Utility of Body Habitus Parameters to Determine and Improve the Accuracy of the Broselow Tape.

OBJECTIVES: The aims of this study were to determine and improve accuracy of the Broselow Tape (BT) in estimating children's weight by adding body habitus parameters. METHODS: This cross-sectional study was conducted in an urban hospital pediatric clinic. Children up to 8 years old coming in for well-child visit were included. Children with acute illness or presence of any chronic condition potentially resulting in growth disturbance and out of BT height range were excluded. The following body habitus parameters were measured using the Centers for Disease Control and Prevention guidelines: actual weight, predicted weight using BT (BTW), mid-thigh circumference (MTC), body mass index, mid-arm circumference, and waist-to-hip ratio. RESULTS: A total of 301 children were enrolled. Of these, 151 were male (50%). Hispanics constituted 160 (53.2%). There was a positive linear association between BTW and actual weight in the overall cohort (adjusted R2 = 0.9164, P < 0.001). However, there was a difference in this association among children younger than 2 years and children older than 2 years (adjusted R2 = 0.89 vs 0.4841). Incorporating MTC and/or waist circumference along with BTW in the model increased the accuracy, providing a better estimate of actual weight (adjusted R2 = 0.94, P < 0.001). CONCLUSIONS: We conclude that there might be inaccuracies in the weight predicted by BT in our patient population, especially those weighing more than 15 kg and older than 2 years. Our study also demonstrates that MTC correlates closely with the actual weight and could be used in addition to BT for more accurate weight estimation.

Parent and Physician Preference for Anxiolytic Medication Prior to Laceration Repair in Young Children.

Objectives Pediatric laceration repair is a daunting process for parents and physicians. The repair could take place quickly if the child is calm and relaxed.This study aimeds to evaluate parental and physician preference for anxiolytic medication administration prior to laceration repair, with a pre-and post-repair survey on parents' and physicians' initial preference and follow-up perception. Methods Parents or guardians of children aged six months to five years who presented with simple lacerations and their physicians were asked to complete a survey on potential benefits and expectations of anxiolytic use before and after the laceration repair.  Results Fifty parents/guardians completed the survey. Forty-three (86%) expressed their preference for anxiolytic medication use if it had been available, before laceration repair. Parents/guardians perceived reactions to laceration repair before and after the procedure were significant, ranging from "uncontrolled crying" to "continuous crying" (p=.032). The parents/guardians overwhelmingly preferred to take part in the decision-making process during the repair (not significant). Preference for anxiolytic use was high before repair at 54% and increased to 62% after witnessing the procedure (not significant). Physicians who completed the survey supported the use of anxiolytics 84% of the time. Forty (80%) physicians preferred the intranasal route, while parents/guardians preferred the oral route (58%). Conclusions Procedural sedation is critical for anxiety control and to minimize the difficulties related to treatment. In our study, parents and physicians supported the administration of an anxiolytic agent to help alleviate anxiety and achieve optimal outcomes.

A Reexamination of the Accuracy of the Broselow Tape as an Instrument for Weight Estimation.

BACKGROUND: Accurate weight estimation is important for calculating appropriate medication dosages, determining rates of fluid replacement, and selecting correct equipment sizes in critically ill children requiring resuscitation. The actual measurement of the weight of a critically ill or injured child is often not possible. The Broselow Pediatric Emergency Tape (BT) is an important tool for predicting a child's weight based on his/her height. Although BT has previously been validated, given the increasing prevalence of obesity in today's society, it behooves clinicians relying on this resuscitation aid to revisit the issue. OBJECTIVE: The aim of this study was to evaluate the accuracy of the color-coded BT in weight estimation and the influence of obesity on its accuracy. METHODS: This is a retrospective study conducted in a pediatric clinic of urban hospital. This study reviewed the medical records of children up to 96 months of age, who presented during 2008-2010. We recorded the child's age (in months), actual (measured) weight (in kilograms), and height (in centimeters). Based on the height, weight estimation was obtained using the color-coded BT. The actual weight was compared with the predicted weight obtained by the height-based BT. Patients presenting with any medical condition that would substantially affect growth of the child were excluded. A univariate logistic regression model was utilized to predict any underestimation based on age, sex, and body mass index (BMI) percentile. RESULTS: The medical records of 538 children were reviewed. There was a discrepancy in 226 children (42%). Broselow Pediatric Emergency Tape underestimated weight (measured weight was higher than predicted weight) in 158 children (29.4%) and overestimated (measured weight was lower than predicted weight) in 68 children (12.6%). Of the 158 underestimated children, 138 were off by 1 color zone, 16 by 2 color zones, and 4 by more than 2 color zones. When characterized by BMI, 46 children (13.6%) had normal BMI, 27 (45.8%) were overweight, and 84 (80.8%) were obese, whereas one child (2.8%) was underweight. CONCLUSIONS: In our population, BT was inaccurate in predicting weight in 42% of children (underestimation in 158 children [29.4%] and overestimation weight in 68 children [12.6%]). However, the majority of discrepancies involved only 1 BT color zone. Emergency physicians should be aware of this discrepancy until more accurate methods become available.

Factors Predicting Asthma in Children With Acute Bronchiolitis.

OBJECTIVE: The aim of this study was to determine if there is an association between bronchiolitis and future development of asthma in children younger than 2 years. METHODS: We reviewed the medical records of 1991 patients younger than 2 years presenting to the emergency department from January 2000 to December 2010 who received a clinical diagnosis of acute bronchiolitis. Their demographic information, the number of bronchiolitis episodes, and family history of asthma were recorded. The primary care clinic records of these children were reviewed for a period of 1 year following their presentation to the emergency department to determine if they had received a diagnosis of asthma. A stepwise logistic regression was performed to determine what factors were associated with future asthma development. RESULTS: We reviewed the medical record of 1991 children with the diagnosis of bronchiolitis for subsequent development of asthma. The following variables were identified as predictors of subsequent asthma: male sex (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.05-1.55), family history of asthma (OR, 1.6; 95% CI, 1.33-1.95), atopy (OR, 1.4; 95% CI, 1.12-1.83), age older than 5 months (OR, 1.4 95% CI, 1.13-1.66), more than 2 episodes of bronchiolitis (OR, 2.4; 95% CI, 1.79-3.07), and allergies (OR1.6; 95% CI, 1.14-2.14). CONCLUSIONS: In this limited sample, the predictor variables for asthma were male sex, age older than 5 months, more than 2 episodes of bronchiolitis, a history of atopy, and allergies.

Isolated LOC in head trauma associated with significant injury on brain CT scan.

BACKGROUND: A report of loss of consciousness (LOC) is frequently considered reason enough to obtain a computed tomography (CT) scan in the evaluation of head trauma. We conducted this study to reduce exposure to radiation from CT, while still not overlooking clinically significant injuries. OBJECTIVE: The objective of the study is to determine the correlation between LOC status and brain CT scan results in patients with blunt head trauma and to determine whether there is a subset of patients for whom CT scan need not be performed, without missing clinically significant intracranial injuries. METHODS: This is a retrospective study conducted in the emergency department of an inner-city hospital. The patient population included patients ranging between 13 and 35 years of age, with blunt head trauma, who presented to the emergency department (ED) between January 2010 and December 2013. Patients were divided into two groups: "LOC" group and "no LOC" group. The results of brain CT scans from each group were compared with LOC status. For study purposes, "clinically significant" were those that required interventions or ICU hospitalization of at least 24 h or extended hospitalization. The results were analyzed using chi-square calculations. RESULTS: During the study period, 494 patients were identified as having suffered head trauma. Of these, 185 (37.5%) reported LOC and 309 (62.5%) did not lose consciousness. In the LOC group, 15 (8.1%) had significant CT findings compared to 1.3% (4/309) of those without LOC (p < .001). Of the 4 who had no LOC and had significant brain CT findings, all 4 patients had positive physical findings of head, neck, or facial trauma. In the LOC group, only 1/15 (6.7%) had significant CT findings with a normal GCS of 15 and no physical signs of the head, neck, or facial trauma. CONCLUSIONS: A small proportion of patients with LOC had CT finding requiring intervention. Head trauma patients with no physical injuries to the head, neck, or face and a normal GCS had no significant brain CT findings. This raises the question of whether a routine brain CT scan should be obtained in patients with LOC, no physical findings, and a normal GCS after blunt head trauma.

Do all children with suicidal ideation receive a significant psychiatric intervention?

BACKGROUND: In most physicians' minds, suicidal ideation carries with it an ominous prognosis requiring intensive evaluation and treatment. The aim of this study was therefore to determine the proportion of children identified with suicide ideation who received a significant psychiatric intervention. METHODS: Medical records were reviewed for psychiatric interventions of all children presenting to the emergency department (ED) with behavioral disorders between 2004 and 2007, for whom a psychiatry consultation was obtained. Suicidal children were those who had expressed suicidal ideation. Significant psychiatric intervention was defined as one of the following: hospitalization in a psychiatric facility, period of observation in the ED (≥ 12 h), use of restraints, and prescription of psychiatric medication. Suicidal labeling was considered appropriate if one or more of the aforementioned interventions were recommended by a psychiatrist. The presence of psychiatric intervention was compared with that in children who presented with a behavioral disorder, not labeled as suicidal. Chi-squared or Fisher's exact test, whenever appropriate, was used to evaluate the association between suicide status and intervention. RESULTS: A total of 160 children (27.1%) were labeled as suicidal, and 431 (72.9%) with a behavioral disorder were classified as non-suicidal. A total of 244/431 (56.6%) in the non-suicidal group had a significant psychiatric intervention compared to 79/160 (49.4%) in the suicidal ideation group (P = 0.116). This 49.4% is significantly different from an a priori assumption that 100% of children with suicidal ideation would have a significant psychiatric intervention. CONCLUSION: More than half (50.6%) of the children presenting with a label of suicidal ideation did not receive significant psychiatric intervention. This study calls into question the accuracy of suicide labeling in children referred to the ED.

Can a simple urinalysis predict the causative agent and the antibiotic sensitivities?

OBJECTIVES: The objective of this study was (1) to determine the reliability of urinalysis (UA) for predicting urinary tract infection (UTI) in febrile children, (2) to determine whether UA findings can predict Escherichia coli versus non-E. coli urinary tract infection, and (3) to determine if empiric antibiotics should be selected based on E. coli versus non-E. coli infection predictions. METHODS: This was a retrospective chart review of children from 2 months to 2 years of age who presented to the emergency department with fever (rectal temperature >100.4°F) and had a positive urine culture. This study was conducted between January 2004 and December 2007. Negative UA was defined as urine white blood cell count less than 5 per high-power field, negative leukocyte esterase, and negative nitrites. Urine cultures were classified into E. coli and non-E. coli groups. These groups were compared for sex, race, and UA findings. Multivariate forward logistic regression, using the Wald test, was performed to calculate the likelihood ratio (LR) of each variable (eg, sex, race, UA parameters) in predicting UTI. In addition, antibiotic sensitivities between both groups were compared. RESULTS: Of 749 medical records reviewed, 608 were included; negative UA(-) was present in 183 cases, and positive UA(+) was observed in 425 cases. Furthermore, 424 cases were caused by E. coli, and 184 were due to non-E. coli organisms. Among 425 UA(+) cases, E. coli was identified in 349 (82.1%), whereas non-E. coli organisms were present in 76 (17.9%); in contrast, in 183 UA(-) cases, 108 (59%) were due to non-E. coli organisms versus 75 (41%), which were caused by E. coli. Urinalysis results were shown to be associated with organism group (P < 0.001). Positive leukocytes esterase had an LR of 2.5 (95% confidence interval [CI], 1.5-4.2), positive nitrites had an LR of 2.8 (95% CI, 1.4-5.5), and urine white blood cell count had an LR of 1.8 (95% CI, 1.3-2.4) in predicting E. coli versus non-E. coli infections. Antibiotic sensitivity compared between UA groups demonstrated equivalent superiority of cefazolin (94.7% sensitive in UA(+) vs 84.0% in UA(-) group; P < 0.0001), cefuroxime (98.2% vs 91.7%; P < 0.001), and nitrofurantoin (96.1% vs 82.2%; P < 0.0001) in the UA(+) group. In contrast, the UA(-) group showed significant sensitivity to trimethoprim-sulfamethoxazole (82.2% vs 71.3% in UA(+); P = 0.008). CONCLUSIONS: Urinalysis is not an accurate predictor of UTI. A positive urine culture in the presence of negative UA most likely grew non-E. coli organisms, whereas most UA(+) results were associated with E. coli. This study also highlighted local patterns of antibiotic resistance between E. coli and non-E. coli groups. Negative UA results in the presence of strong suspicion of a UTI suggest a non-E. coli organism, which may be best treated with trimethoprim-sulfamethoxazole. Conversely, UA(+) results suggest E. coli, which calls for treatment with cefazolin or cefuroxime.

Utility of blood culture in uncomplicated pneumonia in children.

BACKGROUND: It is believed to be the standard of care to obtain a blood culture in a child who is hospitalized for pneumonia. In recent years, many studies have questioned the utility of this practice in the presence of age appropriate immunization. We conducted this study to determine the current prevalence of bacteremia in children with uncomplicated pneumonia and the utility of obtaining blood cultures in these children. OBJECTIVE: To evaluate the risk of bacteremia in hospitalized young children with pneumonia. METHODS: This was a retrospective review from July 2003 until July 2008. The setting was the pediatric emergency department of an urban teaching hospital. The study population included children under 36 months of age who had been fully immunized and who had been hospitalized with radiographic evidence of uncomplicated pneumonia. Excluded were children who were currently using antibiotics or who had used antibiotics within the previous 48 hours, as well as children with immunodeficiency status such as sickle cell anemia, immunoglobulin deficiency, or children on steroid therapy. The radiologist's interpretation of each chest radiograph was reviewed and recorded. The variables studied were age (in months), gender, race, birth history, pneumococcal vaccination status, appearance on arrival, temperature on arrival, respiratory rate, oxygen saturation, white blood cell (WBC) count, neutrophil count, band count, and urine culture. The chi-square test and logistic regression were used to analyze the data. RESULTS: A blood culture was obtained in 535 children hospitalized with radiographic pneumonia. Bacteremia was present in 12 children (2.2%). All organisms isolated from the blood cultures were considered contaminants. CONCLUSION: Children hospitalized with uncomplicated pneumonia have a low rate of positive blood cultures. None of the variables studied predicted bacteremia. The absence of true-positive cultures among the organisms isolated suggests little value in obtaining blood cultures in children hospitalized due to uncomplicated pneumonia.

Victims of bullying in the emergency department with behavioral issues.

BACKGROUND: Bullying has become one of the most significant school problems experienced by our children. Victims of bullying are prone to a variety of psychological and behavioral symptoms. We noted that many children referred to the Emergency Department (ED) with behavioral symptoms provided a history of bullying. OBJECTIVES: To measure the prevalence of bullying in children referred to the ED for behavioral symptoms and to determine its association with psychiatric disorders. METHODS: A retrospective cohort study was conducted in an urban hospital, identifying children from 8 to 19 years of age who presented to the ED with behavioral symptoms. We reviewed the ED psychiatry notes to retrieve the report indicating whether these children were bullied and had previous psychiatric diagnoses. These children were classified into bullied and non-bullied groups. RESULTS: Over the study period, 591 children visited the ED with behavioral issues. Out of 591, 143 (24%) children reported bullying. More boys (100) than girls (43) reported bullying (p = 0.034). The mean age of children in the bullied group was 10.6 years (95% confidence interval 10.1-11.2). One hundred eleven (77.6%) children in the bullied group had a prior psychiatric diagnosis. Children in the bullied group were hospitalized significantly less than children in the non-bullied group (10/143 [7%] vs. 80/368 [18%]; p = 0.002). CONCLUSION: The prevalence of bullying among the ED children with behavioral symptoms is substantial. Every fourth child with behavioral symptoms reported bullying. Four in five children who reported bullying had a prior diagnosis of "disorder of behavior."

Violent and fatal youth trauma: is there a missed opportunity?

INTRODUCTION: Accidents and assaults (homicides) are the leading causes of death among the youth of the United States, accounting for 53.3% of deaths among children aged 1 to19 years. Victim recidivism, defined as repeated visits to the emergency department (ED) as a victim of violent trauma, is a significantly growing public health problem. As 5-year mortality rates for recidivism are as high as 20%, it is important to determine whether victims with a history of violent trauma are at increased risk for fatal outcome with their next trauma. We hypothesized that victims of violent trauma who have had 1 prior ED visit for violent trauma will have increased odds of fatal outcome. METHODS: A retrospective chart review was conducted for patients presenting with penetrating trauma to the ED from January 1, 1999 to December 31, 2009. All patients between the ages of 15 to 25 years who presented to the ED for any penetrating trauma were included. Patients with prior presentations for penetrating trauma were compared to those patients who were first-time presenters to determine the odds ratio of fatal outcome. RESULTS: Overall, 15,395 patients were treated for traumatic presentations. Of these, 1,044 met inclusion criteria. Demographically, 79.4% were Hispanic, 19.4% were African American, and 0.96% were Caucasian. The average age was 21 years, and 98% of the population was male. One hundred and forty-seven (14%) had prior presentations, and 897 (86%) did not. Forty of the 147 patients (27%) with prior presentations had a fatal outcome as compared to 29 patients of the 868 (3%) without prior presentations, with odds ratio of 10.8 (95% confidence interval, 6.4-18.1; Pearson χ(2), P < 0.001). The 5-year mortality rate for those patients with fatal outcomes was calculated at 16.5%. CONCLUSION: Patients who had prior ED visits for penetrating trauma were at greater risk for fatal outcomes compared to those with no prior visits. Therefore, trauma-related ED visits might offer an opportunity for education and intervention. This may help to prevent future fatalities.

Is there a relationship between wound infections and laceration closure times?

BACKGROUND: Lacerations account for a large number of ED visits. Is there a "golden period" beyond which lacerations should not be repaired primarily? What type of relationship exists between time of repair and wound infection rates? Is it linear or exponential? Currently, the influence of laceration age on the risk of infection in simple lacerations repaired is not clearly defined. We conducted this study to determine the influence of time of primary wound closure on the infection rate. METHODS: This is a prospective observational study of patients who presented to the Emergency Department (ED) with a laceration requiring closure from April 2009 to November 2010. The wound closure time was defined as the time interval from when the patient reported laceration occurred until the time of the start of the wound repair procedure. Univariate analysis was performed to determine the factors predictive of infection. A non-parametric Wilcoxon rank-sum test was performed to compare the median differences of time of laceration repair. Chi-square (Fisher's exact) tests were performed to test for infection differences with regard to gender, race, location of laceration, mechanism of injury, co-morbidities, type of anesthesia and type of suture material used. RESULTS: Over the study period, 297 participants met the inclusion criteria and were followed. Of the included participants, 224 (75.4%) were male and 73 (24.6%) were female. Ten patients (3.4%) developed a wound infection. Of these infections, five occurred on hands, four on extremities (not hands) and one on the face. One of these patients was African American, seven were Hispanic and two were Caucasian (p = 0.0005). Median wound closure time in the infection group was 867 min and in the non-infection group 330 min (p = 0.03). CONCLUSIONS: Without controlling various confounding factors, the median wound closure time for the lacerations in the wound infection group was statistically significantly longer than in the non-infection group.

Impact of operational staging to improve patient throughput in an inner-city emergency department during the novel H1N1 influenza surge: a descriptive study.

BACKGROUND: A level 1 pediatric emergency department (ED) in a public hospital of South Bronx rapidly encountered a significant surge in ED patient census over several days as the novel H1N1 influenza outbreak occurred. Our aim was to identify ill patients with influenza-like illness and evaluate and treat them as expeditiously as possible without failing in our responsibility to treat all patients. We describe the ED response to the outbreak during 2009 H1N1-related visits. OBJECTIVE: The objective of this study was to describe and compare pediatric ED visits during the fall 2009 H1N1 to that in the previous year. METHODS: The department reorganized patient flow in the ED to maximize the understanding of where to best apportion our resources and to minimize walkout and return visit rates. We developed staging of the flow of patients. This included, but was not limited to, a rapid screening at pretriage stage, early registration before the formal triage, and expanding the service. We compared walkout rates during fall 2009 and fall 2008. Return visits for asthmatic patients within 7 days were also compared. RESULTS: Over a period of 48 days, 8841 patients visited the pediatric ED. The average number of visits during this outbreak was 184 per day (usual visits per day, 80-110). Overall ED visits increased by 93.6% (95% confidence interval [CI], 78.2%-109.6%; P < 0.001). Fifty-two patients tested positive for H1N1. The walkout rate was 2.9% (95% CI, 1.9%-4.0%) in 2009 compared with the walkout rate of 1.5% (95% CI, 1.0%-2.0%) in 2008. There were no statistically significant differences between walkouts (P = 0.06) and 7-day asthma revisits (P = 0.07) in 2008 and 2009 despite the almost doubling of the ED visits. Admission rates from 2009 did not significantly differ from 2008 (11.2% [990/8841] vs 10.2% [464/4560], P = 0.07). CONCLUSIONS: Staging of a surge volume allows ED administrators to maintain a strong control of a multipatient event to ensure an effective response and appropriate use of limited resources. The implementation of the reorganized measures during the fall 2009 H1N1-related surge in patient's visits resulted in improved patient flow without significant increase in walkout and 7-day asthma revisit rates. Our strategies accommodated the surge of patients in the ED.

A retrospective look at length of stay for pediatric psychiatric patients in an urban emergency department.

OBJECTIVE: The objective of the study was to compare the length of stay (LOS) of patients with psychiatric diagnoses in a pediatric emergency department (ED) to that of patients with nonpsychiatric diagnoses. METHODS: This is a retrospective review of all patients younger than 19 years with psychiatric conditions, who presented to an urban teaching hospital ED with psychiatric symptoms, from January 2004 to December 2007. A control group of patients with nonpsychiatric diagnoses was selected over a random 4-day period. Emergency department LOS (in minutes) of nonpsychiatric versus psychiatric patients was compared. Length of stay was determined from the time of triage to disposition (discharge or admission). Patients with psychiatric diagnoses were further classified into 1 of 2 categories: major psychiatric diagnoses (bipolar disorder, psychoses, major depression, suicidal attempt or ideation, homicidal ideation, and hallucination) and minor psychiatric diagnoses (attention deficit/hyperactivity disorder, adjustment disorder, anxiety or panic attack, and behavioral issues). RESULTS: A total of 1468 patients with psychiatric diagnoses visited the ED. Three hundred eighty-two patients had major psychiatric diagnoses, and 1086 patients had minor psychiatric diagnoses. The control group (patients with nonpsychiatric diagnosis) consisted of 345 patients. Mean LOS of nonpsychiatric patients was 160 minutes (95% confidence interval [CI], 142-177 minutes); LOS for minor psychiatric patients was 737 minutes (95% CI, 670-803 minutes) and 1127 minutes for major psychiatric patients (95% CI, 972-1283 minutes). On the other hand, median LOS of nonpsychiatric patients was 129 minutes; minor psychiatric patients, 328 minutes; and major psychiatric patients, 437.5 minutes. Kruskal-Wallis test showed a significant difference between each group with P = 0.0001. CONCLUSIONS: The LOS was significantly higher in patients with psychiatric diagnoses. The mean and median for LOS both rose steadily from nonpsychiatric to major psychiatric diagnoses.

An innovative approach to orotracheal intubations: the Alexandrou Angle of Intubation position.

Visualization of the vocal cords is paramount during orotracheal intubations. We employed a novel patient position in this derivation study. The Alexandrou Angle of Intubation (AAI) position is defined as a 20°-30° incline where the supine patient's head is elevated in relation to the body and legs. Our study participants were blinded to the goals of the research as well as our novel technique. Using intubation manikins, our participants ranked their preference for visualizing the vocal cords between the Flat, Trendelenburg, and AAI positions. A majority (58.8%) of our study participants preferred the AAI for visualizing the vocal cords over the other two positions. Future studies will reveal whether AAI will play a significant role in emergent airway management.