Controlled balloon inflation reduces long-term restenosis after percutaneous transluminal coronary angioplasty.

PURPOSE: The trauma induced by balloon angioplasty has an impact on the outcome of coronary interventions, such as stent procedures. However, balloon inflation for PTCA is not yet standardized even though procedural and long-term outcomes might be affected. METHODS: During routine PTCA, a total of 454 patients [mean age, 60.9 +/- 9.0 years; 162 (35.7%) with 1-vessel disease; 159 (35%) with 2-vessel disease; 133 (29.3%) with 3-vessel disease] were allotted to computer-assisted dilatation (CAPS) with a pressure slope of 0.2 bar/s (CAPS 0.2; n = 149 patients), 1.0 bar/s (CAPS 1.0; n = 154 patients) or to standard inflation with a hand-driven pump (n = 151 patients). Angiographic follow-up rates after 4.1 +/- 3.2 months were 88.1% for the hand-driven pump, 94% for CAPS 0.2 and 87.7% for CAPS 1.0. RESULTS: Flow reducing (1.3-2.0%) and non-flow reducing (12.6-14.9%) dissections were equally distributed among all groups as were major adverse cardiac events (2.6-4.0%). The stent rate was 1.3% with the hand-driven pump, 0.7% with CAPS 0.2 and 1.3% with CAPS 1.0. Angiographic restenosis rate was 48.9% with the hand-driven pump, 44.3% with CAPS 0.2 and 32.6% with CAPS 1.0. (hand-driven pump versus CAPS 1.0, p < 0.007; CAPS 0.2 versus CAPS 1.0, p < 0.049). CONCLUSIONS: The pressure slope during balloon inflation in PTCA has a significant impact on restenosis. The impact on stent procedures has yet to be determined.

Survey of nationally registered emergency medical services providers: pediatric education.

STUDY OBJECTIVE: To survey emergency medical services (EMS) providers on a national level to determine and describe their perspective regarding their initial and continuing education (CE) needs in pediatrics. METHODS: A 10-question survey was developed, pilot-tested, and sent to EMS providers as a part of their National Registry of Emergency Medical Technicians reregistration materials. RESULTS: Surveys were completed by 18,218 EMS providers, a response rate of 67%. During a typical month, 60% of emergency medical technician-paramedics (EMT-Ps), 84% of EMT-intermediates (EMT-Is), and 87% of basic EMTs (EMT-Bs) care for 0 to 3 pediatric patients. CE was identified by all provider levels as the main source of their pediatric knowledge and skills. A state or national mandate for required CE in pediatrics was supported by 76% of surveyed providers. More than 70% of all providers responded they were comfortable to some degree with their own ability and their EMS system's ability when confronted with a critical pediatric call. Cost, availability, and travel distance were identified by all levels as the primary barriers to obtaining pediatric CE. All levels identified infants as the age of greatest concern if the provider was called to manage a critical case. CONCLUSION: Surveyed practicing nationally registered EMS providers have infrequent contact with pediatric patients and have acquired most of their pediatric knowledge and skills from CE. In general, these providers are comfortable with their personal and their system's ability to care for children, but clearly support the need for required pediatric CE and identify the birth to 3-year age range as the priority for an educational focus. Cost, travel distance, and availability of pediatric CE are barriers that should be considered if pediatric CE is to be required of EMS providers.

Are pediatric emergency medicine training programs adequately preparing graduates for involvement in EMS?

OBJECTIVE: To examine the level of involvement in pre-hospital care for children by faculty and fellows of teaching hospitals with a Pediatric Emergency Medicine (PEM) fellowship. In addition, we hypothesized that a divisional faculty member's involvement as principal investigator (PI) on an EMSC grant would not impact divisional involvement in on or off-line medical direction. DESIGN: Cross-sectional national survey. PARTICIPANTS: PEM fellowship directors. INTERVENTIONS: Self-administered questionnaire. STATISTICS: Descriptive and Chi-square analysis to study null hypothesis. RESULTS: The response rate to the survey was 62% (53/85). Of the programs responding, 53 % provided on-line pediatric medical direction for pre-hospital providers, 77% were involved with paramedic education other than PALS, and 58% of systems had pediatric specific protocols. In 87 % of the programs, a designated faculty member functioned as an EMSC liaison. A division faculty member was or had been the PI on an EMSC grant in 18 programs (34%). There was no significant difference in the provision of on or off-line medical direction comparing programs with or without involvement in an EMSC grant. Only 34% of the responding program directors felt that the current level of exposure to EMS was adequate for PEM fellow training. CONCLUSIONS: The current level of involvement in EMS of PEM faculty and fellows has significant room for improvement. It does not appear that grant support translates into increased local involvement in EMS. Current PEM fellowship curriculum guidelines for training in EMS are not being met by the majority of responding training programs.

Preliminary results achieved by a computer-assisted system for controlled balloon dilatation of coronary and peripheral arteries.

In percutaneous balloon angioplasty the extent of trauma to the vessel as determined by slope of balloon inflation, peak pressure, and inflation time is crucial to the success of the intervention. These parameters are still not standardized and hence open to the operator. To elucidate this problem, a computer-assisted PTCA system (CAPS) was developed. CAPS is composed of a motor driven unit, a central processing and power unit, and a notebook. A syringe is clamped onto the motor unit and connected to a pressure gauge. CAPS may be linked to all types of balloon catheters. The notebook allows for preselection of peak pressure, slope of pressure increase, and inflation time. During balloon inflation, adjustments are made in a closed-loop system. On a screen, the inflation process is supervised in digital numbers and analogous curves. After the procedure, patient data and inflation curves may be recalled for analysis. In conclusion, CAPS by controlled inflation theoretically may reduce the mechanical trauma to the arteries. Further refinements should aim at gaining information on the lesions' characteristics and on the dilatation process itself.

Improved prehospital pediatric ALS care after an EMT-paramedic clinical training course.

The objective was to determine the association between the performance rates of pediatric advanced life-support procedures, intubation and vascular access, by emergency medicine technician-paramedics (EMT-P), and introduction of an EMT-P pediatric advanced life support (PALS) clinical course. Prehospital EMT-P care records from January 1990 to December 1991 were retrospectively reviewed to determine endotracheal intubation and vascular access performance rates. These rates were compared with intubation and vascular access performance rates by EMT-Ps from January 1983 to June 1985. In 1986, an EMT-P PALS clinical course was introduced that included rotations during which an EMT-P trainee performed endotracheal intubation of children, under the supervision of a pediatric anesthesiologist, and vascular access, under the supervision of pediatric emergency medicine nurses and physicians. The trainees and all active EMT-Ps were taught the intraosseous infusion procedure. During January 1990 to December 1991, 193 children received prehospital endotracheal intubation attempts and 167 (87%) were intubated. Intubation performance rates for 90 children younger than 18 months of age was 90% and was 83% for 103 children > or = 18 months of age. Vascular access, intravenous or intraosseous, was established in 130 (73%) of the children; no attempt was made in 14 children. The vascular access performance rate was 64% for children younger than 18 months of age and 79% for children > or = 18 months old. Intubation performance rates of EMT-Ps before the EMT-P PALS clinical course (January 1983 to June 1985) were 48% for children younger than 18 months of age and 85% for children > or = 18 months old.(ABSTRACT TRUNCATED AT 250 WORDS)

Five-year experience in prehospital intraosseous infusions in children and adults.

STUDY OBJECTIVE: To evaluate the ability of emergency medical technician-paramedic (EMT-P) units to become and remain proficient in the performance of the intraosseous infusion procedure. DESIGN AND SETTING: Descriptive nonrandomized trial open to all patients meeting protocol criteria over a five-year period; prehospital urban and suburban area with a population of 951,000. PARTICIPANTS: One hundred fifty-two consecutive patients (age range, newborn to 102 years) who had intraosseous infusion line placement attempted by EMT-Ps. INTERVENTION: Jamshidi sternal intraosseous infusion needle placed in the proximal tibia bone marrow in patients requiring emergency vascular access for fluid and/or medication administration. RESULTS: EMT-Ps performed 165 attempts on 152 patients with a five-year success rate of 76% per patient and 70% per attempt. Success rates per patient age group were 78%, 0 to 11 months; 85%, 1 to 2 years; 67%, 3 to 9 years; and 50%, 10 years or older. Success rates were significantly higher in children 3 years old compared with children and adults 3 or more years old (P = .04). Proficiency was maintained over the five-year study period. Infiltration was the most common complication, occurring in 14 patients (12%). Errors in landmark identification and needle bending were the most frequent identifiable causes for unsuccessful attempts. Evidence of clinical response to fluid or medication infused was noted in 28 patients (24%). CONCLUSION: EMT-P units can successfully perform the intraosseous infusion line procedure in patients of all ages. Proficiency is maintained over time despite its infrequent use by individual EMT-Ps.

The role of abdominal x-rays in the diagnosis and management of intussusception.

The management of intussusception requires early diagnosis and reduction with either barium enema or surgical intervention. Supine and erect abdominal radiographs are often obtained prior to ordering a barium enema. In many pediatric centers, the critical, initial interpretation of these radiographs is made by nonradiologists and, in most instances, by pediatric emergency physicians. We determined the sensitivity and specificity of abdominal radiographs in diagnosing intussusception when interpreted by these physicians. Six full-time pediatric emergency physicians evaluated 126 radiographs from 42 patients with intussusception, 42 in whom the disease was clinically suspected but ruled out, and 42 in whom the final radiology report was "normal." These were presented to pediatric emergency physicians in a blinded, randomized sequence without any additional clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% (range, 71-93%), and the mean specificity was 58% (range, 48-69%). This compares favorably to the sensitivity of signs and symptoms, and we conclude that plain and upright abdominal films are a useful adjunct for the clinician evaluating patients for suspected intussusception.

Clinical predictors of bacterial versus aseptic meningitis in childhood.

STUDY OBJECTIVE: To assess the reliability of meningeal signs and other physical findings in predicting bacterial and aseptic meningitis at various ages. DESIGN: Children requiring lumbar puncture were evaluated prospectively for meningeal signs and other physical parameters before lumbar puncture. SETTING: Emergency department of Children's Hospital of Wisconsin. PARTICIPANTS: One hundred seventy-two children, aged 1 week to 17 years, with meningitis (53 bacterial and 119 aseptic). MEASUREMENTS AND MAIN RESULTS: Nuchal rigidity was present in 27% of infants aged 0 to 6 months with bacterial meningitis versus 95% of patients 19 months or older (P = .0001). Three percent of infants 0 to 6 months old with aseptic meningitis had nuchal rigidity versus 79% of patients 19 months or older (P = .0005). Seventy-two percent of infants 12 months of age or younger with bacterial meningitis has at least one positive meningeal sign versus 17% of infants with aseptic meningitis (P = .0001). Eighty-five percent of children older than 12 months with meningitis had at least one positive meningeal sign, 93% with bacterial meningitis, and 82% with aseptic meningitis. CONCLUSION: Despite a lack of meningeal signs, a high index of suspicion for meningitis is essential when evaluating the febrile infant 12 months of age or younger.

The effect of oral midazolam on anxiety of preschool children during laceration repair.

Preschool age children often experience marked anxiety and physical pain during laceration repair. Locally infiltrated anesthetics or topical tetracaine, adrenaline, and cocaine (TAC) usually control the physical pain but have little or no effect on anxiety. Midazolam is a short-acting benzodiazepine with anxiolytic, hypnotic, and antegrade amnestic effects. In a double-blind, randomized clinical trial, we evaluated the efficacy of midazolam in alleviating anxiety during laceration repair in children less than 6 years old. On admission to the emergency department, anxiety level was determined on a scale of 1 to 4 based on a predetermined behavior criteria. Patients with high anxiety level (3 or 4) received a single oral dose of either midazolam (0.2 mg/kg) or placebo. The anxiolytic effect of midazolam was considered adequate if the anxiety level decreased two or more points (from 4 to less than or equal to 2 or from 3 to 1) during laceration repair. In the midazolam group (30), 70% of the children had a two-point or more decrease in anxiety level compared with 12% in the placebo group (25) (P less than .0001). No respiratory depression or other complications were noted in the midazolam group. We conclude that a single oral dose of midazolam (0.2 mg/kg) is a safe and effective treatment for alleviating anxiety in children less than 6 years old during laceration repair in the ED.

Prehospital countershock treatment of pediatric asystole.

Prehospital care was retrospectively reviewed in 117 pulseless nonbreathing (PNB) pediatric patients (0 to 18 years of age) to determine the effects of immediate countershock treatment of asystole. Of 90 (77%) children with an initial rhythm of asystole, 49 (54%) received countershock treatment. Rhythm change occurred in ten (20%) of the asystolic children who received countershock treatment. Three of the countershocked asystolic children were successfully resuscitated, but none survived. Rhythm change occurred in nine (22%) of the asystolic children not countershocked. Six were successfully resuscitated, and one survived. The two groups (countershocked asystole v noncountershocked asystole) did not differ significantly in age, sex, witnessed arrest, witnessed arrest with bystander basic life support (BLS), prehospital endotracheal intubation, both intubation and vascular access success, or diagnosis. However, prehospital vascular access was successfully established in a significantly greater number of countershocked patients (P less than .05). The mean times to the scene, at the scene, and to the hospital for the countershocked v noncountershocked asystolic patients were 6.2, 23.8, and 6.1 v 5.9, 14.7 and 7.0 minutes. The mean time at the scene was significantly greater in the countershock group (P less than .001). The successful performance of prehospital endotracheal intubation was significantly associated with rhythm change (P less than .05). Patients age, witnessed arrest, witnessed arrest with bystander BLS, successful establishment of prehospital vascular access, diagnosis, and countershock treatment were not significantly associated with rhythm change. In conclusion, prehospital countershock treatment prolonged prehospital care time and was not associated with rhythm change in asystolic children. Therefore, prehospital countershock treatment of asystolic children is not recommended.

Prehospital pediatric endotracheal intubation performance review.

Pediatric prehospital care was reviewed over a one-year period to determine success rate, causes of unsuccessful attempts, and complications of performing endotracheal intubation. The Milwaukee County Emergency Medicine Technician-Paramedics (EMT-Ps) responded to 1467 pediatric (less than 19 years of age) patient calls. This accounted for 11% of the patients who received EMT-P care during the study period. Of the 63 patients requiring pediatric endotracheal intubation, 49 (78%) were successfully intubated. Of the 42 pulseless nonbreathing (PNB) patients, 39 (93%) were successfully Of the 21 patients judged to be in impending respiratory failure, 10 (48%) were successfully intubated. Common difficulties in intubating the PNB patient included inability to visualize the glottis and cords secondary to mucus and/or vomitus, use of inappropriately small endotracheal tubes, and accidental extubation during transport. Difficulties in intubating impending respiratory failure patients included patient resistance and seizure activity. We recommend that the EMT-P training curriculum include a review of these difficulties and that prehospital pediatric endotracheal intubation performance be monitored and reviewed with the EMT-Ps.

Pediatric sexual abuse management in a sample of children's hospitals.

Medical directors of pediatric emergency departments were surveyed by mail to determine the present role of their pediatric hospitals in general, and emergency departments in particular, in the evaluation and management of pediatric sexual assault and abuse. Seventy-four percent of the responses were from communities with an estimated yearly incidence of sexual abuse cases greater than 500. Sixty-eight percent of the communities had a designated pediatric sexual assault center. Thirty-two percent were affiliated with adult facilities and 68% with pediatric facilities. Of those hospitals responding, initial evaluation was most often performed in the emergency department in 77%. Most initial evaluations were performed by resident (PL-2 or above) level physicians (59%). The availability of non-physician professionals, eg, social workers, was felt to be always or usually adequate in 57% and occasionally, rarely, or never adequate in 43%. Estimated physician time required for evaluations averaged less than 60 minutes in 52%, 60 to 90 minutes in 32%, and greater than 90 minutes in 16%. Other patients were felt to be always or frequently compromised in 34% and occasionally compromised in another 44%. The directors rated the abilities of their respective departments to evaluate and manage these patients as excellent in 33%, good in 33%, adequate in 29%, and inadequate in 4%.

Pediatric intraosseous infusions: impact on vascular access time.

A 1-year retrospective chart review was performed to evaluate the effect of intraosseous infusions (IO) on the time required to establish vascular access in pediatric patients requiring immediate vascular access for resuscitation. Eighty-one patients were identified, including 29 pulseless and non-breathing and 52 noncardiopulmonary arrest children, who required intravenous fluids or medication for resuscitation. Comparing the results with a previous review, the IO method effectively reduced the time needed to establish vascular access in the arrested group when standard techniques failed, particularly in the child less than 2 years old. The IO method was not used effectively in the non-arrest group, as evidenced by a significantly greater mean time required to establish vascular access. There were no significant complications related to the IO procedure. Nine (50%) of the patients receiving IO fluids or medication had clinical and/or laboratory evidence that these substances reached the central circulation. Early use of IO infusion in the resuscitation is recommended for not only the arrested patient, but also the critical nonarrested patient requiring immediate vascular access.

Prehospital care of the pulseless, nonbreathing pediatric patient.

The performance of life-saving procedures by prehospital care personnel was reviewed in the cases of 114 pulseless, nonbreathing pediatric patients. Children 18 months to 18 years of age had a significantly greater chance of having prehospital endotracheal intubation and vascular access established compared to children younger than 18 months of age. For all patients, witnessed arrest and initial rhythm of ventricular fibrillation were significantly associated with survival. In the younger children, endotracheal intubation also was associated significantly with survival. Nine (8%) patients survived, and only three of the survivors were without neurologic sequelae. The number of neurologically intact survivors was too small to show a statistically significant association with these factors.

Pediatric emergency departments.

Pediatric emergency departments were surveyed by mail to determine the following patient and physician characteristics: census, triage classification, and staffing characteristics. The average number of patient visits per department per year was 44,615 (SD +/- 15,650). Of these, the mean percentage triaged as emergent, urgent, and nonurgent was 14.6 (SD +/- 13.4%), 35.4 (SD +/- 13.1%), and 52.2 (SD +/- 8.7%), respectively. The average number of full-time attending physicians per department was five. Fifty-nine (91%) of the physicians were pediatric board certified, and five (7.6%) were emergency medicine board certified. Academic standing, salaries, clinical research requirements, teaching responsibilities, and average patient care hours were also reviewed. From these data, suggestions for the management of patient care, teaching, and clinical research are presented.