Knowledge assessment of sports-related concussion among parents of children aged 5 years to 15 years enrolled in recreational tackle football.

BACKGROUND: Sports-related concussion among professional, collegiate, and, more recently, high school athletes has received much attention from the media and medical community. To our knowledge, there is a paucity of research regarding parental knowledge of sports-related concussion. The aim of this study was to evaluate parental knowledge of concussion in young children who participated in recreational tackle football. METHODS: Parents of children aged 5 years to 15 years attending recreational tackle football games were asked to complete an anonymous questionnaire based on the Centers for Disease Control and Prevention's Heads Up: Concussion in Youth Sports Quiz. The parents were asked about their level of agreement regarding statements that represent definition, symptoms, and treatment of concussion. RESULTS: A total of 310 of 369 parents (84% response rate) voluntarily completed the questionnaire, with 94% believing that their child had never had a concussion. However, only 13% (n = 41) could correctly identify all seven statements. Most did not identify that a concussion is considered a mild traumatic brain injury and can be achieved from something other than a direct blow to the head. Race, sex, and zip code had no significant association with correctly answering statements. Education (r = 0.24, p < 0.0001) and number of years the child played (r = 0.11, p = 0.049) had a small association. Fifty-three percent and 58% of the parents reported that someone had discussed the definition and the symptoms of concussion with them, respectively, with only about half reporting that information came from their health care provider. No parent was able to classify all symptoms listed as correctly related or not related to concussion. However, identification of correct concussion statements correlated with identification of correct symptoms (r = 0.25, p < 0.001). CONCLUSION: While most parents of young athletes demonstrated some knowledge regarding concussion, important misconceptions remain regarding the definition, symptoms, and treatment of concussion. This study highlights the need for health care providers to increase concussion educational efforts.

The role of high-fidelity simulation in training pediatric emergency medicine fellows in the United States and Canada.

OBJECTIVES: The American Academy of Pediatrics Section on Emergency Medicine's Simulation Interest Group developed a survey targeting pediatric emergency medicine (PEM) fellowship program directors to assess the use of high-fidelity simulation (HFS) in PEM fellow training. METHODS: Content experts in simulation and in PEM developed a 38-item Internet-based questionnaire that was distributed to PEM program directors via e-mail though www.surveymonkey.com. RESULTS: Seventy-seven percent (51/66) of PEM program directors in the United States and Canada responded to the survey. Sixty-three percent of programs incorporate HFS in PEM fellowship training. For programs with HFS, the most frequent uses of HFS include (1) decision making for trauma resuscitations (97%, 31/32) and medical emergencies (91%, 29/32), and for the application of advanced life support (84%, 27/32); (2) technical skills: intubation (100%, 31/31), bag-mask ventilation (94%, 29/31), cardioversion/defibrillation (90%, 28/31), and difficult airway management (84%, 26/31). Of program directors without simulation, a majority valued simulation for PEM fellow training, and 59% (11/19) plan on expanding efforts. Perceived barriers to an active simulation program exist: lack of financial support (79%, 15/19), lack of simulator equipment (74%, 14/19), lack of a dedicated physical space (68%, 13/19), and insufficiently experienced simulation faculty (58% 11/19). CONCLUSIONS: Sixty-three percent of PEM fellowship programs integrate HFS-based activities. The majority of PEM fellowship program directors value the role of HFS in augmenting clinical experience and documenting procedural skills. Regional simulation centers are one possible solution to offer HFS training to fellowships with limited financial support and/or lack of experienced simulation faculty.

Neonatal scalp abscess: is it a benign disease?

BACKGROUND: Neonatal scalp abscesses are a rare but potentially very serious condition. OBJECTIVES: This report serves to demonstrate meningitis as a potential complication of neonatal scalp abscess. In addition, we review the current literature on the subject and comment on the most appropriate evaluation and treatment. CASE REPORT: We describe six cases of neonatal scalp abscesses with one complication of enterococcal meningitis. CONCLUSION: The emergency practitioner should recognize that a neonate with a scalp abscess needs to be evaluated for potential serious complications and treated empirically to cover for organisms of vaginal origin.

Acute ethanol poisoning in a 6-year-old girl following ingestion of alcohol-based hand sanitizer at school.

BACKGROUND: Alcohol-based hand sanitizers (ABHSs) have been widely used in homes, workplaces and schools to prevent the spread of infectious diseases. We report a young child unintentionally ingested ABHS at a school, resulting in intoxication. METHODS: The child was a 6-year-old girl who had been brought to the emergency department (ED) for hypothermia, altered mental status (AMS), periods of hypoventilation, hypothermia and vomiting. Computed tomography of her head revealed nothing abnormal in intracranial pathology. Urine drug screening was negative. Alcohol level was 205 mg/dL on admission. Other abnormal values included potassium of 2.8 mEq/L, osmolality of 340 mOsm/kg and no hypoglycemia. Further investigation revealed that the patient had gone frequently to the class restroom for ingestion of unknown quantities of ABHSs during the day. The patient was admitted for one day for intravenous fluid hydration and close observation of her mental status. RESULTS: The patient was discharged from the hospital the next day without any complications. CONCLUSION: Despite the large safety margin of ABHSs, emergency physicians need to be aware of the potential risk of ingestion of a large amount of such products in children and consider it in the assessment and management of school-age children with acute AMS.

Penetrating neck injuries in children: a retrospective review.

OBJECTIVE: Penetrating Neck Injuries (PNI) are uncommon in the pediatric population, but they constitute a significant management challenge. Literature has been scant regarding the evaluation and treatment of such injuries in children. Our objective is to evaluate if physical examination alone is sufficient in the assessment and management of pediatric PNI. DESIGN: Retrospective chart review. SETTING: Pediatric emergency center of an urban emergency department (ED) and level 1 trauma center (TC). PARTICIPANTS: All patients 16 years or younger that had penetrating neck injuries between January 1995 and June 2000. INTERVENTIONS: None. RESULTS: During the study period, a total of 148,000 and 9900 patients were seen in the pediatric ED and the TC, respectively. Thirty-one children (22 males, 9 females) with PNI were identified. The median age was 9.5 years (range of 10 months to 16 years). Most children (81%) with PNI were evaluated in the TC. Motor vehicle crashes accounted for 32% of PNI and gun shot wounds for 23% of cases. Most PNI (84%) occurred in zone II of the neck. Eight patients underwent surgical exploration (25.8%) for platysmal penetration, none of which revealed any vascular injuries. Only 4 patients had barium swallows performed based on physical examination findings. All barium swallows were normal. There were no angiograms performed during the study period. A total of 3 patients died (mortality rate of 9%), all of which had major physical examination findings. CONCLUSION: PNI are infrequent in the pediatric population. Most of the patients in our review presented with minor physical examination findings and did not require exploration or diagnostic studies. Observation of the stable child in our case series was found to be an acceptable choice of management of PNI. Further prospective studies are needed to validate these results.

Antibiotic resistance patterns of uropathogens in pediatric emergency department patients.

OBJECTIVES: To evaluate the prevalence of resistance of the various urinary tract infection (UTI) pathogens obtained from patients in an urban pediatric emergency department (PED), and to identify risk factors for infection with resistant strains. METHODS: The data were collected retrospectively in an urban, academic PED in northeastern Florida. The microbiology-computerized database was used to identify all positive urine cultures from October 1999 through June 2000. All patients aged 17 years or less, whose urine specimen was collected in the ED and grew cultures with greater than 10,000 colony forming units (CFU) per milliliter of a single organism on Maconkey or blood agar, were included. The medical records of the patients were reviewed and selective demographic and clinical data were collected. Patients were excluded if their charts were unavailable for review or if the pathogen that grew in culture was a suspected contaminant. All patients lacking clinical symptoms of UTI (frequency, dysuria, abdominal pain, fever, or urgency) and whose urine was collected by clean-catch were excluded if their culture grew between 10,000 and 100,000 CFU. Resistance to trimethoprim-sulfamethoxazole (T-S) was estimated for the subset of gram-negative pathogens. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated to compare rates of resistance among patients with and without the following risk factors: age greater than 4 years; current or recent antibiotic use; day care attendance; and previous UTI. RESULTS: A total of 126 urine cultures were identified for inclusion. Of these, 45 patients were excluded, leaving 81 who met the study criteria. The majority of isolated organisms were Escherichia coli, accounting for 89% of the patients (n = 72). Other organisms identified were Klebsiella 3.7%, Proteus 1.2%, Citrobacter 1.2%, Staphylococcus 1.2%, and Enterococcus 3.7% (all in children < 4 years old). The resistance to T-S was 6.5% (95% CI = 0.9% to 12.1%) for gram-negative pathogens. Overall, 48% of gram-negative isolates were resistant to one or more antibiotics, any resistance (95% CI = 36.5% to 59.5%). T-S resistance was nominally higher for older children and for those with a history of antibiotic use, although not to a significant degree. Children less than age 4 were more likely to have any resistance (OR 2.6; 95% CI = 1.0 to 6.7). CONCLUSIONS: The resistance to T-S in this study was 6.7% for gram-negative pathogens. These rates are lower than rates reported in adult populations, international pediatric studies, and the authors' hospital antibiograms, demonstrating the importance of local, population-specific data in selecting antibiotics. This study did not identify any statistically significant risk factors for resistance to T-S, but suggests that those with a recent history of antibiotic use may be at highest risk. While children less than 4 years old with gram-negative pathogens have nominally lower rates of T-S resistance, they are at higher risk for resistance to one or more antibiotics (any resistance) and are at risk for UTI caused by enterococcus (uniformly nonsusceptible to T-S). Prospective studies are needed to validate these results and to identify predisposing factors for urinary pathogens with antibiotic resistance.

Hand and fingertip injuries in children.

BACKGROUND: Hands are frequently injured in children. To date, the literature has focused on the type and treatment of hand injuries. This study examines the epidemiology of hand and fingertip injuries in children who present to an emergency department (ED). DESIGN: Retrospective chart review. SETTING: Pediatric emergency center of an urban ED. PARTICIPANTS: All patients over a period of 8 months who presented with a chief complaint of hand injury. METHODS: A total of 17,859 charts were reviewed during the study period; 382 patients were enrolled in the study (male preponderance of 1.4:1; median age, 10 y). RESULTS: The most frequent injury setting was outdoors (47%). The most frequent injuries were lacerations (30%), followed by fractures (16%). Only five patients required hospitalization (1.3%). The digits are the most commonly injured part of the hand, particularly the thumb (19%). Fingertips are involved in 21% of cases. Radiographs and consultations were obtained in 64% and 16% of cases, respectively. Infection occurred in 14 (3.7%) patients. CONCLUSION: Hand injuries occur in a bimodal distribution in children. Children younger than 2 years suffered fingertip injuries in the home, and children aged 12 to 16 years suffered hand injuries. Sports injuries tend to present late and are the most common cause of hand fractures.

Managing the unique size-related issues of pediatric resuscitation: reducing cognitive load with resuscitation aids.

A resuscitation is a complicated event that requires for its optimal outcome the effective completion of a distinct series of actions, some simple, some complex, most occurring simultaneously or in close proximity. In children, these actions are determined not only by the clinical situation, but also by a series of age and size factors particular to each child. Different tasks require different levels of cognitive load, or mental effort. Cognitive load describes the mental burden experienced by the decision maker and will be higher when the task is less familiar or more demanding. In the setting of resuscitation, it refers to the cumulative demands of patient assessment, the ongoing decisions for each of the various steps, and decisions around procedural intervention (e.g., intubation). In children, the level of task complexity and, hence, cognitive load is increased by the unique component of variability of pediatric age and size, introducing logistical factors, many of which involve computations. The purpose of this paper is to examine the effects of age/size-related variables on the pediatric resuscitative process and to explore how these effects can be mitigated using resuscitation aids. The concept of cognitive load and its relation to performance in resuscitation is introduced and is used to demonstrate the effect of the various aids in the pediatric resuscitative process.