Racial and ethnic differences in pediatric unintentional injuries requiring hospitalization.

BACKGROUND/OBJECTIVE: This study aims to comprehensively examine racial and ethnic differences in pediatric unintentional injuries requiring hospitalization by age across injury mechanisms. STUDY DESIGN: This was a retrospective, nationally representative cross-sectional analysis of discharge data within the 2016 Kids' Inpatient Database for 98,611 children ≤19 years with unintentional injuries resulting in hospitalization. Injury categories included passengers and pedestrians injured in a motor vehicle crash, falls, drownings, burns, firearms, drug and nondrug poisonings, suffocations, and other injuries. Relative risk (RR) for injuries requiring hospitalization were calculated for children of Black, Hispanic, and Other races and ethnicities compared with White children, and then RR were further stratified by age. Excessive hospitalizations were calculated as the absolute number of hospitalizations for each race and ethnicity group that would have been avoided if each group had the same rate as White children. RESULTS: Black children were significantly more likely to be hospitalized compared with White children for all injury mechanisms except falls, and in nearly all age groups with the greatest RR for firearm injuries (RR 9.8 [95% confidence interval: 9.5-10.2]). Differences were associated with 6263 excessive hospitalizations among all racial and ethnic minority children compared with White children. CONCLUSIONS: Racial and ethnic minority children represent populations at persistent disproportionate risk for injuries resulting in hospitalization; risk that varies in important ways by injury mechanism and children's age. These findings suggest the importance of the environmental and societal exposures that may drive these differences, but other factors, such as provider bias, may also contribute.

Relationship between socioeconomic factors and severe childhood injuries.

The objective was to examine the relationship between injury rates and socioeconomic factors for children in Hamilton County, Ohio, using small-area analysis. The subjects were county residents less than 15 years old who were hospitalized or died of injuries between January 1, 1993, and December 31, 1995; they were identified through a population-based trauma registry. The census tract was the unit of analysis; the rate of injury per 100,000 population was the dependent variable. Risk factors included median income, level of education, percentage below the poverty level, percentage unemployment, percentage non-Caucasian, and percentage families headed by females. There were 2,437 children meeting the case definition; injuries per census tract ranged from 0 to 2,020.2 per 100,000 per year. Census tracts with higher injury rates had lower median incomes, more people with less than a high school education, more unemployment, more families headed by females, more people living below the poverty level, and more non-Caucasians than those with lower rates. In a regression model, percentage of people living below the poverty level, percentage of those who did not graduate from high school, and percentage unemployment were significant risk factors for injuries, P < .001. Since small-area analysis examines associations on an ecological level rather than an individual level, these studies should always be interpreted with caution because an association found at the level of the census tract may not apply at the individual level. Interventions to reduce injuries should target socioeconomically disadvantaged children living below the poverty level and those in areas with fewer high school graduates and more unemployment.

Removing the pediatric cervical collar: current practice patterns.

OBJECTIVES: To identify the current practice patterns of emergency medicine practitioners and the typical criteria used in discontinuing cervical spine immobilization (CSI) in the pediatric patient. DESIGN: Mail-in survey. PARTICIPANTS: All physicians on the mailing list of the American Academy of Pediatrics Section of Emergency Medicine and an equal number of randomly chosen members of the American College of Emergency Physicians. The total number of participants was 1360. METHODS: The survey consisted of a case scenario describing a 3-year-old child brought to the emergency department with CSI. The approach to such a scenario was assessed. Surveys were mailed with self-addressed stamped envelopes; repeat mailings were sent at 4 and 8 weeks after the first mailing. Those not currently in active practice or not involved in the decision to discontinue CSI were excluded from the study. RESULTS: The response rate was 55%. Most respondents were younger than 44 years (71%), in practice less than 10 years (56%), and practiced in an urban setting (68%). Nearly two thirds (62.6%) had completed residency training in pediatrics, 24% in emergency medicine and 36% a pediatric emergency medicine fellowship. Most (63%) would discontinue CSI without obtaining radiographs. Factors associated with removal were residency training in pediatrics and being in practice for less than 10 years. The most common criteria for discontinuing CSI were normal neurological (96%) and cervical spine (98%) examinations, normal mental status (92%), and absence of neck pain (93%). CONCLUSIONS: Discontinuing CSI without obtaining radiographs is common, especially among those with residency training in pediatrics and those in practice for less than 10 years. Knowledge of current practice is essential to future development of guidelines for managing pediatric trauma patients for whom cervical spine injury is a consideration.

Can urine clarity exclude the diagnosis of urinary tract infection?

OBJECTIVES: To determine the association of clear urine by visual inspection with the absence of significant bacteruria, and to compare it with standard urinalysis. METHODS: The study was performed in the emergency department of Children's Hospital Medical Center, Cincinnati, Ohio. It was a prospective, convenience sample of children <21 years of age who had catheterized or midstream clean-catch urine specimen collected for culture. Clinical findings including the presence or absence of fever, abdominal pain, dysuria, frequency, and urgency were collected for each patient. Urine was visually assessed for clarity by 2 independent observers using a standardized technique. Standard laboratory urinalysis and microscopy were also performed on all specimens. A positive urine culture was defined as >/=10(4) colony-forming unit (CFU)/mL of a urinary pathogen if obtained by catheterization and >/=10(5) CFU/mL if obtained by midstream. RESULTS: Samples were obtained from 159 patients ranging in age from 4 weeks to 19 years. Females comprised 77% of the patients. One hundred ten of the samples (69%) were clear to visual inspection. There were a total of 29 positive cultures; however, 3 were in children with clear urine. The finding of clear urine on visual inspection had a negative predictive value of 97.3%. These results were similar to those obtained with standard urinalysis. CONCLUSION: Clear urine on visual inspection cannot completely eliminate the possibility that a child has a urinary tract infection. However, it is a reproducible test that offers the advantages of being simple, fast, and inexpensive. The finding of clear urine should be considered a reasonable and relatively effective bedside screen for the presence of a urinary tract infection.

Maximizing the sensitivity and specificity of pediatric trauma team activation criteria.

BACKGROUND: Care of the severely injured child requires the rapid assembly of personnel trained in pediatric trauma care. Trauma team activation criteria, which are highly sensitive and maximally specific for identifying the child who requires resuscitation, are necessary to provide rapid care to all who need it, while using resources efficiently. OBJECTIVE: To determine the sensitivity and specificity of the standard trauma team activation (TTA) criteria for identifying patients who receive resuscitation in the emergency department. METHODS: A one-year study was conducted of all patients transported by emergency medical out-of-hospital services for a trauma-related complaint. For all patients, out-of-hospital medical control operators recorded whether patients met TTA criteria and, if so, which criteria were met. Criteria included standard physiologic, anatomic, and mechanism parameters. Sensitivity and specificity for the outcome of resuscitation (volume restoration, assisted ventilation or intubation, chest tube insertion/needle decompression, operative intervention) were calculated. RESULTS: A total of 492 patients met the case definition. Two-thirds were male, the mean age was 8 years (+/-4.8 SD), and the Injury Severity Score was > or =15 in 9.3%. Trauma team activation criteria were met by 179 patients (36. 4%) and, of these, 107 met mechanism criteria only. A resuscitative intervention was received by 54 (10.9%) of the total and none in the mechanism-only group. Sensitivity and specificity of the TTA criteria for predicting receipt of a resuscitation procedure were 98. 1% and 71.2%, respectively. When mechanism criteria were excluded, the sensitivity remained 98.1% and the specificity increased to 95. 7%. CONCLUSIONS: Criteria for TTA that include patients who meet mechanism criteria only are not specific for identifying patients who receive a resuscitative intervention. Use of anatomic and physiologic criteria only results in an increase in specificity, thereby reducing overtriage while retaining a high sensitivity.

Teenagers' perceptions of personal safety and the role of the emergency health care provider.

STUDY OBJECTIVE: We designed this study to determine the experiences, attitudes, and beliefs of teenagers regarding violence in their lives and to gain an understanding of the perceived role of the emergency health care professional. METHODS: A qualitative study involving 10-person focus groups was conducted in 4 cities representing urban/low socioeconomic and suburban/high socioeconomic areas. Participants were 14 or 15 years of age and were recruited from local community centers. Moderators were matched by sex to the teenagers, and groups were segmented by race and sex. A semistructured guide was developed to help facilitate the discussion. All groups were audiotaped and videotaped, and the tapes were reviewed by the investigators for reoccurring themes. RESULTS: A total of 140 adolescents (14 groups of 10) participated; one half were male. Urban teenagers expressed concerns about gangs, rape, and homicide; suburban teenagers were concerned about parental pressure and suicide. The teenagers expressed distrust of teachers, police officers, and doctors and felt safest with their parents. The emergency department was viewed as a confusing and frightening place, and participants believed that the role of the ED staff was to treat the patient's medical problem and not inquire or counsel about violence. CONCLUSION: All of the teenagers, regardless of socioeconomic status, were concerned about violence in their lives. All of the teenagers believed that the emergency department is not the place for patients to be counseled about safety and violence prevention. A better understanding of the problem of violence from the point of view of the teenager is important in refining an effective role for the emergency health care provider in adolescent violent injury prevention.

Clinical factors associated with focal infiltrates in wheezing infants and toddlers.

It can be challenging to determine which findings are associated with focal infiltrates in young wheezing children. A prospective study of wheezing children < or = 18 months of age revealed focal infiltrates on chest radiograph in 23%. By use of multivariate analysis, findings significantly associated with focal infiltrates included grunting (OR 4.1, 95% CI, 2.0, 8.6) and oxygen saturation < or = 93% (OR 2.2, 95% CI, 1.1, 4.8); with a sensitivity and specificity of 12.5% and 97%, respectively. Variables not associated with focal infiltrates included first-time wheezing, fever, and tachypnea. The combination of grunting and oxygen saturation < or = 93% is highly specific and can be used to help diagnose pneumonia in wheezing infants and toddlers.

Pediatric acetaminophen overdose: risk factors associated with hepatocellular injury.

OBJECTIVES: To characterize demographic and clinical factors associated with pediatric acetaminophen overdose and identify risk factors for hepatocellular injury. DESIGN: Retrospective 10-year chart review. SETTING: Two regional children's hospitals. MATERIALS AND METHODS: Records of patients examined because of acetaminophen ingestion from January 1, 1988, through December 31, 1997, were reviewed. Hepatocellular injury was defined as elevation of serum aminotransferase levels greater than 2 times the reference values. Severe hepatotoxic effect was defined as hepatotoxic effect with evidence of encephalopathy and/or coagulopathy. RESULTS: Data from 322 patients (208 girls and 114 boys, aged 1-17 years) were obtained. Ingestions were intentional in 140 patients (median age, 14 years) and unintentional in 172 (median age, 2 years). Another 10 cases represented dosing errors with therapeutic intent (median age, 3.5 years). Twenty-seven patients had hepatocellular injury; of these, 4 had severe hepatotoxic effects and 1 died. Hepatocellular injury occurred in 10.0% of the dosing error group, 17.9% of the intentional group, and 0.6% of the unintentional group. No patients underwent liver transplantation. Hepatocellular injury was associated with presentation longer than 24 hours after ingestion (odds ratio [OR], 335.0; 95% confidence interval [CI], 40.8-275.0), age 10 to 17 years (OR, 36.9; 95% CI, 4.9-275.4), intentional overdose (OR, 37.2; 95% CI, 5.0-278.2), dose greater than 150 mg/kg (OR, 17.9; 95% CI, 2.3-139.2), and white race (OR, 2.8; 95% CI, 1.1-7.2). CONCLUSIONS: Intentional and unintentional acetaminophen overdoses occurred with similar frequency. Therapeutic misadventure was relatively uncommon, as was hepatocellular injury. Practitioners should have greater suspicion of acetaminophen-associated hepatocellular injury in patients who present more than 24 hours after ingestion, older children, and those who have intentional ingestion.

Childhood injury prevention at home and play.

Unintentional injuries are the leading cause of death for children and adolescents in the United States, and they create a significant burden of disability and financial cost. If motor vehicle-associated injuries are not considered, children are most commonly injured in their home and play environments. The reduction over the past 20 years in childhood deaths related to motor vehicle injury has been significant, but rates of childhood death due to other causes, such as firearms, have increased. This review focuses on several categories of injuries other than motor vehicle injuries and highlights a few recent successful community- and practice-based injury-prevention programs. In addition, recent epidemiologic studies describing risk factors for injury-related death are discussed. Injuries due to interpersonal violence and motor vehicles are covered elsewhere.

Relationship between serum glucose and injury severity score in childhood trauma.

PURPOSE: The aim of this study was to examine the relationship between initial serum glucose and injury severity score (ISS) in children with multiple trauma. METHODS: Charts from all patients 0 to 19 years of age admitted to a children's hospital in 1995 with acute multiple trauma were reviewed. Data collected included initial serum glucose level, heart rate (HR), systolic blood pressure (SBP), Injury Severity Score (ISS), age, gender, location of trauma, and need for intravenous fluids or epinephrine. Data were analyzed using multiple linear regression. RESULTS: A total of 185 charts were reviewed. The mean ISS was 11.3; the mean glucose was 162.8 mg/dL. After adjusting for age, gender, HR, SBP, and administration of epinephrine or fluid bolus, a significant direct relationship between serum glucose and ISS was found (r = 0.52, P < .01). A stronger relationship was found in children less than 2 years old (r = 0.60, P = .04). CONCLUSIONS: A significant direct relationship exists between glucose and ISS in children with multiple trauma. High glucose values may indicate more severe injury, especially in children less than 2 years old.

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.

Bridging the emergency medical services for children information gap.

OBJECTIVE: To determine the epidemiological features of pediatric usage of prehospital emergency medical services (EMS) in a defined urban population. METHODS: Residents of Kansas City, Mo, younger than 15 years who used EMS during the calendar years 1993-1995 were included. In this geographic area there is a single provider of prehospital care; all numerator data were taken from this single source. Denominator data were provided by 1995 intercensal estimates based on the 1990 US Census. Rates were calculated as an annual average and reported as the number of children transported per 1 000 persons per year. RESULTS: There were a total of 7296 pediatric EMS transports during the study period, for an annual rate of 21.9. Infants younger than 1 year had the highest rate (47.4), followed by those aged 1 to 4 years (26.2), 10 to 14 years (17.5), and 5 to 9 years (17.3). Medicaid was the insurer for half and 27% were uninsured. One quarter of the patients used EMS more than once. Children living in ZIP codes in the lowest median income tertile were 5.8 times more likely to use EMS than those in the upper income tertile (95% confidence interval, 5.4-6.3). One third of all transports occurred between the hours of 4 and 8 PM. CONCLUSIONS: Children using the Kansas City EMS were more likely to be infants, insured by Medicaid or uninsured, and live in low-income ZIP codes. Further study is needed to determine if this increased usage is due to greater incidence and severity of illness and injury, lack of transportation, lack of education, or other factors.

Short vertical falls in infants.

OBJECTIVE: To define injuries from short vertical falls (SVF) in infants, and to compare those with minor or no injuries to those with significant injury. DESIGN: Descriptive, retrospective chart review. SETTING: Pediatric emergency department (PED) of an urban teaching hospital. SUBJECTS: Infants < or = 10 months treated between January 1990 and December 1992 presenting with a SVF (< or = 4 feet). RESULTS: 167 patients met the definition. The mean age was 5.2 months; 56% were male. The mechanisms of injury included rolling off a bed (55%), being dropped from a caretaker's arms (20%), rolling off a couch (16%), and falling from other objects (10%). The majority of patients (85 %) had minor or no injury. Significant injuries were sustained by 15% (n = 25), including 16 with a closed head injury (12 with skull fractures), two with intracranial bleed, and seven with a long bone fracture. Subsequently, the two patients with intracranial hemorrhages were confirmed as being from child abuse. After excluding cases of suspected abuse, the only characteristic found to be independently associated with significant injury was being dropped by the caretaker (odds ratio: 6.4 vs rolling or falling from furniture, 95% CI: 2.0, 21.5). CONCLUSION: The most common mechanism of a SVF was rolling off a bed. Most patients sustained minor or no injury. No child sustained an intracranial hemorrhage from a SVF. The child with intracranial injury and/or multiple injuries warrants an investigation. Being dropped appears to be a greater risk for significant injury than rolling off or falling from furniture.

Handgun purchase trends, Washington state: differences by age of buyer.

STUDY OBJECTIVES: To examine trends in legal handgun purchases from federally licensed dealers and specifically to describe recent changes in age and gender of purchaser and caliber of handguns purchased. METHODS: A cohort study was performed of the adult population of Washington state from 1950 through 1992 using a state dealer record of handgun sales database. The purchase of handguns from licensed dealers was expressed as the number purchased per 100,000 population per year. RESULTS: The handgun purchase rate increased for the total population between 1950 and 1992, from 169 to 2,076 per 100,000 persons. Between 1983 and 1992, the purchase rate among men aged 21 to 24 years increased 184%; among women of this age group, the rate increased 127%. Among men aged 21 to 24 years, the rate of 9 mm handgun purchases increased 1,682% between 1983 and 1992, the greatest increase for any age-caliber category. CONCLUSION: The greatest increase in rate of legal handgun purchases in Washington state from 1983 through 1992 was among the youngest purchasers. Sales of 9 mm handguns increased most rapidly, especially among the youngest buyers.

Pediatric emergency medicine practice patterns: a comparison of pediatric and general emergency physicians.

OBJECTIVE: To determine whether differences exist between general emergency physicians (GEMs) and pediatric emergency physicians (PEMs) in the emergency care of children with common pediatric emergencies. METHODS: We carried out a survey study of all members of the American Academy of Pediatrics Section of Emergency Medicine and the Washington State American College of Emergency Physicians. We identified current therapeutic interventions for croup, asthma, bronchiolitis, seizures, febrile infant, conscious sedation, head trauma, and coin ingestion, and compared the practice patterns of GEMs and PEMs. RESULTS: A total of 66% of the surveys were returned, including 211 GEMs and 329 PEMs. The majority of PEMs practice in children's hospitals, whereas most GEMs practice in general community hospitals. Slightly over half (51%) of PEMs are PEM fellowship-trained versus 1% of GEMs. CROUP: The majority of GEMs and PEMs use racemic epinephrine (RE) in the treatment of a child with stridor at rest; approximately one-third admit to the hospital after RE (39 vs 30%, NS). PEMs are more likely to observe the child for >2 hours after RE (94% vs 79%, P < 0.01). The majority of PEMs and GEMs use steroids in these patients (94 vs 88%, NS). ASTHMA: There is no significant difference in the use of albuterol, aminophylline, or steroids. Steroids are more likely to be given orally by PEMs than GEMs (74 vs 50%, P < 0.01). BRONCHIOLITIS: The majority of both groups of physicians routinely use nebulized beta-agonists; however, significantly more GEMs than PEMs use steroids (68 vs 45 %, P < 0.01). SEIZURES: Half of GEMs vs 78% of PEMs use lorazepam as a first line drug in the treatment of seizures (P < 0.01). There is no significant difference with respect to the use of rectal diazepam in the pre-hospital setting. FEBRILE INFANT: GEMs are less likely than PEMs to admit the febrile infant <4 weeks of age (68 vs 87%; P < 0.01). Admission of older febrile infants (four to six weeks and eight weeks of age) is not significantly different between PEMs and GEMs. CONSCIOUS SEDATION: Both groups use a wide array of drugs alone or in combination to sedate children for complex facial laceration repair, closed fracture reduction, and cranial computed tomography (CT). GEMs are more likely to use ketamine for laceration repair (28 vs 16%, P < 0.01). Both GEMs and PEMs use midazolam plus a narcotic for fracture reduction. For further sedation for cranial CT, after an initial dose of midazolam, GEMs are more likely to use additional midazolam (64 vs 47%, P < 0.01), and PEMs are more likely to add pentobarbital (15 vs 4%, P < 0.01). HEAD TRAUMA: Most GEMs (87%) and PEMs (81%) would obtain a cranial CT on a neurologically normal two year old who had fallen down the stairs with a six-minute loss of consciousness. COIN INGESTION: Most GEMs and PEMs would obtain radiographs on an asymptomatic two year old with a recent coin ingestion. CONCLUSION: With some notable exceptions, GEMs and PEMs have similar pediatric practice patterns despite differences in training and practice environments.

Consequences of violence. Premature death, violence recidivism, and violent criminality.

The burden of violence is born disproportionately by the youngest of our country. In this article, three important aspects of violence are discussed: premature death, violence recidivism, and violent criminality. The author emphasizes the role of the pediatrician in preventing these consequences.

Serious and fatal air gun injuries: more than meets the eye.

OBJECTIVE: To describe the epidemiology of air gun injuries to children that required hospitalization. DESIGN: A consecutive series of children with air gun injuries. SETTING: Urban pediatric teaching hospitals in Cincinnati, OH; Kansas City, MO; and Seattle, WA. METHODS: A retrospective chart review. RESULTS: A total of 101 children were studied: 81% were male; 80% were white, 18% were black, and 2% were other races. The median age was 10.9 years (range, 0.5 to 18.8). Victims were most commonly shot by a friend (30%) or sibling (21%). A total of 34% occurred at the victim's home, and 36% occurred at the home of a friend or relative. Although 71% of shootings were unintentional, 5% were assaults, and 1% were suicides. The median hospital stay was 3 days (range, 1 to 17 days). Fifteen children (15%) required treatment in intensive care. A total of 56% required at least one surgical procedure. Forty-nine had injuries to the head, including 38 with injuries to the eye, 10 with intracranial injuries, and 1 with a skull injury. Fourteen children were shot in the neck; 15 were shot in the chest, with 2 patients sustaining lacerations of the pericardium and 1 having a right ventricular foreign body. Another child had a laceration of the innominate artery. Nineteen had abdominal injuries, including laceration of the stomach (N = 3), small bowel (N = 4), colon (N = 2), and liver (N = 3). Three of 10 children with intracranial injuries died. Two had long-term neurologic deficits. Of children with eye injuries, 25 (66%) had permanent visual loss and 15 (39%) of these were blind. CONCLUSION: Air guns are associated with serious and fatal injuries. Families should be counseled that air guns may cause serious injuries and even death. Furthermore, pediatric care givers should advocate for increased regulation of air guns and expansion of safety standards.

Suicide with an air rifle.

We report the case of a 14-year-old boy who committed suicide with the use of an air rifle. We include a brief description of his clinical presentation and course, as well as radiography and autopsy findings. This case represents an uncommon mechanism of suicide with an instrument commonly possessed by adolescents and demonstrates the potential lethality of air rifles. Today's air rifles employ one of three gas-compression systems: pneumatic, spring-air or gas compression. They are capable of generating velocities between 200 and 770 feet/second, enabling pellets or BBs to penetrate skin, soft tissue, and bone. This case also highlights the need for preventive measures, including public education and legislation.