Safety and efficacy of rocuronium for controlled intubation with paralytics in the pediatric emergency department.

BACKGROUND: Controlled intubation in the pediatric emergency department (ED) requires a paralytic agent that is safe, efficacious, and of rapid onset. The safety of succinylcholine has been challenged, leading some clinicians to use vecuronium as an alternative. Rocuronium's onset is similar to that of succinylcholine. OBJECTIVE: To evaluate the safety and efficacy of rocuronium for controlled intubation with paralysis (CIP) in the pediatric ED. METHODS: A retrospective, observational study reviewed the records of patients less than 15 years of age, who received controlled intubation with paralytics at two Dallas EDs. The patients received either vecuronium or rocuronium. RESULTS: The study included 84 patients (vecuronium 19, rocuronium 65). Complications were similar between the two groups. Rocuronium had a shorter time from administration to intubation when compared to vecuronium (P < 0.05). CONCLUSION: Rocuronium is as safe and efficacious as vecuronium for CIP in the pediatric ED.

Noninvasive capnometry monitoring for respiratory status during pediatric seizures.

OBJECTIVE: To determine the reliability and clinical value of end-tidal CO2 by oral/nasal capnometry for monitoring pediatric patients presenting post ictal or with active seizures. DESIGN: Clinical, prospective, observational study. SETTING: University affiliated children's hospital. INTERVENTIONS: One hundred sixty-six patients (105 patients with active seizures, 61 post ictal patients) had end-tidal CO2 obtained by oral/nasal sidestream capnometry, and respiratory rates, oxygen saturation, and pulse rates recorded every 5 mins until 60 mins had elapsed. End-tidal CO2 values were compared with a capillary PCO2 and clinical observation. MEASUREMENTS AND MAIN RESULTS: The mean end-tidal CO2 reading was 43.0 +/- 11.8 torr [5.7 +/- 1.6 kPa] and the mean capillary PCO2 reading was 43.4 +/- 11.7 torr [5.7 +/- 1.6 kPa]. The correlation between end-tidal CO2 and capillary PCO2 was significant (r2 = .97; p < .0001). A relative average bias of 0.33 torr (0.04 kPa) with end-tidal CO2 lower than capillary PCO2 was established with 95% limits of agreement +/-4.2 torr (+/-0.6 kPa). Variability of difference scores was not related to range of mean scores (r2 = .00003), age (r2 = .0004), or respiratory rates (r2 = .0009). End-tidal CO2 (r2 = .22; p < .001) correlated better with respiratory rate changes when compared with oxygen saturation (r2 = .02; p = .01). CONCLUSIONS: Dependable end-tidal CO2 values can be obtained in pediatric seizure patients using an oral/nasal cannula capnometry circuit. Continuous end-tidal CO2 monitoring provides the clinician with a reliable assessment of pulmonary status that can assist with decisions to provide ventilatory support.

Noninvasive capnometry in a pediatric population with respiratory emergencies.

OBJECTIVE: This study was designed to investigate the reliability, safety, and efficacy of measuring end tidal CO2 (ETCO2) in nonintubated pediatric patients presenting to an emergency department (ED) with respiratory emergencies. DESIGN/SETTING/PATIENTS: Eighty-five children were enrolled in a clinical, prospective, observational study at a university-affiliated children's hospital. Children age four weeks to 15.3 years with upper and lower respiratory diseases were enrolled by convenience sampling over a five-month period. INTERVENTIONS: ETCO2 measurements were obtained on each patient by oral/nasal side-stream capnometry. When a consistent waveform was obtained, the value was compared with a capillary arterial partial pressure of CO2 (CapCO2), oxygen saturation (O2Sat), and clinical observations. RESULTS: Study patients had a mean ETCO2 reading of 33 mmHg with a standard deviation (SD) of 4.6 mmHg and CapCO2 reading of 36 mmHg with a SD of 4.5 mmHg. Pulmonary findings, final diagnosis, and age did not significantly alter the relationship between CapCO2 and ETCO2. The relationship between CapCO2 and ETCO2 was significant (t = 14.9, P < 0.0001, r = 0.87), with a 95% confidence interval for prediction of +/-5 mmHg. CONCLUSION: Dependable ETCO2 values can be obtained using an oral/nasal capnometry circuit, and they consistently correlate with CapCO2 in a pediatric population with upper and lower respiratory diseases. Noninvasive ETCO2 analysis is safe and reliable within the limitations of this study group. Further exploration is necessary to determine the value of this technology in assisting with clinical decisions in the patient with impending respiratory failure.

A 7-month-old with bilious vomiting.

We present the case of a 7-month-old boy who presented with a history of bilious vomiting, abdominal distention with a mass, anorexia, and no urinary or stool output for 2 days. Air enema demonstrated a mass effect on the rectosigmoid area, with urinary contrast revealing a large Hutch diverticulum with a narrow neck of the urinary bladder. This patient illustrates a rare case of an infant with bilious vomiting.

Comparison of pediatric end-tidal CO2 measured with nasal/oral cannula circuit and capillary PCO2.

This study was designed to determine whether end-tidal carbon dioxide (ETCO2) values obtained by noninvasive oral/nasal cannula circuit with side-stream capnometry correlate reliably with capillary PCO2 (CapCO2) in a pediatric population without cardiopulmonary problems. Each patient was monitored until a reliable 5-minute ETCO2 waveform was obtained. A capillary blood gas sample was drawn while, simultaneously, ETCO2 was recorded. The difference between CapCO2 and ETCO2 levels was tested with a paired t-test at P < .001. The limits of agreement were established with a 95% confidence level. The stability of the measured difference across the range of mean scores (CapCO2 + ETCO2/2), age, and respiratory rate was tested using simple linear regression. Fifty-eight children (23 girls and 35 boys) had mean ETCO2 readings of 33.96 mm Hg (SD 4.26), and mean CapCO2 readings of 35.93 (SD 4.04). A relative average bias of 1.96 with ETCO2 lower than CapCO2 was established with 95% limits of agreement of +/- 5.2 mm Hg (t = 5.71). Variability of difference scores was not related to range of mean scores (r = .08), age (r = .09), or respiratory rate (r = .25). End-tidal CO2 measured by an oral/nasal cannula capnometry circuit is a noninvasive method of assessing indirect measurements of PCO2 in a normal pediatric population.

Initial approach to the infant younger than 2 months of age who presents with fever.

Fever is common in infants presenting to their physicians for evaluation. Infants younger than 2 months of age are at increased risk of SBI because of their exposure to different pathogens and because of their immature immune systems. The bacteria that may infect them include E coli, group B Streptococcus, and L monocytogenes, as well as Pneumococcus, Neisseria meningitidis, S aureus, and H influenzae. They are also susceptible to viruses, parasites, and fungi. Clinical characteristics associated with increased risk of SBI have been identified. Infants who are ill-appearing, have abnormal hemograms or urinalyses, or have evidence of bacterial infection on physical examination are at higher risk. There has been an association of very high fever with SBI, although this has been inconclusive. Clinical judgment is important, although not always completely reliable in ruling out SBI. Young infants with fever should be evaluated with a thorough history, physical examination, and selected laboratory studies. Those younger than 29 days of age should usually be admitted for observation and parenteral antibiotics. Infants from 29 to 60 days of age may be evaluated carefully and considered for outpatient management, either with or without antibiotics.

Serious group A beta-hemolytic streptococcal infections complicating varicella.

STUDY OBJECTIVE: To alert practicing emergency physicians to an important and possibly increasing relationship between life-threatening group A beta-hemolytic streptococcal (GABHS) infections and children recovering from varicella. DESIGN: A case series of six patients managed from January through March 1993. SETTING: A university-affiliated pediatric specialty emergency department. TYPE OF PARTICIPANTS: Six previously healthy immunocompetent children between 1 and 5 years of age seen in our ED over a nine-week period. RESULTS: Six children had onset of varicella two days to two weeks before developing a serious life-threatening GABHS infection. Children presented with clinical symptoms of invasive GABHS infection with bacteremia (one patient); streptococcal toxic shock syndrome with negative blood culture (two), pneumonia with pleural effusion and streptococcal toxic shock syndrome (one), pneumonia with pleural effusion (one), and pyomyositis of the thigh (one). Four of six patients required intensive care admissions and aggressive support of vital signs. All six survived. CONCLUSION: Emergency physicians should be aware of the association between varicella and serious GABHS infections and be prepared to recognize and aggressively manage serious complications should they occur.

Pulse oximetry and peak flow as indicators of wheezing severity in children and improvement following bronchodilator treatments.

This study examined the changes from the initial peak flows and oxygen saturations (OSAT) of wheezing children at presentation to the emergency department through their treatment in the emergency department. Data was collected prospectively on 785 patients 5 to 20 years of age during an 11-month period from November 1, 1990, to September 30, 1991. Both the initial OSAT and peak flows were correlated with the number of bronchodilator treatments required in the emergency department and with the need for hospitalization. Both the initial OSAT and the peak flows had a limited ability to predict the need for hospitalization. Oxygen saturation appears to be a valid measure of wheezing severity and is more easily obtained in children of all ages. Following bronchodilator treatment, peak flow results in a larger quantitative improvement than OSAT; however, this difference does not appear to have any significant advantage. Aerosolized albuterol and subcutaneous epinephrine resulted in a similar degree of improvement as measured by peak flow and by oxygen saturation, with clinically similar changes in heart rate.

Oxygen saturation changes during the pediatric emergency department treatment of wheezing.

This study examined the oxygen saturation (OSAT) changes measured by pulse oximetry during emergency department (ED) bronchodilator treatment of wheezing patients. Data were collected prospectively on two cohorts (November 1987 to November 1988, 2,468 patients; and December 1988 to October 1990, 4,913 patients) presenting to a pediatric ED with wheezing-associated respiratory illnesses. Initial, posttreatment, and discharge OSAT was recorded in many of these patients. Improvement in OSAT following ED bronchodilator administration was noted in most patient groups. Initial OSAT was indicative of severity as measured by the need for hospitalization and the number of bronchodilator treatments administered in the ED. Subcutaneous epinephrine and aerosolized albuterol were compared in OSAT improvement and side effects. Aerosolized albuterol was not shown to be superior to epinephrine. Improvements in OSAT following bronchodilator administration documents the presence of relative preexisting hypoxemia which is reversed to some degree with bronchodilators. Pulse oximetry is an objective means of assessing asthma severity.

A one-year series of pediatric ED water-related injuries: the Hawaii EMS-C project.

During a 12-month period ending on November 30, 1988, data on 133 pediatric patients visiting a pediatric emergency department with water-related injuries were collected. Of these patients, 70% were male. There were 13 submersions, seven cases of head trauma, three cases of neck trauma, 88 cases of external injury, and 34 other injuries. Incidents took place at beaches (75%) in public pools (12%), in friends' pools (4%), and in home pools (4%). Eighty-six percent of the cohort knew how to swim. Swimming, playing, and surfing activity accounted for most of the injuries. Measures for prevention are described.

The Hawaii EMS-C project data: I. Reducing pediatric emergency morbidity and mortality; II. Statewide pediatric emergency registry to monitor morbidity and morality.

During a 12-month period ending on 11/30/88, data were collected on 16,010 pediatric patients who visited a pediatric emergency department (ED). These ED patients prospectively fell into one of the target areas for further study, including wheezing (15%), trauma (excluding burns; 29%), burns (1%), water-related injuries (1%), ingestions and toxic substance exposures (2%), child abuse (3%), handicapping conditions (5%), preventable incidents (33%), and ambulance arrivals (7%). Handicapped patients were more likely to require an ambulance. Younger patients, males, and patients with handicaps, wheezing, and Medicaid insurance were more likely to visit the ED on multiple occasions. Primary care physicians could be identified in 77% of the cohort. Large-scale interventions to reduce preventable pediatric morbidity and mortality have suffered from difficulties in documenting their effect in a population-based sample. A statewide pediatric emergency encounter registry is proposed.

A one-year series of pediatric emergency department wheezing visits: the Hawaii EMS-C project.

During a 12-month period ending on November 30, 1988, data were collected on 2468 pediatric patients with wheezing who visited a pediatric ED. Cohort characteristics included: sex (64% male, 36% female), history of prematurity (12%), evidence of concurrent infection (82%), taking theophylline (35%), taking beta adrenergics (60%), taking cromolyn (6%), and taking corticosteroids (4%). The hospitalization rate was 10.5%. Seasonal variations, weather, air quality, and infections appeared to have significant effects on the daily variation of wheezing exacerbations. Initial oxygen saturation (OSAT) correlated with disease severity as measured by hospitalization risk and the number of bronchodilator treatments required in the ED. A suggestion for categorizing the treatment of asthma based on past history is proposed. Using this system in conjunction with pulse oximetry, wheezing severity and appropriate therapy can be more objectively determined.

A one-year prospective ED cohort of pediatric trauma.

During a 12-month period ending on November 30, 1988, data were collected on 4623 pediatric patients visiting a pediatric emergency department with trauma (excluding burns). Sixty-one percent were male. Common causes of the trauma included suspected child abuse (4%), organized sports (6%), nonorganized sports (4%), pedestrian motor vehicle accidents (MVAs) (3%), bicycle MVAs (2%), and automobile MVAs (3%). However, most of the incidents had none of the identified associated activities surrounding the trauma (60%). Incidents took place at home (41%), on the street (11%), at school (10%), and at a playground or park (10%). Injuries involved the external body (59%), extremity (26%), head or neck (13%), face (4%), chest (1%), and abdomen (2%) and were more common during the summer. Injury severity scores had a mean of 1.8 and were grouped as: less than 3 (80%), 3-6 (19%), and greater than 6 (1.6%). Factors associated with higher trauma severity included MVAs, water-related injuries, sports, streets, schools, parks, playgrounds, skateboards, skates, and alcohol.

A one-year series of pediatric prehospital care: I. Ambulance runs; II. Prehospital communication; III. Interhospital transport services.

During a 12-month period ending on November 30, 1988, all ambulance arrivals at a pediatric emergency department (ED), all prehospital communications with this ED, all first-responder ambulance runs on Oahu and the state of Hawaii, and all neonatal/pediatric interhospital transports were examined to evaluate pediatric prehospital care. Handicapped patients were more likely to use an ambulance, and their care was more likely to be perceived as a weakness on the part of ambulance personnel. Poorer communication clarity was associated with longer duration of communication. Common pediatric diagnoses were trauma, respiratory problems, seizures, near drownings, and poisonings. Mean transport times were shorter on Oahu than on the outer islands. Premature newborns and handicapped children commonly required interhospital transport. The care of children can be improved by addressing some of the identified problem areas, eg, improving prehospital communication and improving the training of prehospital personnel in the care of infants and handicapped children.

Triage in the emergency department.

Accurate patient triage to provide early identification of potentially seriously ill or high-risk infants and children is an important part of any emergency care system. Use of the SAVE-A-CHILD mnemonic in a busy ED setting provides systematic organization of important clinical observations that may serve as markers of serious disease. Early recognition of the high-risk patient will reduce morbidity and mortality. The discussion included may be helpful to emergency physicians in training their staff to provide a safe triage environment.

Toxic exposures and ingestions in Honolulu: I. A prospective pediatric ED cohort; II. A prospective poison center cohort.

Poisonings and toxic exposures are a frequent cause of preventable morbidity in children requiring emergency care. Ingestions and toxic substance exposures were studied in two prospective cohorts in Hawaii to examine the epidemiology of these events in this community in order to assess the effectiveness of current poison prevention practices and to identify additional measures to further prevent and reduce morbidity and mortality. During a 12-month period ending on 11/30/88, data were collected on 286 pediatric patients visiting a pediatric ED with an ingestion or a toxic substance exposure. Most of the younger children were males with unintentional incidents. Most of the adolescents were females with intentional ingestions. Syrup of ipecac was given in 16% of the patients. When given at home, ipecac was given an average of 1.3 hours after an ingestion. Activated charcoal was given to 32% of the patients. During a 13-month period ending 1/31/90, 14,408 phone calls to the Hawaii Poison Center were analyzed. Twenty-six percent of the callers had ipecac at home. Sixty-eight percent of callers with acute ingestions claimed to have called within 30 minutes of the ingestion, and 77% claimed to have called within 60 minutes of the ingestion. Of those calling within 60 minutes, 36% had ipecac at home. Although ipecac is widely recommended as a pre-hospital intervention, it use is limited owing to unavailability in the home and the short period of time during which it must be given. Since the dispensing of pharmaceuticals in limited quantities and in childproof containers began, it appears that other measures to further reduce morbidity and mortality owing to poisonings have had less additional effect. It appears that serious morbidity and mortality from poisonings in this cohort were uncommon.

A one-year prospective ED cohort of pediatric burns: a proposal for standardizing scald burns.

During a 12-month period ending on 11/30/88, data were collected on 143 pediatric patients visiting a pediatric emergency department with burns. Sixty-four percent were males. Common causes of the burns included hot water (17%), hot food (23%), hot appliances (18%), and charcoal and grills (9%). Sixty-six percent of the burns took place at home. The hospitalization rate was 8%. A suggestion for standardizing scalds based on fluidity and function is proposed, since there is ambiguity regarding definition of a scald.