Documented arterial gas embolism after spinal epidural injection.

We report the case of a 90-year-old man with syncope, arrhythmia, cardiac ischemia, and neurologic deficit after undergoing spinal epidural injection for control of pain related to post-herpetic neuralgia. The diagnosis of arterial gas embolus was made after air was identified in the left ventricle of the heart on an abdominal computed tomographic scan. Emergency physicians should consider and rapidly diagnose this rare but potentially fatal complication of spinal epidural puncture.

Chest radiographs in the pediatric emergency department for children < or = 18 months of age with wheezing.

There are no widely accepted predictors of pneumonia in wheezing infants and toddlers who present to the emergency department (ED). A 10-month retrospective review of ED visits of wheezing children < or = 18 months of age revealed the following chest radiograph (CXR) results: normal (21%), findings consistent with uncomplicated bronchiolitis or asthma (61%), focal infiltrates (18%), and other abnormalities (< 1%). Patients with focal infiltrates on CXR were more likely to have the following: a history of fever (p = 0.03, OR 2.1, 95% CI 1.0, 4.4), temperature > or = 38.4 degrees (p = 0.01, OR 2.5, 95% CI 1.1, 5.8) or crackles on examination (p < 0.0005, OR 3.9, 95% CI 1.7, 9.0). Selective use of CXRs has the potential to save health care dollars and limit unnecessary radiation.

Emergency department presentations of Lyme disease in children.

OBJECTIVE: To review the clinical characteristics and diagnostic evaluation of children with Lyme disease evaluated in an emergency department (ED) in an endemic area. DESIGN: A retrospective review of the demographic, historical, clinical, and laboratory data of pediatric patients with a final diagnosis of Lyme disease. SETTING: The pediatric ED of an urban university hospital. PARTICIPANTS: Children with Lyme disease evaluated during the three-year period from 1992 to 1994. RESULTS: Twenty-nine children ranging in age from three to 19 years who were diagnosed with Lyme disease subsequent to a visit to a pediatric ED were identified. Four patients had early localized disease with erythema migrans and varying degrees of systemic symptoms. Ten had early disseminated Lyme disease, with multiple erythema migrans, neurologic involvement (including three patients with pseudotumor cerebri), or carditis. Fifteen cases of late Lyme disease with arthritis were identified. Recognition of Lyme arthritis proved particularly difficult; seven children were initially diagnosed as having septic arthritis, six of whom underwent arthrotomy. Marked elevations of the erythrocyte sedimentation rate and synovial fluid white blood cell counts were observed in these patients, making it difficult to distinguish Lyme disease from septic arthritis on the basis of laboratory findings. CONCLUSION: Lyme disease is an infrequent, often difficult, diagnosis in children who present to an ED. Early disseminated and late disease predominate; classic erythema migrans is uncommon in the ED in comparison with other ambulatory venues. Diagnosis of Lyme arthritis may be difficult; exposure in an endemic area and clinical findings may help distinguish it from septic arthritis. Overall, underdiagnosis of Lyme disease may actually be more of a problem than overdiagnosis in the ED setting. Recognition of Lyme disease by emergency medicine practitioners requires familiarity with its epidemiology and its multiple manifestations.

Children and adults in cardiopulmonary arrest: are advanced life support guidelines followed in the prehospital setting?

STUDY OBJECTIVE: To compare the proportions of children and adults in whom advanced life support (ALS) guidelines for prehospital management of cardiopulmonary arrest. METHODS: We conducted a retrospective cross-sectional study of an urban EMS system and an urban ED. We studied 141 consecutive patients (47 children and 94 adults, matched by date of presentation) in cardiopulmonary arrest who were transported to the pediatric and adult EDs by ALS-trained prehospital providers (paramedics) between January 1992 and July 1995. We reviewed ambulance trip reports and ED records to determine when and which interventions were performed in the prehospital setting. Significance of differences between the groups was determined with Fisher's exact test and Student's t test. RESULTS: In 47 children (median age, 1 year; range, 2 days to 15 years) and 94 adults (median age, 67 years; range, 16 to 95 years), pulselessness was documented at the time of the initial response of the ALS provider. Basic life support was performed in all patients. Among the 21 children and 7 adults who were not intubated, intubation was attempted in 13 children (62%) and in 6 adults (86%) (P = .26). Among the 29 children and 16 adults in whom intravascular access was not established, unsuccessful attempts to establish access were made in 1 child (3%) and in 15 adults (94%) (P = .0001). Among the 30 children and 91 adults who were intubated, in whom intravascular access was established, or both, epinephrine was not administered to 12 children (40%) and 6 adults (7%) (P < .0001). CONCLUSION: In our study population endotracheal intubation, intravascular access, and administration of epinephrine were attempted and performed significantly less frequently in children than in adults. Given the relative infrequency with which ALS providers encounter children in cardiopulmonary arrest, they need additional training to maintain their skills.

Fever without apparent source on clinical examination, lower respiratory infections in children, bacterial infections, and acute gastroenteritis and diarrhea of infancy and early childhood.

This section focuses on issues in infectious disease that are commonly encountered in pediatric office practice. Paul McCarthy discusses recent literature regarding the evaluation and management of acute fevers without apparent source on clinical examination in infants and children and the evaluation of children with prolonged fevers of unknown origin. David Bachman reviews recent literature about lower respiratory tract infection in children and focuses on community-acquired lower respiratory infections and respiratory syncytial virus. Eugene Shapiro discusses literature concerning several infectious diseases commonly seen in office settings and concerning which recent developments are of interest: the hemolytic-uremic syndrome and enterohemorrhagic Escherichia coli. Streptococcus pneumoniae resistant to penicillin, infections in day care centers, and new antimicrobial drugs. Michael Baron reviews recent literature about gastroenteritis and diarrhea of infancy and early childhood and discusses diagnosis, complications, pathogenesis and physiology, epidemiology, and treatment.