Effect of ketorolac in pediatric sickle cell vaso-occlusive pain crisis.

BACKGROUND: Ketorolac is a parenteral, nonsteroidal analgesic that does not have a narcotic's risks of respiratory depression, hypotension, or dependence. Its usefulness in providing pain relief in pediatric patients with acute vaso-occlusive crisis of sickle cell disease has not been studied to date. METHODS: Twenty-nine patients with sickle cell disease between the ages of 5 and 18 years who presented to The Children's Hospital of Alabama emergency department (ED) with 41 distinct episodes of acute vaso-occlusive pain crisis were enrolled prospectively and randomized to receive either 0.9 mg/kg intravenous (IV) ketorolac or placebo in a double-blind fashion. All patients also received IV fluids and an initial 0.1 mg/kg of IV morphine. Subsequent standardized doses of morphine were given every 2 hours over a 6-hour observation period based upon severity of pain as scored by a 10-cm linear visual analog scale (VAS). Vital signs and pain severity were recorded initially and assessed hourly. Disposition was made at the end of the observation period. RESULTS: Patients receiving ketorolac and those receiving placebo were of similar age, weight, gender, number of prior ED visits, number of prior hospital admissions, duration of pain prior to presentation, and initial pain score. The total dose of morphine received, reduction in severity of pain as measured by VAS, rate of hospital admission, and rate of return to the ED for discharged patients did not differ significantly between the two groups. CONCLUSION: We were unable to demonstrate a synergistic analgesic effect for ketorolac in the treatment of pain from acute vaso-occlusive crisis in pediatric sickle cell disease. Further investigations involving larger samples of sickle cell patients may be needed to further define a role for ketorolac in the acute management of sickle cell vaso-occlusive pain.

Fatal iron intoxication in an infant.

Iron ingestion continues to be one of the major contributors to pediatric poisoning deaths. In 1995, more than 22,000 children unintentionally received preparations containing iron. Despite child-resistant packaging and education of both the public and medical personnel, the number of deaths has not significantly declined. Our patient, a 13-month-old child, ingested prenatal vitamins and despite aggressive efforts died 13 hours after his initial presentation. The patient's 3-year-old sibling had been evaluated at a local hospital 12 hours earlier for iron ingestion. Although there have been previous reports of death from iron ingestion, this case report is important because of the sibling's presentation and medical evaluation 12 hours before our patient's presentation. This case illustrates the need for physicians to inquire about other children in the home, possibly preventing further tragic outcomes.

Respiratory depression in a child unintentionally exposed to transdermal fentanyl patch.

A 2-year-old boy was found unresponsive after sleeping in bed with his grandmother. After the patient was intubated and ventilated, paramedics discovered a transdermal fentanyl patch on the victim's back. Removal of the patch and treatment with naloxone resolved symptoms. This is the first reported case of secondary exposure to a fentanyl patch causing clinically significant respiratory depression in the pediatric population, and it emphasizes a new hazard of such drug use.

Urban/rural differences in child passenger deaths.

Motor vehicle crashes are the leading cause of death for Alabama children. This fact persists despite a child restraint law and an amendment designed to prevent such deaths in preschoolers. This study compared cumulative motor vehicle-passenger death rates by county and by urban and rural residence. Rural children had twice the rate of death of urban children. Additionally, these death rates demonstrated a sharp negative gradient when residence areas were ordered by increasing population densities (rural agricultural, rural manufacturing, suburban, and urban, respectively). Because child passenger death rates are significantly higher among rural children, future research should focus on hazards associated with the rural environment. A list of key study elements is provided.