxic exposures and ingestions in Honolulu: I. A prospective pediatric ED cohort; II. A prospective poison center cohort.

Poisonings and toxic exposures are a frequent cause of preventable morbidity in children requiring emergency care. Ingestions and toxic substance exposures were studied in two prospective cohorts in Hawaii to examine the epidemiology of these events in this community in order to assess the effectiveness of current poison prevention practices and to identify additional measures to further prevent and reduce morbidity and mortality. During a 12-month period ending on 11/30/88, data were collected on 286 pediatric patients visiting a pediatric ED with an ingestion or a toxic substance exposure. Most of the younger children were males with unintentional incidents. Most of the adolescents were females with intentional ingestions. Syrup of ipecac was given in 16% of the patients. When given at home, ipecac was given an average of 1.3 hours after an ingestion. Activated charcoal was given to 32% of the patients. During a 13-month period ending 1/31/90, 14,408 phone calls to the Hawaii Poison Center were analyzed. Twenty-six percent of the callers had ipecac at home. Sixty-eight percent of callers with acute ingestions claimed to have called within 30 minutes of the ingestion, and 77% claimed to have called within 60 minutes of the ingestion. Of those calling within 60 minutes, 36% had ipecac at home. Although ipecac is widely recommended as a pre-hospital intervention, it use is limited owing to unavailability in the home and the short period of time during which it must be given. Since the dispensing of pharmaceuticals in limited quantities and in childproof containers began, it appears that other measures to further reduce morbidity and mortality owing to poisonings have had less additional effect. It appears that serious morbidity and mortality from poisonings in this cohort were uncommon.