Pediatric equestrian injuries: assessing the impact of helmet use.

OBJECTIVE: To assess the impact of helmet use on the pattern, and severity of pediatric equestrian injuries. DESIGN: A prospective observational study of all children less than 15 years of age who were brought to the University of Virginia children's Emergency Department with horse-related injuries. RESULTS: During the two-year period of the study, 32 children were evaluated. Two children were injured when a horse stepped on them. Thirty children fell from or were thrown from a horse. Of these, 20 were wearing a helmet. Head injuries were more frequent in those patients not wearing helmets. The mean Modified Injury Severity Scale (MISS) score for riders without a helmet (12.9) was significantly higher (more severe) than that for helmeted riders (2.8). All three patients with a Glascow Coma Score < 15 on arrival were not wearing a helmet at the time of injury. The frequency of hospitalization was significantly higher for those not wearing a helmet. Compared with other common mechanisms of childhood injury the mean Modified Injury Severity Scale score of injured riders was exceeded only by that of pedestrians struck by a car. CONCLUSION: Equestrian injuries are more severe than those suffered from other common pediatric mechanisms. Helmet use is associated with decreased frequency and severity of central nervous system injury.

Stairway-related injuries in children.

OBJECTIVE: To identify the pattern and severity of injury associated with stairway-related falls in children. METHODS: During a 2-year period, all children less than 5 years of age presenting to the University of Virginia Pediatric Emergency Department with a stairway-related injury were prospectively studied. At the time of the emergency department visit, demographic and epidemiologic information was obtained. Injuries were assigned E codes and N codes. A Modified Injury Severity Scale (MISS) score was calculated for each child. Excluded from the study were children with suspected intentional trauma and children with walker-related stairway injuries. RESULTS: Sixty-nine children were enrolled in the study. The median age was 2 years. Head and neck injuries occurred in 90% of the patients, extremity injuries in 6%, and truncal injuries in 4%. Injury to more than one body region did not occur. The majority of injuries were minor. Ninety-six percent had a total MISS score < or = 2. Fifteen patients (22%) suffered significant injuries, including concussion in 11 (16%), skull fracture in 5 (7%), cerebral contusion in 2 (3%), subdural hematoma in 1 (1%), and a C-2 fracture in 1 (1%). CONCLUSIONS: The majority of stairway-related injuries are minor. Injuries to the head and neck region predominate. Injuries to multiple body regions are rare. However, significant stairway-related injuries may be more common than previously reported.

Infant walker-related injuries: a prospective study of severity and incidence.

OBJECTIVE: To determine the incidence and significance of walker-related injuries in infants. METHODS: During a 3-year, 8-month period, all infants who were brought to the University of Virginia Pediatric Emergency Department with a walker-related injury were prospectively studied. During the emergency department visit, demographic and epidemiologic information were recorded. The annual incidence of walker-related injuries occurring in infants < 1 year of age that resulted in a hospital emergency department visit was calculated from the home zip codes of the injured patients and from the population of infants < 1 year of age living in Charlottesville and in Albemarle County. RESULTS: Sixty-five patients were enrolled in the study. The age distribution ranged from 3 months to 17 months, with 95% younger < 1 year old. Mechanisms associated with walker-related injuries included stairway falls in 46 infants (71%), tip-overs in 14 infants (21%), falls from a porch in 2 infants (3%), and burns in 3 infants (5%). These injuries predominantly involved the head and neck region (97%), with few injuries to the extremities (6%) and trunk (3%). Although the majority of injuries were minor, significant injuries occurred in 19 infants (29%). These injuries included skull fracture, concussion, intracranial hemorrhage, full-thickness burns, c-spine fracture, and death. After excluding the burned patients, all the serious injuries resulted from falls down stairs. The annual incidence of injuries occurring in infants < 1 year of age, related to the use of walkers, and resulting in an emergency department visit was 8.9/1000, and for serious injuries was 1.7/1000. CONCLUSIONS: The incidence and significance of infant walker-related injuries in infants are unacceptably high.

Skin disorders encountered in a pediatric emergency department.

A total of 1381 visits to a pediatric emergency department (ED) during a six-week period were surveyed to determine the types and frequency of skin disorders encountered. A primary skin complaint accounted for 431 (31%) visits. There was a skin complaint of secondary importance in another 35 (3%) visits, and a skin disorder not mentioned by the patient or parent was detected on examination in a further 88 (6%) visits. In total, 554 (40%) visits included a skin complaint or a skin finding. As expected, cutaneous trauma (including abrasions, contusions, lacerations, and burns) accounted for a substantial number of visits, but a wide range of other dermatologic conditions was also represented, including skin infections, contact dermatitis, and numerous other disorders. Skin diseases are encountered frequently in the pediatric ED setting and should be included in the formal teaching curriculum for training programs in pediatrics and emergency medicine.

Childhood sexual abuse reported by facilitated communication.

Facilitated communication remains an unproven and controversial strategy for nonspeaking children with developmental disabilities. It is possible that the process may be influenced by the facilitator. The evaluation of alleged sexual abuse reported by FC must include a full psychosocial history, complete physical examination for evidence of abuse, and the assessment of the child's communicative competence. The demonstration of communicative competence requires a strategy similar to that utilized with Carla. The successful documentation of the child's communication of general information should precede the pursuit of specific abuse issues.

Pain reduction in local anesthetic administration through pH buffering.

The effects of pH buffering on the pain of administration and efficacy of three local anesthetics (1% lidocaine, 1% lidocaine with 1:100,000 epinephrine, and 1% mepivacaine) were investigated in a randomized, prospective, double-blind study of 25 adult volunteers. Plain and buffered solutions of the three local anesthetics were prepared, and a 0.5 intradermal injection of each was administered. Pain of anesthetic infiltration was rated from zero to ten. The area of anesthetized skin surrounding each injection site was measured at time intervals following each injection. Buffering the local anesthetics significantly reduced the mean quantitative pain estimates compared to the nonbuffered controls: 1) 1% lidocaine compared with buffered 1% lidocaine, 4.9 +/- 0.4 versus 1.1 +/- 0.2 (P less than 10(-6)); 2) 1% lidocaine with epinephrine compared with buffered 1% lidocaine with epinephrine, 5.1 +/- 0.4 versus 1.8 +/- 0.4 (P less than 10(-6)); and 3) 1% mepivacaine compared with buffered 1% mepivacaine, 5.1 +/- 0.4 versus 0.9 +/- 0.2 (P less than 10(-6)). Onset, extent, and duration of skin anesthesia were not statistically altered by pH buffering. The pain of local anesthetic administration can be dramatically reduced by buffering the local anesthetic prior to its infiltration. Anesthetic efficacy is not compromised, and patient acceptance may be significantly increased.

A pharmacokinetic evaluation of peritoneal dialysis for phenytoin intoxication.

Despite the indications of previous case reports and standard references, peritoneal dialysis did not appreciably enhance the elimination of phenytoin in our patient. In view of our observations, the effectiveness of peritoneal dialysis for phenytoin poisoning should be seriously questioned. A careful reassessment of the efficiency of peritoneal dialysis for phenytoin should be performed and should consider the possible role of phenytoin metabolites contributing to toxicity. Until well-controlled studies support the use of any dialytic procedure for phenytoin overdosage, the management of these patients must rely on general measures to minimize absorption of the drug and on supportive treatment as indicated by the patient's condition.