Variation in utilization of computed tomography scanning for the investigation of minor head trauma in children: a Canadian experience.

OBJECTIVES: To compare the utilization rates of CT scans in investigating minor head trauma in children in Canada, to identify the injuries determined by these scans, and to identify clinical findings that are highly associated with its diagnosis and the injury itself. METHODS: A retrospective cohort study involving nine pediatric hospitals in Canada was conducted. A structured data collection method was used. Inclusion criteria included age 16 years or less, history of blunt head trauma, and a Glasgow Coma Scale score (GCS) greater than or equal to 13. Data collected included demographic information, type of injury, relevant clinical information, computed tomography (CT) scan data, and clinical outcome. Clinical findings associated with CT scan and positive CT scan were identified using logistic regression. RESULTS: One thousand one hundred sixty-four children were included in the study. One hundred seventy-one (15%) had a CT scan, of which 60 (35%) were abnormal. There was a significant difference in the rate of ordering of CT scans among the participating hospitals, but no significant difference in the rate of abnormal CT scans. Mechanism of injury, GCS, and loss of consciousness were significantly related to the presence of an abnormal CT scan. CONCLUSIONS: Although there is a significant difference in the utilization of CT scans to investigate minor head trauma in children across Canada, there is no significant difference in the frequency of head injuries in these patients. This suggests that it may be possible to determine clinical criteria that are predictive of a head injury in these patients.

Antimicrobial use in febrile children diagnosed with respiratory tract illness in an emergency department.

BACKGROUND: In an era of increasing antibiotic resistance, the prevalence of antibiotic usage and associated factors should be ascertained to optimize their use. We set out to determine the prevalence of antibiotic use in febrile children diagnosed with respiratory tract illnesses at a children's hospital emergency department; to determine how often viral studies were conducted; and to identify patient characteristics associated with antibiotic use. METHODS: We conducted a retrospective study of antibiotic use in febrile children 3 months to 10 years old presenting with respiratory illnesses during two 1-month periods. Patient charts and laboratory tests were reviewed. Antibiotic use was related to diagnosis by logistic regression. RESULTS: A total of 836 patient visits were selected. Antibiotics were prescribed for otitis media in 96% of patients, for pneumonia in 100%, for pharyngitis in 66%, for bronchiolitis in 38%, for reactive airway disease in 24% and for viral or "upper respiratory tract illness" in 14%. For viral illness or upper respiratory tract infection, antibiotic use was associated with a fever duration of >48 h [odds ratio (OR), 3.2; 95% confidence interval (CI) 1.7, 5.9] and having a chest radiograph performed (OR 2.1; 95% CI 1.02, 4.37). Patients with pharyngitis who had a throat swab were less likely to receive an antibiotic (OR 0.08; 95% CI 0.02, 0.4) than those who did not have a swab. In this emergency department antibiotic use for these indications decreased by 11% during the 1997 to 1998 study interval (P < 0.001). CONCLUSION: Antibiotics were commonly prescribed for pharyngitis, bronchiolitis and reactive airway disease, which are conditions principally caused by viruses. Addressing reasons why there is a difference between guidelines and antibiotic use in these conditions may be important.

Emergency department management of blunt cervical tracheal trauma in children.

A case history of a young girl who sustained a small posterior laceration of her cervical trachea after blunt trauma is presented. She was brought to the emergency department (ED) by her parents roughly two hours after the incident with only minor symptoms. While in the ED, she developed significant airway compromise over a span of minutes. Orotracheal intubation was performed to secure her airway, and she responded to conservative management of her laceration. Her signs and symptoms, resolved, and she was discharged after five days. This case illustrates the importance of urgent evaluation and careful observation of patients with possible tracheal damage, as even very small tears have the potential to cause life-threatening airway compromise.