Salbutamol intoxication: is salbutamol a drug-inducing fever? A case report and treatment strategy.

A four-year-old female with salbutamol intoxication was referred to our paediatric emergency medicine unit, due to agitation, tremulousness, sinus tachycardia, mild hypokalaemia and hyperglycaemia. On admission the child was agitated and had a noticeable tremor, an axillary temperature of 38 degrees C and a pulse rate of 185 beats/min. She had no identifiable focus of infection on physical examination to explain her fever. Gastric lavage, activated charcoal, intravenous hydration and electrocardiogram (ECG) monitoring were performed. Her plasma potassium level, blood sugar and QT interval were closely monitored during her hospital stay. Her fever, tachycardia and serum potassium and glucose levels returned to normal and she was discharged in good condition 24 h after admission. The difference of this case from prior cases of salbutamol intoxication was the observation of fever in the absence of evidence of infection. Since the cause of fever was not a reaction to the medication used in the treatment or related to environmental factors, it is assumed that salbutamol is a fever-inducing drug.

Accuracy of clinical variables in the identification of radiographically proven constipation in children.

STUDY OBJECTIVE: To determine whether clinical variables accurately identify children with radiographically proven constipation. METHODS: Prospective, cross sectional case series of children 2-12 years of age with abdominal pain (AP) requiring radiographic evaluation. Constipation was defined radiographically as the presence of fecal material throughout the colon. The presence of other pathology was noted. The pediatric emergency department (ED) physicians recorded a comprehensive history and physical examination and a provisional diagnosis was made. Radiographs were initially interpreted by the pediatric ED attending physicians; the official interpretation was later provided by a single board certified pediatric radiologist who was blinded to the ED interpretation. A discriminant analysis was performed to identify variables that could best discriminate between patients with, and without, radiographically proven constipation. RESULTS: In total 251 patients were enrolled over a 12 month period. Four variables were noted to be more common in constipated patients: a history of normal or hard stools, absence of rebound tenderness, presence of tenderness in the left lower quadrant and stool in the rectal vault on exam. Stool present on rectal exam was the best discriminator between patients with and without constipation. The discriminant analysis model had a sensitivity of 77%, specificity of 35% and a negative predictive value of 55%. CONCLUSION: No clinical variable, either as a single variable or in a model, accurately identified patients with abdominal pain and radiographically proven constipation.

Effects of propofol on H-reflex in humans.

BACKGROUND: Depression of spinal cord motoneuron excitability has been proposed to contribute to surgical immobility. The H-reflex, which measures alpha-motoneuron excitability, is depressed by volatile anesthetics, whereas the action of propofol is unknown. The objective of this study was to determine the effects of propofol anesthesia on the H-reflex. METHODS: In 13 patients (group 1), H-reflex was measured before (T0), 3 min after (T1), and 10 min after (T2) a 2-mg/kg bolus dose of propofol, followed by an infusion of 10 mg x kg(-1) x h(-1). Ten patients (group 2) were studied when propofol was given via a programmable pump set to a propofol blood concentration of 6 microg/ml, and 10 patients (group 3) were studied with the pump set to 9 microg/ml. Latencies and amplitudes of H-reflexes (H0, H1, H2) and M-responses (M0, M1, M2) of the soleus muscle were recorded, and H/M ratios (H0/M0, H1/M1, H2/M2) were calculated. RESULTS: In group 1, H-reflex amplitudes and the H/M ratio were diminished after induction with propofol (H0 vs. H1, P = 0.033; H0/M0 vs. H1/M1, P = 0.042). After 10 min of propofol infusion, the H2/M2 ratio was still decreased versus H0/M0 (P = 0.031). In group 2, no difference was detected. In group 3, propofol depressed H-reflex amplitudes at T2 (H0 vs. H2, P < 0.01), and amplitudes were also lower at T2 than at T1 (H1 vs. H2, P < 0.01). In this group, the H/M ratio decreased from T0 to T2 (H0/M0 vs. H2/M2, P < 0.002). CONCLUSIONS: During steady state conditions using propofol as the sole agent, a depression of the H-reflex is observed only at a high blood concentration of 9 microg/ml. The authors suggest that immobility during propofol anesthesia is not caused by a depression of spinal motoneuron circuit excitability.

Feasibility survey for a study on selective antibiotic management of acute otitis media.

OBJECTIVE: To assess the views of community physicians on management of acute otitis media (AOM) without antibiotics and their willingness to support research on this issue. METHODS: Community physicians who admit to a children's hospital were surveyed using a questionnaire containing questions on current issues in AOM management and their willingness to support research on management of AOM without antibiotics. RESULTS: Fifty-two percent of the surveys were returned. All respondents report concern about antibiotic resistant bacteria. Sixty-three percent treat otitis media with effusion with antibiotics and 68% give prophylactic antibiotics for recurrent otitis media. Thirty-five percent consider management of AOM without antibiotics as a possible alternative management practice. Forty-five percent of the respondents are willing to support research in this practice and 46% need more information. CONCLUSIONS: Surveyed physicians indicate concern about antibiotic resistance and a willingness to support further research on the initial management of acute otitis media without antibiotics.

Accidental isopropanol ingestion in children.

OBJECTIVE: To describe the clinical course and determine the minimal observation period required following isopropanol ingestion in children. METHODS: The emergency department records of children less than 6 years of age with isopropanol ingestion who presented between June 1992 and December 1998 were identified. Demographics, type, and amount of ingested substance, and time of ingestion were recorded. Symptoms, time of onset, and the results of physical examination and laboratory tests were collected. Group 1 included patients who did not have isopropanol level assayed, and group 2 members had isopropanol level assayed. RESULTS: Ninety-one cases of isopropanol ingestion were identified. Clinical evidence of toxicity was noted in 26 (29%) patients. Symptoms included spontaneous emesis in (24/26), ataxia (5/26), altered mental status (3/26), and apnea (1/26). Toxic isopropanol levels were noted in three patients; all had altered mental status. Clinical evidence of toxicity developed between 0.5 and 2 hours post-ingestion. Patients who ingested more than 1 ounce of isopropanol were more likely to become symptomatic (RR 4.26, 95% CI = 1.61-11.2). CONCLUSIONS: An observation period of 2 hours post-ingestion can be used to rule out clinical toxicity in pediatric patients with suspected isopropanol ingestion. Patients with a history of ingesting more than 1 ounce are likely to develop adverse clinical effects. The development of altered mental status is the most useful clinical predictor of a toxic blood isopropanol level.

Serum neuron-specific enolase as a predictor of intracranial lesions in children with head trauma: a pilot study.

OBJECTIVE: To determine the reliability of serum neuron-specific enolase (NSE) levels in predicting intracranial lesions (ICL) in children with blunt head trauma (HT). METHODS: A prospective pilot study was conducted of patients 0 to 18 years of age presenting to a children's hospital emergency department (ED) between December 1997 and October 1998. Children presenting within 24 hours of injury who required head computed tomography (CT) were eligible. Blood samples were obtained to measure serum NSE level. Data collected included patient demographics, historical information, Glasgow Coma Scale score (GCS), physical examination, head CT results, and outcome. Patients were assigned to one of two groups based on the head CT results (PICL; presence of intracranial lesion, or NICL; no intracranial lesion). Data were analyzed using Student's t-test and chi-square. The 95% confidence interval (95% CI) was calculated when appropriate. A receiver operating characteristic curve was constructed to determine the NSE level that yielded the highest sensitivity and specificity for predicting ICL. RESULTS: Fifty patients were enrolled; 22 (45%) had abnormal head CT. No difference in demographics or mechanism of injury was observed between those with abnormal or normal CT scans. The mean GCS level was 11.9 +/- 4.2 for PICL and 13.9 +/- 2.6 for NICL (p = 0.045; 95% CI = -0.05 to -3.9). The mean NSE level was 26.7 +/- 21.4 for PICL and 17.7 +/- 7.8 for NICL (p = 0.048; 95% CI = 0.1 to 17.9). An NSE level > or = 15.3 ng/mL yielded a sensitivity of 77%, a specificity of 52%, and a negative predictive value of 74%. CONCLUSIONS: These results suggest that serum NSE may be a useful screening tool for predicting ICL in children with blunt head trauma. However, the NSE alone was neither sensitive nor specific in predicting all patients with ICL.

The need for a second dose of ceftriaxone in febrile infants age 4-8 weeks.

OBJECTIVE: To determine if a second intramuscular injection of ceftriaxone was necessary in febrile infants who meet low-risk criteria for outpatient therapy. SETTING: Children's Hospital Emergency Department. PATIENTS: Febrile infants 4-8 weeks of age. METHODS: Outpatient treatment criteria included non-toxic appearance, no identifiable source for infection on physical examination, CSF WBC > or = 10/mm3, peripheral WBC < or = 15,000/mm3, normal UA, and normal chest radiograph study, if obtained. Additional requirements included a reliable caretaker and re-evaluation in 24 hours. Infants who met these criteria received intramuscular ceftriaxone 50 mg/kg with instructions to follow-up in 24 hours. At the follow-up visit, infants with no identifiable source for infection and negative cultures received a second dose of intramuscular ceftriaxone and were discharged. Cultures were read at 48 hours and at the conclusion of the study. Medical records were reviewed to identify delayed complications. RESULTS: 172 infants were enrolled. The mean age was 45 days. All CBC, UA, CSF analyses were normal. Chest radiographs were obtained in 56 (30%) infants; all were normal. One (.05%) patient was admitted at the follow-up visit. The mean time to follow-up was 25 hours. Two positive cultures were identified at the re-evaluation visit; one blood culture grew Salmonella and a urine culture grew E. coli. The CSF cultures were all negative at follow-up and remained negative. CONCLUSION: Febrile infants 4-8 weeks of age who meet outpatient therapy criteria and have negative cultures and no identifiable source for infection at 24 hours may not require the second dose of intramuscular ceftriaxone.

Adult-worn child carriers: a potential risk for injury.

OBJECTIVES: To examine and describe types of injuries associated with adult-worn child carriers and illustrate the need for careful use of these products by parents. METHODS: A literature search for the terms infant carriers, backpack carriers, infant slings, baby carriers, and baby slings was conducted. Information was also obtained and tabulated from the three Consumer Product Safety Commission databases: the National Electronic Injury Surveillance System (NEISS), the In-Depth Investigations File, and the Injury/Potential Injury Incident File. RESULTS: No reports of injuries were found in the medical literature. In the NEISS database, 51 injuries were reported between January 1990 and September 1998. Of these injuries, 38 (74.5%) were head traumas and eight (15.7%) were facial trauma. Of the 51 injuries, 11 (22%) required hospitalization. CONCLUSIONS: Based on the data presented in this paper, injuries associated with the use of adult-worn child carriers appear to come from three general sources: product appropriateness and design, product condition, and product use. It is important for health care providers to assist in the dissemination of information regarding the safe use of these products to parents in an effort to prevent injuries.

[Treatment of acute clinical stroke]. / Akute klinische Schlaganfallbehandlung.

Stroke is an emergency. Treatment must begin as soon as possible because significant sustained neurological improvement has been demonstrated when thrombolytic treatment, mainly with recombined tissue plasminogen activator (rtPA) is initiated within the first hours of stroke onset. On the other hand in the acute phase of stroke it is critical that patients get adequate management for the prevention of early complications. Management of the acute phase of stroke is the target of this article. Preclinically started treatment must be continued in the neurological emergency unit. Clinical examination is followed by technical investigations: cerebral computer tomography (CCT) is the most useful radiological investigation in the acute phase. It allows to distinguish between ischemia and hemorrhagic lesions and also to rule out nonstroke brain conditions. Multimodal magnetic resonance imaging (mMRI) may provide data on viable versus irreversibly damaged tissue. Sufficient stroke treatment is based on well managed in-hospital infrastructure. Thrombolysis is the only causative treatment of stroke in selected patients. Complications of acute stroke comprise changes of blood pressure with hemodynamically relevant effects on cerebral perfusion pressure, acute post- ischemic brain edema, and intracerebral bleedings.

A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department.

OBJECTIVE: To compare the effectiveness, recovery time from sedation, and complication rate of propofol with those of midazolam when used for procedural sedation in the pediatric emergency department (PED). METHODS: A prospective, blinded, randomized, clinical trial comparing propofol and midazolam was conducted in the PED of a tertiary pediatric center. Eligible patients were aged 2-18 years with isolated extremity injuries necessitating closed reduction. All patients received morphine for pain, then were randomized to receive propofol or midazolam for sedation. Vital signs, pulse oximetry, and sedation scores were recorded prior to sedation and every 5 minutes thereafter until recovery. Recovery time, time from cast completion to discharge, and other time intervals during the PED course and all sedation-related complications were also recorded. RESULTS: Between August 1996 and October 1997, 91 patients were enrolled. Demographic data, morphine doses, and sedation scores were similar between the propofol and midazolam groups. Mean +/- SD recovery time for the propofol group was 14.9+/-11.1 minutes, compared with 76.4+/-47.5 minutes for the midazolam group, p<0.001. Mild transient hypoxemia was the most significant complication, occurring in 5 of 43 (11.6%) patients given propofol and 5 of 46 (10.9%) patients given midazolam (odds ratio 1.08, 95% CI = 0.24 to 4.76). CONCLUSION: In this study, propofol induced sedation as effectively as midazolam but with a shorter recovery time. Complication rates for propofol and midazolam were comparable, though the small study population limits the power of this comparison. Propofol may be an appropriate agent for sedation in the PED; however, further study is necessary before routine use can be recommended.

Current income profile for academic pediatric emergency medicine faculty.

STUDY OBJECTIVES: To survey academic pediatric emergency medicine (PEM) programs for information on financial compensation and patient care activities of PEM faculty and compare the results to the financial data published by the AAEM, AAAP, and MGMA. METHODS: A survey was mailed to program directors requesting information on medical school affiliation, ED census, recruitment, patient care activity and annual income for each academic rank. The survey also included questions on CME benefits, and income adjustment mechanisms/bonus plans for PEM faculty. The survey income data were stratified by program size and geographic region and then compared to income data from the AAMC, AAAP, and MGMA. RESULTS: Of 47 eligible programs, 37 (78.7%) responded,and four were excluded. Mean number of clinical hours per week for academic faculty and clinical faculty were 27.9 +/- 3.5 and 32.4 +/- 3.9, respectively, (P = 0.000). Clinical appointments in academic departments were offered by 82% of the programs. Mean annual income for all academic ranks was $121,503 +/- $15,795, and is nearly $37,000 less than the annual income for academic adult emergency medicine (AEM) faculty. Compared to medium and large programs, small programs are offering higher salaries to recent fellowship graduates (P = 0.004). When income data were stratified by program size or geographic region, no significant difference in average annual income was observed. Bonus or incentive plans were available only in 45.5% of the programs. CONCLUSION: Direct patient care responsibility of PEM academic faculty has not changed significantly in the past 13 years, despite the availability of clinical appointments within most of the surveyed programs. Our data indicate that the annual income for PEM faculty in academic institutions is significantly less than AEM faculty. No significant difference was observed between programs at the assistant, associate, or full professor level when stratified by size or geographic region. Bonus/incentive plans for exceptional patient care or scholarly activity were available in less than half of the surveyed programs.

Otitis media in infants aged 0-8 weeks: frequency of associated serious bacterial disease.

OBJECTIVE: To determine the frequency of serious bacterial infection in well appearing infants aged 0-8 weeks with isolated otitis media (OM). METHODS: Infants with confirmed OM underwent tympanocentesis with middle ear fluid (MEF) culture and complete sepsis evaluation. Enrolled infants were admitted to the hospital for parenteral antibiotics until blood, urine, and CSF cultures were negative for 48 hours. RESULTS: Forty non-toxic appearing infants were enrolled between January 1994 and April 1995, of whom 15 (38%) had a documented rectal temperature > or =38 degrees C. Bacterial pathogens were isolated from MEF cultures in 25 (62.5%) infants. All afebrile infants had negative blood, urine, and cerebrospinal fluid cultures (upper limit (UL) 95% CI 0.11). Only two febrile infants had positive cultures from sites other than the MEF (UL 95% CI 0.36). CONCLUSION: In our study population, previously healthy, non-toxic appearing afebrile infants aged 2-8 weeks and having isolated OM infrequently have an associated serious bacterial infection, suggesting that outpatient treatment with oral antibiotics and close follow-up may be an option. Further studies with large numbers of infants are necessary to confirm this conclusion.

A randomized clinical trial of dermal anesthesia by iontophoresis for peripheral intravenous catheter placement in children.

STUDY OBJECTIVE: To assess the efficacy of dermal anesthesia by lidocaine iontophoresis in children undergoing peripheral intravenous (PIV) catheter placement in the emergency department. METHODS: A double-blind, randomized, clinical trial was conducted at a tertiary children's hospital ED. Alert children 7 years or older requiring nonemergency PIV were eligible. Patients in the lidocaine group received 1 mL of 2% lidocaine with 1:100,000 epinephrine over a potential PIV site by iontophoresis. The control group received 1 mL of.9% saline solution with 1:100,000 epinephrine. After PIV placement, patients ranked the procedural pain using a visual analog scale. Complications were noted by visual inspection or telephone follow-up. RESULTS: During a 6-month period, 22 patients were assigned to the lidocaine group and 25 to the control group. There was no significant difference in age, sex, or ethnic background between the 2 study groups, and mean application time was 12.0 minutes. The median pain score was.5 in the lidocaine group compared with 4 in the control group (P =.0002; 95% confidence interval [CI] 1 to 5). No significant immediate or delayed complications were observed. CONCLUSION: Lidocaine iontophoresis provides effective dermal anesthesia for children older than 7 years of undergoing nonemergency PIV placement in the ED.

Stroke--a medical emergency.

Stroke is the third leading cause of death and number one cause of disability in industrialised countries. A number of new therapeutic approaches are currently in development for use in the acute phase of ischaemic stroke and all trials have, to date, demonstrated the importance of early diagnosis and subsequent initiation of treatment. It is well known that, for most patients, there is a long delay between the onset of symptoms and the start of treatment. A number of factors are responsible for this time delay: signs and symptoms often go unrecognised by patients, relatives, and bystanders and, unlike trauma or myocardial infarction, stroke is not given a high priority by medical staff. Studies into the pathophysiology of acute ischaemic stroke have indicated that treatment options are likely to be optimised when early signs of stroke are recognised and treatment is initiated within six hours of symptom onset. Although a small number of stroke patients are treated as emergencies and attended to by the emergency medical services within this time window, this number could easily be increased by intensified public and emergency personnel education. In the future, it is hoped that treatments which must be administered within the first few hours of acute stroke will be able to be initiated by the emergency medical services. In the same way that hospitals are notified and prepared in advance to receive trauma victims, early notification by the emergency medical services about stroke patients would enable stroke teams to be present at admission, thus improving the likelihood of a better outcome for patients.

[Preclinical treatment of patients with stroke]. / Präklinisches Management des Patienten mit Schlaganfall.

Stroke is the third leading cause of death and number one cause of disability in industrialised countries. Studies into the pathophysiology of acute ischaemic stroke have indicated that treatment options are likely to be optimized when early signs of stroke are recognized and treatment is initiated within 3 hours from symptom onset. Therefore, new conceptions heading towards early diagnosis, fast preclinical treatment, structured diagnostics, immediate initiation of acute therapy as well as early initiation of rehabilitation are required. It is well known that, for most patients, there is a long delay between the onset of symptoms and the start of therapy. Many factors are responsible for the time delay:signs and symptoms often go unrecognized and/or are minimized by patients, relatives and bystanders. Unlike trauma or myocardial infarction, stroke is not given a high priority by medical staff and/or emergency medical services (EMS). Although a small number of stroke patients is treated as emergency and attended to by the emergency medical services within this time window, this number could easily be increased by intensified public and emergency personnel education. At present the standard of care by the EMS personnel includes adequate cerebral oxygenation, treatment of cardiac arrhythmia, management of hypertension as well as therapy of hyperglycemia and hyperthermia. For the future, we hope that emergency medical services will be able to initiate therapies which must be administered within the first few hours of acute stroke after onset of symptoms. Early notification of hospitals would enable a particular stroke team to be present at the patient's admission.

A review of violence statistics among children and adolescents in the United States.

This article defines the violence and data on juvenile homicide rates and arrest rates for violent crimes in the United States. Mortality data associated with juvenile violence from the United States and similar data from other industrial countries are also compared.