Adult Chest Pain in the Pediatric Emergency Department: Treatment and Timeliness From Door In To Door Out.

OBJECTIVES: The American College of Cardiology Foundation/American Heart Association guidelines for acute coronary syndrome (ACS) recommend immediate aspirin (ASA) administration, an electrocardiogram (ECG) in less than 10 minutes, and a door-in to door-out (DIDO) time less than 30 minutes for interfacility transfer. We sought to determine if compliance is hindered when adults with suspected ACS present to pediatric facilities. METHODS: Visits to the 2 tertiary care emergency departments of a pediatric healthcare system using an adult chest pain protocol were examined from October 2006 to September 2012. Patients older than 18 years with a diagnosis suggestive of ACS and an initial ECG interpretation were identified. Proportions of patients receiving ASA were calculated as well as median times to ECG and DIDO. Bivariate analysis of ECG and DIDO time and the proportion of the patients receiving ASA was conducted for ECG findings positive and negative for ACS. RESULTS: One hundred thirteen patients were identified. Aspirin was administered in 69% of eligible cases. Electrocardiogram and DIDO times met recommended intervals in 42% (median, 12 minutes) and 5% (median, 59 minutes) of the patients, respectively. No significant differences between positive (22% of total) and negative (78% of total) ECG findings groups were detected in median DIDO time (57 vs 59 minutes, P = 0.99), time to ECG (14 vs 12 minutes, P = 0.45), or the proportion receiving ASA (84% vs 64%, P = 0.08). CONCLUSIONS: Despite the use of an emergency department protocol, compliance with the American College of Cardiology Foundation/American Heart Association guidelines for adults with suspected ACS remained challenging at this pediatric center. The ECG findings did not seem to impact ASA administration, ECG time, or DIDO time.

Rare-earth magnet ingestion: a childhood danger reaches adolescence.

Ingestion of multiple magnets may cause serious gastrointestinal morbidity, such as pressure necrosis, perforation, fistula formation, or intestinal obstruction due to forceful attraction across bowel wall. Although the consequences of multiple magnet ingestion are well documented in young children, the current popularity of small, powerful rare-earth magnets marketed as "desk toys" has heightened this safety concern in all pediatric age groups. A recent US Consumer Product Safety Commission product-wide warning additionally reports the adolescent practice of using toy high-powered, ball-bearing magnets to simulate tongue and lip piercings, a behavior that may increase risk of inadvertent ingestion. We describe 2 cases of older children (male; aged 10 and 13 years, respectively) with unintentional ingestion of multiple rare-earth magnets. Health care providers should be alerted to the potential for misuse of these high-powered, ball-bearing magnets among older children and adolescents.

Going viral: adapting to pediatric surge during the H1N1 pandemic.

OBJECTIVES: The objective of this study was to assess hospital and emergency department (ED) pediatric surge strategies utilized during the 2009 H1N1 influenza pandemic as well as compliance with national guidelines. METHODS: Electronic survey was sent to a convenience sample of emergency physicians and nurses from US EDs with a pediatric volume of more than 10,000 annually. Survey questions assessed the participant's hospital baseline pandemic and surge preparedness, as well as strategies for ED surge and compliance with Centers for Disease Control and Prevention (CDC) guidelines for health care personal protection, patient testing, and treatment. RESULTS: The response rate was 54% (53/99). Preexisting pandemic influenza plans were absent in 44% of hospitals; however, 91% developed an influenza plan as a result of the pandemic. Twenty-four percent reported having a preexisting ED pandemic staffing model, and 36% had a preexisting alternate care site plan. Creation and/or modifications of existing plans for ED pandemic staffing (82%) and alternate care site plan (68%) were reported. Seventy-nine percent of institutions initially followed CDC guidelines for personal protection (use of N95 masks), of which 82% later revised their practices. Complete compliance with CDC guidelines was 60% for patient testing and 68% for patient treatment. CONCLUSIONS: Before the H1N1 pandemic, greater than 40% of the hospitals in our study did not have an influenza pandemic preparedness plan. Many had to modify their existing plans during the surge. Not all institutions fully complied with CDC guidelines. Data from this multicenter survey should assist clinical leaders to create more robust surge plans for children.

Adverse effects of oral nonstimulant psychotropic medications in young children reported to a regional poison center.

BACKGROUND: Use of nonstimulant psychotropic medications other than antidepressants in young children is reported to be increasing. The patient safety ramifications of this remain unclear. OBJECTIVES: To evaluate the frequency of calls to a regional poison center reporting adverse drug effects and the level of medical attention required in young children who are receiving oral nonstimulant psychotropic medications. MATERIALS AND METHODS: A retrospective review of 544 267 consecutive human exposure poison center records between 2000 and 2008 was conducted for cases of young children given nonstimulant psychotropic medications with therapeutic intent. RESULTS: A total of 597 cases met criteria for analysis. Drugs involved were 286 risperidone, 133 clonidine, 114 quetiapine, 37 aripiprazole, 43 olanzapine, 29 ziprasidone, and 5 buspirone; two or more were involved in 250 cases. Reasons for exposure included excess dose given unintentionally (61%), wrong medication unintentionally (12%), adverse effects with correct dose (11%), excess dose intentionally (0.6%), therapeutic error by health-care provider (0.5%), and unclear circumstances (15%). Moderate effects (such as dystonic reaction) occurred in 34 patients at their usual dose (53% of 64) and in 15 at unintentionally excessive doses (4% of 361). Emergency department evaluation of 22% of the children resulted in 5% of the total being admitted to a non-intensive care unit (ICU) bed and 2% of all admitted to an ICU bed. CONCLUSION: Dosing errors and adverse effects involving nonstimulant psychotropic medications are cause for concern in young children. Additional information about safety and optimal dosage of these medications is needed to guide appropriate use.

Pandemic H1N1 influenza in the pediatric emergency department: a comparison with previous seasonal influenza outbreaks.

STUDY OBJECTIVE: We compare the acuity of pediatric emergency department (ED) patients between the ongoing H1N1 influenza pandemic and previous seasonal influenza outbreaks. METHODS: An observational, cross-sectional analysis of patient visits at 2 pediatric tertiary care EDs was made for the following periods: (1) regional fall 2009 H1N1 influenza surge (August 17 to September 20, 2009), and (2) combined regional 2007 to 2009 early peak influenza seasons (January 28 to March 2, 2008, and February 2 to March 8, 2009). Proportions of admissions, return visits, and return visits resulting in admission were compared between the 2 periods. Subset analysis of patients with influenza-like illness was performed. RESULTS: Of total visits, no difference was found in the proportions of hospital admissions between the 2009 H1N1 surge (18,503 visits) and the previous influenza seasons (29,002 visits): non-ICU 9.9% versus 10.4%, 95% confidence interval of the difference -0.07% to 1.0%; ICU 0.9% versus 0.9%, 95% CI of the difference -0.1% to 0.2%. Of patients with influenza-like illness, no difference was found in the proportions of non-ICU admissions between the 2009 H1N1 surge (7,064 visits) and the previous influenza seasons (8,489 visits): 4.8% versus 5.2%, 95% CI of the difference -0.3% to 1.1%, whereas the proportion of ICU admissions increased during the 2009 H1N1 surge: 0.3% versus 0.1%, 95% CI of the difference 0.05% to 0.4%. The proportions of return visits within 7 days, including those resulting in admission, were similar between the 2 periods for both the total ED population and the influenza-like illness subset. CONCLUSION: The severity of illness during the 2009 H1N1 surge appeared similar to that of previous influenza seasons for the total population of the 2 pediatric tertiary care EDs, whereas an increase in the proportion of ICU admissions was observed for patients with influenza-like illness.