Effectiveness of oral or nebulized dexamethasone for children with mild croup.

OBJECTIVE: To assess the efficacy of oral dexamethasone or nebulized dexamethasone sodium phosphate in children with mild croup. METHODS: Double-blind, placebo-controlled study of 264 children between 6 months and 6 years of age with symptoms of croup for fewer than 48 hours. Patients were excluded if they received racemic epinephrine or corticosteroid treatment. Other exclusion criteria included corticosteroid treatment during the 14 days prior to enrollment or complicating medical condition. Subjects randomly received oral dexamethasone (0.6 mg/kg), nebulized dexamethasone sodium phosphate (160 microg), or placebo. Telephone follow-up was obtained on days 1, 2, 3, 4, and 7. MAIN OUTCOME MEASURES: The primary outcome measure was treatment failure, defined as receiving corticosteroid or racemic epinephrine treatment during the 7 days after enrollment in the study. Secondary outcome measures included seeking additional care and the parental assessments of the patients' condition obtained during follow-up (worse, same, better, or gone). RESULTS: Eighty-five patients received oral dexamethasone, 91 received nebulized dexamethasone, and 88 received placebo. There were 3 treatment failures in the oral dexamethasone-treated group, 12 in the nebulized dexamethasone-treated group, and 10 in the placebo-treated group (P =.05). Ten children in the oral dexamethasone-treated group sought additional care compared with 27 and 29 in the nebulized dexamethasone-treated and placebo-treated groups, respectively (P =.002). Parents of children in the oral dexamethasone-treated group reported greater improvement on day 1 (P<.001) compared with the nebulized dexamethasone-treated and placebo-treated groups. CONCLUSIONS: Children with mild croup who receive oral dexamethasone treatment are less likely to seek subsequent medical care and demonstrate more rapid symptom resolution compared with children who receive nebulized dexamethasone or placebo treatment.

Delayed diagnosis in pediatric blunt trauma.

OBJECTIVE: Identification of injuries of a traumatized patient is a mandate for the emergency department (ED) and the trauma team. Delayed diagnosis of injury in trauma patients leads to increased morbidity, mortality, dissatisfaction, and risk of litigation. Comparing children admitted for blunt trauma, with and without delay, this study examines risk factors for delayed diagnosis. METHODS: Delays in diagnosis from 1991 to 1996 were identified during prospective collection of trauma registry data. Controls were randomly selected from the trauma registry. Charts from both groups were retrospectively reviewed. RESULTS: Fifty-eight patients had 65 delays in diagnosis. Significant independent delay variables included: female, motor vehicle crash (MVC)-related mechanism, altered consciousness, higher injury severity score, and multiple injuries (P < 0.05). Trauma team activation, documentation of tertiary survey, and length of hospitalization were greater in patients with delay injuries (P < 0.05). Logistic regression identified MVC-related mechanism, female, facial, and extremity injuries as a combination of predictors. CONCLUSIONS: Delays occurred in 1% of patients. Trauma team care itself did not protect all patients from delay. Injury severity at presentation alone is not an adequate predictor of delayed diagnosis in the pediatric patient. A combination of variables was identified as negative predictors of delay. Further study is needed to validate these criteria, and determine if earlier diagnosis would effect quality.

Maximizing the sensitivity and specificity of pediatric trauma team activation criteria.

BACKGROUND: Care of the severely injured child requires the rapid assembly of personnel trained in pediatric trauma care. Trauma team activation criteria, which are highly sensitive and maximally specific for identifying the child who requires resuscitation, are necessary to provide rapid care to all who need it, while using resources efficiently. OBJECTIVE: To determine the sensitivity and specificity of the standard trauma team activation (TTA) criteria for identifying patients who receive resuscitation in the emergency department. METHODS: A one-year study was conducted of all patients transported by emergency medical out-of-hospital services for a trauma-related complaint. For all patients, out-of-hospital medical control operators recorded whether patients met TTA criteria and, if so, which criteria were met. Criteria included standard physiologic, anatomic, and mechanism parameters. Sensitivity and specificity for the outcome of resuscitation (volume restoration, assisted ventilation or intubation, chest tube insertion/needle decompression, operative intervention) were calculated. RESULTS: A total of 492 patients met the case definition. Two-thirds were male, the mean age was 8 years (+/-4.8 SD), and the Injury Severity Score was > or =15 in 9.3%. Trauma team activation criteria were met by 179 patients (36. 4%) and, of these, 107 met mechanism criteria only. A resuscitative intervention was received by 54 (10.9%) of the total and none in the mechanism-only group. Sensitivity and specificity of the TTA criteria for predicting receipt of a resuscitation procedure were 98. 1% and 71.2%, respectively. When mechanism criteria were excluded, the sensitivity remained 98.1% and the specificity increased to 95. 7%. CONCLUSIONS: Criteria for TTA that include patients who meet mechanism criteria only are not specific for identifying patients who receive a resuscitative intervention. Use of anatomic and physiologic criteria only results in an increase in specificity, thereby reducing overtriage while retaining a high sensitivity.

Linking emergency department patients to primary care: phone vs face-to-face interaction.

OBJECTIVE: To compare the patient compliances and time analyses of two methods of assigning primary care providers (PCPs) to ED patients who are without a PCP: phone interview vs face-to-face interaction. METHODS: Prospective observational cohort study following an intervention, performed in a pediatric ED, serving a population of 1.7 million, with a census of 80,000 pediatric ED visits per year. Over one year, a consecutive sampling of 1,062 patients evaluated in the ED and without a PCP were approached to participate in our study (536 enrolled, 526 declined). Patients enrolled were addressed by a nurse practitioner/social worker (NP/SW) who arranged an appointment with a PCP, either in person (in ED) or by phone after discharge. The primary outcome measure was compliance with the arranged appointment. Secondarily, the authors analyzed the time necessary for each approach in person-hours. RESULTS: Of the 536 enrolled, 81 were excluded because data collection was incomplete at the time of the study's completion, leaving 455 study patients. Seventy-six percent of the study patients were between the ages of 1 month and 12 years. Contact was made by phone for 151 (33%) patients and face-to-face for 304 (67%). Sixty-two percent of the phone patients kept their appointments, compared with 52% of face-to-face patients (p = 0.048, RR = 1.20, 1.02 < RR < 1.41). Phone interaction was also more time effective. CONCLUSION: Linking ED patients without a medical provider to PCPs via phone is as effective as a face-to-face interaction.

A pilot study of the predictive value of plasma tumor necrosis factor alpha and interleukin 1 beta for Streptococcus pneumoniae bacteremia in febrile children.

OBJECTIVE: To determine the value of tumor necrosis factor alpha (TNF) and interleukin 1 beta (IL1) levels in predicting Streptococcus pneumoniae bacteremia in nontoxic-appearing, febrile children who do not have a bacterial source for their fever on physical examination. METHODS: A prospective, nested case-control study was conducted in a children's hospital ED. All febrile children < 3 years old who were believed to be immunocompetent and not in shock, had no obvious bacterial source for their fever on physical examination, and had a blood culture obtained were eligible. Plasma obtained at the time of the blood culture was available for analysis by enzyme-linked immunosorbent assays for TNF and IL1. Children who had positive blood cultures for Streptococcus pneumoniae were the cases. The controls were selected from children who had negative blood cultures. RESULTS: During a 1-year period, 12 cases and 65 controls were identified. There was no significant difference in age, height or duration of fever, or illness acuity between the groups. The following were used as threshold values for positive test: white blood cell (WBC) count > 15.0 x 10(9) cells/L, TNF > 21.5 ng/mL, and IL1 > 9.0 ng/mL. Using an estimated prior probability of bacteremia of 4%, the positive predictive value (PPV) and the negative predictive value (NPV) for bacteremia were 11.7% and 98.6% using the WBC count, 11.1% and 98.6% using the IL1 level, and 9.0% and 98.9% using the TNF level. The combination of WBC count with either TNF or IL1 gave an NPV of 100%, with PPVs of 8.5% for TNF and 9.9% for IL1. CONCLUSIONS: Like the WBC count, TNF and IL1 are good negative but poor positive predictors of Streptococcus pneumoniae bacteremia in nontoxic-appearing, febrile children. At present, the addition of plasma TNF or IL1 levels would add little to emergency physicians' ability to predict Streptococcus pneumoniae bacteremia. However, as the quantification of these cytokines becomes more rapid, available, and standardized, and more knowledge of TNF and IL1 levels during various illnesses is gained, their utility in the clinical setting for ruling out bacteremia should be further assessed.

An update on pediatric trauma.

Trauma care for children is examined from a demographic perspective. Critical issues, such as "who should care for acutely injured children" and "where should they receive care" are addressed. Specific issues regarding blunt trauma and indications for and outcome of emergency department thoracotomy are discussed also. A strategy for injury prevention is reviewed.

Development of a polymerase chain reaction assay to detect the presence of Streptococcus pneumoniae DNA.

In this study, we have developed a chemically sensitive and specific polymerase chain reaction (PCR) assay to detect the presence of Streptococcus pneumoniae genomic DNA. The target DNA sequence was a 322-base pair segment of the S. pneumoniae DNA polymerase I gene (pol I). PCR products of pure cultures of a set of pneumococcal serotypes commonly associated with human infection could be amplified in water and in blood cultures of clinical isolates containing S. pneumoniae. We were able to detect 2 fg of purified S. pneumoniae DNA. There were no false-positive reactions when the assay was performed on samples containing the following clinically encountered bacteria: Haemophilus influenzae type B, Neisseria meningitidis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas spp. nontypeable H. influenzae, Staphylococcus aureus, coagulase-negative staphylococci, and Streptococcus pyogenes. The addition of EDTA and citrate-anticoagulated whole blood to the PCR reaction mixture inhibited the PCR assay, whereas the addition of lithium heparin, sodium heparin, and sodium polyanetholesulfonate-anticoagulated whole blood to PCR reaction mixture did not interfere with the ability to detect the presence of S. pneumoniae DNA.

Smoke inhalation injury.

Smoke inhalation injury in children still represents a significant cause of pulmonary disease and mortality. Carbon monoxide and other toxic products of combustion are major determinants of severity. Early hypoxemia is a contributor to over 50% of deaths. There are several clinical entities: upper airway obstruction, bronchospasm, consolidation, pulmonary edema, ARDS, and late pneumonia. Intensive care has improved outcome from burns, but pulmonary injury is still an important cause of mortality. New therapies such as high frequency ventilation may improve the outcome. Primary prevention is the most important way to reduce the poor outcome from significant exposure.

Electrocardiographic findings in children with Lyme disease.

The incidence of cardiac involvement in Lyme disease (LD) has been estimated to be 4 to 10% in adults, with conduction and rhythm disturbances noted most frequently. To assess the frequency of electrocardiographic abnormalities in children with LD, we prospectively performed 12-lead electrocardiograms in 32 randomly selected children presenting with LD between May and September 1989. No patient had symptoms of cardiac involvement. Using defined diagnostic criteria, combining symptoms, signs, serology, and residence in or travel to an endemic area, 14 patients were classified as having definite LD and 10 were categorized as probable. The incidence of electrocardiographic abnormalities in the definite group was 29% (4/14), including two patients with 1 degree atrioventricular block, one with left axis deviation, and one with ventricular ectopy. Thirty percent (3/10) of the probable group had abnormal ECGs, including one with ST-T wave abnormalities, one with prominent sinus arrhythmia, sinus bradycardia, and wandering atrial pacemaker, and one with ectopic atrial bradycardia. No patient required cardiac therapy. The incidence of abnormal ECG findings in this group of children with either probable or definite LD was thus 29%, with 1 degree atrioventricular block noted most frequently. When the diagnosis of LD is highly suspected, an electrocardiogram may be a useful screening test for cardiac involvement.

Respiratory distress in a child in the office.

We have reviewed respiratory distress from a pathophysiologic approach. Two specific disease entities, epiglottitis and asthma, which commonly present with respiratory distress, are reviewed. The office management of respiratory distress encompasses early recognition of disease to prevent symptoms from progressing. Referral should be considered in any difficult cases.

Three-wheeled vehicle injuries in children.

Injuries associated with nonmotorized three-wheeled vehicles were prospectively evaluated through a standard questionnaire during the summer months at the emergency department of the Children's Hospital of Philadelphia, Pa. Forty-four children, including 32 boys, with a mean age of 3.77 years, reported such injuries. Most fell (36.4%), but a second vehicle was often involved. Most children (33 of 44) were on low-slung Big Wheels. Head, neck, and dental injuries accounted for the majority. Most injuries were not serious. Two patients were admitted; both had fractures, one of them had a concussion. Data from the US Consumer Product Safety Commission corroborate the epidemiology of these injuries. Recommendations of safety precautions with non-motorized three-wheeled vehicles are reviewed.

Hypoelectrolytemia, hypovolemia, and alkalosis in cystic fibrosis with wood-burning stove in winter.

Hypoelectrolytemia, alkalosis, and shock were present in an infant subsequently diagnosed as having cystic fibrosis (CF). Environmental temperature control was poorly maintained by a wood-burning stove in winter and contributed to the process of fluid and electrolyte loss. Pediatricians must consider CF and other processes when electrolytes and fluid are lost during environmental heat excess.

Pediatric chest pain: a prospective study.

Previous studies of childhood chest pain have been retrospective or considered only limited age groups or referred patients. In this study, all children who were admitted to the emergency department with chest pain were evaluated prospectively. Patients with ill-defined chest pain had ECGs and echocardiograms performed. A total of 407 children were evaluated. The most common causes of the pain were idiopathic (21%) and musculoskeletal (15%). Cardiac problems were found in 4%. Chest pain was acute (of less than 48 hours' duration) in 43% and chronic (of greater than 6 months' duration) in 7%. Pain caused 30% of children to stay out of school and 31% to awaken from sleep. Chest wall tenderness was the most common abnormality. ECGs were obtained in 47%; results of 31/191 were abnormal but only 4/191 ECG abnormalities were related to the diagnosis. Echocardiograms were obtained in 34%; results of 17/139 were abnormal (12/139 showed mitral valve prolapse). Young children are more likely to have cardiorespiratory problems; children older than 12 years of age are more likely to have psychogenic pain. The description and location of the pain and the patient's sex are not related to the diagnosis. Nonorganic disease is related to a family history of heart disease or chest pain or having chronic pain. Organic disease is related to pain of acute onset, abnormal physical examination results, pain that awakens the child from sleep, and the presence of fever. Laboratory tests are rarely helpful in evaluating children with chest pain. Chest pain in children is usually benign. Psychogenic pain and idiopathic pain are less common than previously believed.

Correlates of reported smoke detector usage in an inner-city population: participants in a smoke detector give-away program.

As part of a smoke detector give-away program, 388 adults were surveyed to characterize smoke detector ownership in a low-income population and to identify those who would acquire a free smoke detector following their child's visit to the hospital. Factors associated with smoke detector ownership included higher education, home ownership (vs public housing), knowledge of the city smoke detector law, and the practice of other injury prevention measures. Regardless of ownership, the great majority of parents (82 per cent) acquired a free smoke detector, but those previously without a smoke detector were more likely to do so. These characteristics of smoke detector usage and acquisition should be considered in targeting future intervention strategies.

Abnormal sweat electrolytes in a case of celiac disease and a case of psychosocial failure to thrive. Review of other reported causes.

Sweat electrolytes were initially elevated in a child who was diagnosed as having celiac disease and also in one with psychosocial failure to thrive. Subsequent sweat tests were normal after nutritional status of the patients had improved with therapy. The reports of elevated sweat electrolytes in conditions other than cystic fibrosis are discussed. It is emphasized that sweat test methods other than the quantitative pilocarpine iontophoresis method are not reliable. The occurrence of false-positive sweat tests demonstrates the need for care in the interpretation of elevated sweat electrolytes and the necessity of performing repeat quantitative pilocarpine iontophoresis for the establishment of the diagnosis of CF. Celiac disease and malnutrition from other causes may cause sweat electrolytes to be elevated.

Aerosolized metaproterenol compared to subcutaneous epinephrine in the emergency treatment of acute childhood asthma.

In a double-blind, randomized trial, we compared the effects of aerosolized metaproterenol to subcutaneous epinephrine in 35 episodes of acute asthma in children between 6 and 19 years of age. Patients were randomized to two parallel groups and then received both a placebo medication and an active medication to a maximum of three treatments. Repeated treatments were given to 15 patients on metaproterenol and 12 patients on epinephrine. Initial improvement in PEFR and FEV1 were statistically significant and comparable in both groups. Patients receiving a second metaproterenol treatment had more improvement in respiratory rate and clinical score compared with those in the epinephrine group. There were fewer treatment failures in the metaproterenol group. Followup at 24 to 48 hours showed significant treatment failure differences between the two groups (metaproterenol = 0, epinephrine = 5; p less than 0.05). Side effects were similar in both groups; in all instances they were mild, and their frequency did not increase in patients receiving repeated doses of medications. In conclusion, aerosolized metaproterenol was well tolerated in acute childhood asthma in repeated doses, and it appeared to be associated with prolonged bronchodilation and improved outcome.

Pediatric trauma: an approach to the injured child.

The approach to the injured child requires great care and clinical acumen to establish the diagnosis and institute appropriate treatment. Loss of life from occult internal hemorrhage or neurologic sequelae from a missed unstable cervical spine injury may be devastating. Yet, physicians in the ED must also know which children need only a careful physical examination, and when laboratory testing or admission is unnecessary. We have described a schema for providing appropriate care to children with trauma in such a way that specific issues about management can be reasonably approached by the emergency physician.