Cervical Spine Motion During Airway Management Using Two Manual In-line Immobilization Techniques: A Human Simulator Model Study.

OBJECTIVE: The aim of this study is to evaluate cervical spine motion using 2 manual inline immobilization techniques with the use of a human simulator model. METHODS: Medical students, pediatric and family practice residents, and pediatric emergency medicine fellows were recruited to maintain cervical manual in line immobilization above the head of the bed and across the chest of a human simulator while orotracheal intubation was performed. Participants were then instructed on appropriate holding techniques after the initial session took place. Orotracheal intubation followed. A tilt sensor measured time to intubation and cervical extension and rotation angle. RESULTS: Seventy-one subjects participated in a total of 284 successful orotracheal intubations. No change in cervical spine movement or time to intubation was observed when using 2 different inline manual immobilization techniques with no training. However, a statistically significant difference with assistants above the head versus across the chest was observed after training in: extension 2.1° (95% confidence interval [95% CI], 1.15 to 3.00; P < 0.0001); rotation 0.7° (95% CI, 0.26 to 1.19; P = 0.003) and intubation time of -1.9 seconds (95% CI, -3.45 to -0.13; P = 0.035) after training. CONCLUSIONS: Cervical spine movement did not change when maintaining cervical spine immobilization from above the head versus across the chest before training. There was a statistically significant change in extension and rotation when assistants were above the head and in time to intubation when assistants were across the chest after training. The clinical significance of these results is unclear.

Accuracy of laceration length estimation in a pediatric emergency department and its impact on billing practices.

OBJECTIVES: This study aimed to determine the accuracy of laceration length estimation in a pediatric emergency department among health care providers of varying levels of training and its impact on billing practices. METHODS: This study involves a prospective case series. Children younger than 21 years with lacerations evaluated and repaired in the pediatric emergency department between January 1 and April 30, 2012, were eligible for enrollment. Each laceration was evaluated by a trainee/midlevel provider (frontline provider) and by an attending physician; each one offered an estimated laceration length. The true measurement was then documented by 1 of 6 pediatric emergency medicine fellows on shift. Data were analyzed using descriptive statistics. The mean error of estimation (the absolute differences between the estimated and the true laceration length) of attending physicians and frontline providers were determined and compared. The proportions of lacerations whose estimated length was in a different billing category were compared using χ(2). Cost analysis was documented. RESULTS: One hundred ninety patients were enrolled. The mean age was 5.9 years. A total of 119 patients (62.6%) were male, and 134 lacerations (70.5%) were located on the face. Most repairs were simple (79%). There was no difference between the estimated and measured length among attendings and frontline providers (P = 0.583). An average of 8.2% of lacerations were misclassified and billed incorrectly with 20% (4/20) of facial lacerations up-coded. The mean overcharge was $12.04. Of 11 lacerations elsewhere on the body, 3 (27%) were down-coded, with an average difference of $6.97 for simple and $38.51 for layered repairs. CONCLUSIONS: Pediatric emergency medicine practitioners are accurate estimators of laceration length. Eight percent of lacerations are misclassified and billed incorrectly. Physicians should be required to report measured lengths for billing.

Anaphylaxis knowledge and practice preferences of pediatric emergency medicine physicians: a national survey.

OBJECTIVES: To assess the knowledge and practice preferences of anaphylaxis in pediatric emergency medicine (PEM) physicians by practice setting, and to identify factors associated with intramuscular (IM) epinephrine administration and admission of patients with anaphylaxis. STUDY DESIGN: The cohort was a cross-sectional convenience sample; potential participants were recruited using contact information obtained from the American Board of Pediatrics and American Board of Medical Specialties membership databases and were asked to complete a 12 item survey. Board-certified PEM physicians were categorized by practice setting: university hospital, non-university hospital with a residency training program, or community hospital with no residency training program. Management practices based on practice setting are presented as proportions. Multivariate logistic regression identified factors associated with IM epinephrine administration and admission of patients with anaphylaxis for observation. RESULTS: Of the 1114 PEM physicians solicited, 620 (56%) completed the survey. The majority (93.5%) correctly identified epinephrine as the treatment of choice for anaphylaxis, yet only 66.9% used the IM route of administration, and only 37.4% admitted affected patients for observation. Factors associated with the use of IM epinephrine included the presence of a residency program at the site of care (OR, 2.28, 95% CI, 1.3-4.04) and higher volume of anaphylaxis cases (OR, 1.21; 95% CI, 1.06-1.38). Increasing anaphylaxis case volume was associated with decreased likelihood of admission of patients with anaphylaxis (OR, 0.81; 95% CI, 0.72-0.92). CONCLUSION: Even though the majority of PEM physicians correctly report using epinephrine in pediatric anaphylaxis, not all use the preferred administration route, and many discharge patients home after an abbreviated period.

Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

False-positive colorimetric capnometry after ingestion of carbonated beverages.

STUDY OBJECTIVE: To investigate the potential for false-positive colorimetric capnometric readings during esophageal intubation after ingestion of carbonated beverages. METHODS: The study was conducted in the human patient simulation laboratory of a tertiary care pediatric hospital. The sole outcome measurement was the capnometric indicator membrane color after expiration for 10 breaths. Readings were recorded for scenarios simulating 8 different models. RESULTS: For all carbonated beverage trials with a cuffed endotracheal tube (ETT) and those with 2 and 6 oz of beverage in the gastric sac with an uncuffed ETT, a false-positive result was observed on the capnometer's indicator for breaths 1 through 10. The sensitivity of the capnometer for the detection of CO2 after full exhalation of breath 6 for these trials was 100%. For trials containing 12 oz in the gastric sac and an uncuffed ETT, yellow was observed on the capnometer indicator for breaths 1 through 3, tan for breaths 4 through 6, and purple for breath 7. The sensitivity of the capnometer for the detection of adequate CO2 after full exhalation of breath 6 for these trials was 0%. The overall sensitivity of the capnometer for the carbonated beverage models with a cuffed ETT was 100%, whereas the combined sensitivity for the trials with an uncuffed ETT was 67%. CONCLUSIONS: Under proper circumstances, a significant potential exists for false-positive colorimetric capnometric results in the presence of even small amounts of carbonated beverages.

Heelys injuries: a review of the National Electronic Injury Surveillance System data.

OBJECTIVE: The purpose of this study was to describe the types and severity of Heelys-related injuries reported to the National Electronic Injury Surveillance System (NEISS). Strategies for prevention of these injuries may be developed using this information. METHODS: We performed a retrospective analysis of the NEISS data of the US Consumer Safety Product Commission between 2002 and 2006. RESULTS: The NEISS had 131 reported Heelys injuries in children. The mean age was 10.02 years. The upper extremity was most commonly injured, accounting for 75 (57.3%) of the 131 injuries. Fractures were the most common injuries, accounting for 66 (50.4%) of the 131 injuries. Children younger than 12 years were more likely to sustain fractures than their older counterparts (P = 0.001). Children 12 years or older were more likely to sustain sprains than the younger children (P ≤ 0.001). There was no difference in injury patterns between the sexes (P = not significant). Six children required hospital admission. There was 1 reported death. CONCLUSIONS: Most injuries sustained from Heelys use are orthopedic injuries. However, a wide variety of other injuries occur with Heelys use. Children can sustain injuries serious enough to require hospital admission. Parents and children should be educated about the importance of protective gear use while "heeling."

Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation.

OBJECTIVE: To determine if a difference exists in perceived pain between the forced pronation and supination-flexion methods of radial head subluxation (RHS) reduction. DESIGN AND METHODS: We developed a prospective randomized trial of children aged 6 months to 7 years who presented to the emergency department (ED) at Miami Children's Hospital with an immobile arm and physical findings suggestive of RHS. Children were randomized into 2 groups for RHS reduction: forced pronation and supination-flexion. Parents, physicians, and nurses were given a standard visual analog pain scale for pain assessment before, during, and at 1 minute after successful reduction. RESULTS: Seventy-five children presented to the ED with RHS; 3 children were excluded from the study because of nonadherence to the protocol and another 9 were excluded because of unsuccessful reduction during the first attempt. Of the remaining children, 32 children underwent forced pronation and 31 underwent supination-flexion. Physicians did not find a significant difference in gain scores between their perceptions of the premeasure and postmeasure of pain between those patients receiving supination-flexion and those receiving forced pronation. For nurses (P < 0.031) and parents (P < 0.043), there were statistically significant differences in gain scores. Nurses and parents perceived forced pronation as being less painful. The mean difference for parents was 1.7 cm, which exceeded the value of 1.3 cm identified as clinically significant. CONCLUSIONS: Forced pronation is perceived as less painful than the supination-flexion method by parents of children treated for RHS in our ED.

Diagnosis of acute appendicitis in children using a clinical practice guideline.

PURPOSE: In October 2000, our institution implemented a clinical practice guideline (CPG) utilizing selective computed tomography (CT) and ultrasound scan (US) for the evaluation of children with suspected appendicitis. The authors sought to determine surgical outcomes and diagnostic accuracy in the CPG period. METHODS: The authors retrospectively analyzed the medical records of patients evaluated under the CPG at their institution between January 1 and December 31, 2001. Depending on a patient's clinical presentation, the CPG recommends immediate surgery or further evaluation with CT or US. CPG patients were identified if they received an appendectomy or a CT or US for suspected appendicitis. Negative appendectomy and perforation rates, as well as admissions for inpatient observation were compared with control patients treated for suspected appendicitis at our hospital in 1997, before frequent utilization of imaging studies. RESULTS: In the CPG period, 571 patients were evaluated for acute appendicitis, with 272 undergoing an appendectomy. Whereas 513 patients (90%) received a CT or US, only 34 patients (6%) were admitted to the surgical service for serial examinations. Patients with a histologically normal appendix decreased from 27 of 255 (10.6%) in 1997 to 15 of 272 (5.5%) in 2001 (P =.03). Fifty-seven patients (22.2%) in 2001 had a perforated appendix compared with 65 (28.5%) in 1997 (P =.11). The CPG, incorporating clinical judgment and selected imaging, had a sensitivity of 98.8%, a specificity of 95.2%, and positive and negative predictive values of 94.4% and 99.0%, respectively. CONCLUSIONS: A clinical practice guideline selectively utilizing CT and US is highly accurate in the diagnosis of acute appendicitis, minimizing the need for inpatient admission for serial examinations.

Selective imaging strategies for the diagnosis of appendicitis in children.

BACKGROUND: We previously reported an appendiceal imaging protocol in which children with equivocal clinical presentations for acute appendicitis undergo ultrasonography (US) followed by computed tomography (CT). However, risk groups of children who would benefit most from imaging studies have not been established. OBJECTIVE: To define and test selective imaging guidelines to increase diagnostic accuracy and reduce unnecessary testing for children with suspected appendicitis. METHODS: We modeled outcomes under 3 different management guidelines. Patients were risk-stratified by a recursive partitioning analysis of a retrospective cohort. Subjects included children with equivocal presentations of acute appendicitis evaluated between January 1996 and December 1999. By using recursive partitioning, 3 risk groups were identified: low, medium, and high risk for acute appendicitis. Three imaging guidelines were defined. Under the first guideline, representing standard clinical practice at Children's Hospital Boston at the time of the study, all children with equivocal signs and symptoms for acute appendicitis undergo US first. If the US is positive, the child proceeds to appendectomy. If the US is negative, the child undergoes CT. Under guideline 2, low-risk children undergo US and, if negative, are discharged from the hospital. High-risk children undergo CT, and medium-risk children undergo US followed by CT. Under the third guideline, low-risk children undergo no imaging and are admitted for observation. High-risk children proceed directly to appendectomy without imaging studies. Medium-risk children undergo US followed by CT. Clinical outcomes and the number of imaging studies performed were modeled under current practice and under each guideline. RESULTS: Identified were 1401 cases of equivocal appendicitis; 958 (68.4%) with complete data. The mean age was 11 +/- 4.3 years. Of 958 children, 588 (61.4%) had acute appendicitis. One hundred forty-three patients were in the low-risk group, defined as neutrophils 67%, white blood cell count >10,000/mm(3), guarding, and abdominal pain >13 hours. Of these, 202 (90%) had appendicitis. Under guideline 1, there were 22 negative appendectomies, 35 missed or delayed diagnoses, and 958 USs and 673 CT scans performed. Under guideline 2, there would have been 23 negative appendectomies, 36 missed or delayed diagnoses, and 733 USs and 637 CT scans performed. Under guideline 3, there would have been 36 negative appendectomies, 37 missed or delayed diagnoses, and 590 USs and 412 CT scans performed. CONCLUSIONS: Selective imaging guidelines can reduce the number of radiographic studies performed with minimal diminution in accuracy of diagnosis of pediatric appendicitis.