Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing.

OBJECTIVE: Steroid use for the treatment of croup has been supported by several studies, although few have addressed the use of oral dexamethasone for outpatient management. The efficacy of oral (PO) versus intramuscular (IM) dosing of dexamethasone in the outpatient treatment of moderate croup are compared in this study. METHODS: Patients between the ages of 3 months and 12 years with moderate croup (history or presence of stridor, cyanosis, or retractions) were eligible for enrollment in this single-blind, prospective study. Patients were randomized to receive a single dose (0.6 mg/kg, maximum 8 mg) of IM or PO dexamethasone. Parents were contacted by phone to assess resolution of symptoms and need for further evaluation. RESULTS: Two hundred seventy-seven patients were enrolled (median age: 2.1 years). One hundred thirty-nine patients received IM dexamethasone, and 138 received PO. At phone follow-up, 141 (51%) had total resolution of symptoms (75 in IM, 66 in PO). Eighty patients (29%) returned for further evaluation (45 in IM, 35 in PO). Twenty-three (8%) received either more steroids, racemic epinephrine, or admission (11 in IM, 12 in PO). CONCLUSION: No statistically significant difference was found in the need for subsequent interventions after a single dose of either IM or PO dexamethasone. A single PO dose of dexamethasone can be effectively and safely used for the outpatient treatment of moderate croup.

Pediatric Emergency Medicine (PEM) fellowship: essentials of a three-year academic curriculum. Three-Year Academic Subcommittee of the PEM Fellowship Committee of the Section of Emergency Medicine, American Academy of Pediatrics.

This committee of fellowship directors has proposed guidelines for an academic curriculum for training fellows in PEM. The curriculum should be modified to each unique program, but is based on current expectation of the American Board of Pediatrics and the ACGME for graduate education. This is the first PEM academic curriculum document in publication. Ongoing refinement and adaptation based on feedback from fellows and directors is essential to provide the best fellowship experience to our trainees. The proposed curriculum is also subject to further change as more details are given for ACGME approval of the fellowship programs.

Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup.

STUDY OBJECTIVE: To identify patients with croup who after treatment with nebulized racemic epinephrine, oral dexamethasone, and mist may be safely discharged home after a period of observation. DESIGN: Prospective interventional. SETTING: Urban children's hospital emergency department. PARTICIPANTS: Children with croup who received racemic epinephrine for the treatment of stridor at rest. INTERVENTIONS: After treatment with .5 mL racemic epinephrine, .6 mg/kg dexamethasone PO, and mist, patients who were assessed as being safe for discharge after 3 hours of observation were discharged home and contacted for 48-hour follow-up. RESULTS: Fifty-five patients with croup were treated with racemic epinephrine. Thirty patients (55%) had sustained responses and were discharged home after 3 hours of observation. No recurrence of respiratory distress and no return visits for medical care were reported (95% confidence interval, 0% to 8.0%). CONCLUSION: Patients with croup who are treated with racemic epinephrine, oral dexamethasone, and mist may be safely discharged home if the patient is assessed as ready for discharge after 3 hours of observation.

Slipped capital femoral epiphysis without hip pain leads to missed diagnosis.

Prompt diagnosis of slipped capital femoral epiphysis (SCFE) is dependent on recognition of variable clinical manifestations. The charts of 116 children and adolescents with SCFE were reviewed to identify characteristics of patients whose diagnosis was initially missed. Missed diagnosis was found in 34 patients (29%). Sixteen of the 34 whose diagnosis was missed had hip pain, while 58 of the 82 whose diagnosis was not missed had hip pain (P = .0157). Of the 34 patients with missed diagnosis, 15 patients had thigh pain. In comparison, of the 82 patients without missed diagnosis, 19 had thigh pain (P = .0241). It is concluded that SCFE is more likely to be missed at the initial visit if hip pain is absent or if thigh pain is present. This review indicates that despite the evidence that patients with SCFE frequently complain of symptoms other than hip pain, the disorder continues to be missed.