Taste test: children rate flavoring agents used with activated charcoal.

OBJECTIVE: To compare flavoring agents added to activated charcoal (AC) to determine which mixture is most palatable to children. DESIGN: Healthy volunteers between the ages of 3 and 17 years participated in a prospective masked trial. Five identical pitchers were prepared containing AC alone, AC with chocolate milk, AC with Coca-Cola (Coca-Cola Corp, Atlanta, Ga), AC with cherry-flavored syrup, and AC with sorbitol. Subjects tasted all 5 substances in random order. Children younger than 8 years rated taste on a 10-point Faces Scale. Children 8 years and older used a 100-point visual analog scale to rate taste and, separately, ease of swallowing. All children were asked which mixture was best. Ratings were compared using 1-way analysis of variance, and comparisons for all pairs were made using the Tukey test. P<.05 was considered significant. RESULTS: Mean age among the 53 children enrolled was 8.3 years; 23 children were younger than 8 years. Girls made up 52% of the group. Taste scores for chocolate milk, Coca-Cola, and cherry-flavored syrup were significantly better than those for no flavoring agent. The scores for ease of swallowing for Coca-Cola, chocolate milk, and cherry-flavored syrup were significantly better than those for either no flavoring agent or sorbitol. When asked to choose a single best flavoring agent, 39% chose chocolate milk, 23% picked Coca-Cola, and 23% chose cherry-flavored syrup. CONCLUSION: The addition of chocolate milk, Coca-Cola, or cherry-flavored syrup to AC improves palatability for children and is favored over no flavoring agent or sorbitol.

Do parents choose appropriate automotive restraint devices for their children?

This study aims to describe parental choices of childhood automotive restraints and compare them with guidelines based on weight and height. Parents were surveyed and their children's heights and weight were measured. Results indicated that many parents believed their child fit a lap or shoulder belt when their children were too short to fit these devices. For children weighing < 40 pounds, 45% of parents believed the lap belt fit. Thirteen percent of 4-7-year-olds used booster seats, appropriate for 72% by sitting height criteria; and 33% of children < or = 7 years used the lap/shoullder belt, appropriate for 8% by sitting height criteria. Implications are that parental perceptions of fit may lead to inappropriate restraint choices for children. Practitioners should discuss child restraint use with parents in the context of their child's weight and height.

The addition of ceftriaxone to oral therapy does not improve outcome in febrile children with urinary tract infections.

OBJECTIVE: To determine whether the addition of a single dose of ceftriaxone sodium to a 10-day course of trimethoprim and sulfamethoxazole hastens urine sterilization or resolution of clinical symptoms in febrile children with urinary tract infections. DESIGN: Prospective, single-blind, randomized study. SETTING: Tertiary care children's hospital emergency department. PATIENTS: Febrile children aged 6 months to 12 years with a presumptive urinary tract infection based on history, physical examination, and urinalysis findings. INTERVENTIONS: A history was taken, a physical examination and urinalysis and culture were performed, and a white blood cell count and erythrocyte sedimentation rate were obtained. Children were randomized to receive an intramuscular dose of ceftriaxone then 10 days of trimethoprim-sulfamethoxazole (IM + PO group) or oral trimethoprim-sulfamethoxazole alone (PO group). After receiving study medication, patients were discharged from the hospital to return in 48 hours for a follow-up evaluation and urine culture. Treatment failure was defined as the persistence of a positive culture at 48 hours or the need for hospital admission for intravenous rehydration or antibiotic therapy. RESULTS: Sixty-nine children were enrolled, 34 in the IM + PO group and 35 in the PO group. The 2 groups were similar at the initial visit with respect to age, sex, clinical degrees of illness, white blood cell count, and erythrocyte sedimentation rate (P>.05). At the 48-hour follow-up visit, there were no differences between the 2 treatment groups in resolution of vomiting, fever, general appearance, abdominal tenderness, and hydration state (P>.05). There were 9 treatment failures, 4 in the IM + PO group and 5 in the PO group (P =.93). CONCLUSION: The addition of a single dose of intramuscular ceftriaxone to a 10-day course of oral trimethoprim-sulfamethoxazole for urinary tract infection with fever resulted in no difference at 48 hours in the urine sterilization rate, degree of clinical improvement, or subsequent hospital admission rate.

Localizing ingested coins with a metal detector.

This study was conducted to determine the utility of metal detection in coin localization by inexperienced operators, and determine the rate of spontaneous passage of asymptomatic esophageal coins. All children who presented to the emergency department of an urban children's hospital with a suspected coin ingestion were eligible. Coin location was predicted from metal detector results, while radiographs confirmed location. Asymptomatic patients with esophageal coins were observed for spontaneous passage. Ninety-one children (ages 9 months to 17 years) were prospectively enrolled. The metal detector had a sensitivity of 98% (53/54) in coin detection and 98% (81/83) in determining coin location as esophageal. Symptoms were poor predictors of coin location. Six of eight asymptomatic patients with esophageal coins spontaneously passed their coins. These results show that metal detection is a good screening test for coin presence and to determine coin location as esophageal. Spontaneous passage of asymptomatic esophageal coins warrants further study.

ABCs of scoring systems for pediatric trauma.

This review presents an overview of scoring systems used in pediatric and adult trauma. Triage scoring systems, using readily available physical examination, physiologic, and/or mechanism of injury parameters, are used to determine appropriate prehospital referral patterns. The Trauma Score, Revised Trauma Score, Circulation/Respiration/Abdomen/Motor/Speech Scale, Prehospital Index, and Trauma Triage Rule were reviewed. Injury scoring systems based upon anatomic descriptions of all identified injuries, are retrospectively used to analyze trauma populations. The Abbreviated Injury Scale, Injury Severity Score, Modified Injury Severity Score, Organ Injury Scaling, and Anatomic Profile were discussed. The two trauma outcome analysis systems presented, TRISS and ASCOT, allow for reproducible quantification of trauma severity, and survival comparison between trauma populations. Many of these triage, injury severity, and outcome analysis systems were developed with patient survival as the major outcome variable. Although subsequent studies may have found them to have some predictive value for measures of trauma morbidity, these scoring systems do not specifically address long-term risk of impairment, and therefore overlook one of the most crucial elements of pediatric trauma care. The last 2 decades have seen considerable development of scoring systems and analysis methods applicable to the trauma patient. As presented, this trend includes both the elaboration of increasingly simple, field-oriented triage tools, and more complex mathematical techniques for trauma outcome analysis. Although not all systems were designed specifically with the pediatric patient in mind, validation or modification of these systems for the pediatric patient will likely occur in the future. It is anticipated that this field will continue to evolve with greater mathematical sophistication; a baseline familiarity of the early stages of this evolution may be of benefit to those caring for the pediatric trauma patient.

Evaluation of pediatric cervical spine injuries.

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.

Too many pediatric trampoline injuries.

BACKGROUND: Recent reports note a dramatic increase in the number of pediatric trampoline injuries (PTI) during the past several years. In 1996, the US Consumer Product Safety Commission estimates that 83 000 patients received treatment for trampoline injuries in US hospital emergency departments (EDs), and that approximately 75% of these patients were <15 years of age. We sought to review our experience with PTI since our previous report (Pediatrics 1992;89:849), and to determine if the American Academy of Pediatrics' current (Pediatrics 1981;67:438) safety recommendations are adequate. METHODS: Retrospective medical record review of all PTI patients presenting to the pediatric ED from November 1990 through November 1997. RESULTS: A total of 727 PTI patients were included; medical records were unavailable for 3 patients. The annual number of PTI nearly tripled during the study period, from 51 in 1991 to a peak of 148 in 1996. PTI patients were 53% female, with a median age of 7 years; 37% were <6 years of age. Privately owned trampolines accounted for 99% of PTI. Most injuries (66%) occurred on the trampoline, 28% resulted from falls off, and 4% from imaginative mechanisms. One hundred eleven patients (15%) suffered severe injury (1990 Abbreviated Injury Scale value >/=3), usually of an extremity (89 out of 111). Fractures occurred in 324 patients (45%). Spinal injuries were common (12%), including 7 patients with cervical or thoracic fractures, and 1 with C7 paraplegia. Fractures were more frequently associated with falls off the trampoline, whereas spinal injuries more frequently occurred on the trampoline. Eighty patients (11%) required prehospital medical transport to our ED, 584 (80%) had ED radiographs, and 382 (53%) required pediatric surgical subspecialty involvement. Seventeen percent of PTI patients (125 out of 727) were admitted to the hospital, including 9 to the pediatric intensive care unit; 99 (14%) required one or more operations. Mean hospital stay was 2 days (range, 1-63 days); 24 stays (19%) were for >/=3 days. We estimate that the hospital charges for the acute medical care of PTI study patients at our institution totaled approximately $700 000. CONCLUSIONS: PTI are dramatically increasing in number, and result in considerable childhood morbidity. Most PTI occur on privately owned trampolines. Few, if any, safety recommendations for the trampoline are followed. We support recommendations for a ban on the recreational, school, and competitive pediatric use of trampolines.

Management of febrile children with urinary tract infections.

This study of the management of children with fever and urinary tract infection (UTI) was conducted to identify factors associated with initial admission, outpatient treatment, and outpatient treatment failure. A retrospective chart review identified children 3 months to 16 years of age with an emergency department (ED) diagnosis of cystitis, pyelonephritis, or UTI, a positive urine culture, and an ED temperature of >38 degrees C. Sixty-nine patients (90% female) were studied; 19% were admitted initially. Age younger than 2 years was associated with admission (P < .001). Of those initially discharged, 63% received parenteral antibiotics (usually intramuscular ceftriaxone), followed by oral antibiotics; 9% failed outpatient treatment. Outpatient failure was associated with higher initial temperatures (median 40.1 degrees C v 39.2 degrees C, P=.03, Mann-Whitney U) but was unrelated to age, initial white blood cell count, or use of parenteral antibiotics. These results indicate that most children with fever and UTI do not require hospital admission; those with temperatures of > or = 40 degrees C are at increased risk for outpatient failure.

Pediatric male rectal and genital trauma: accidental and nonaccidental injuries.

OBJECTIVE: To characterize accidental pediatric rectal/genital trauma in males and compare these physical findings to a cohort of boys evaluated for sexual abuse. DESIGN: Retrospective chart review. SETTING: Tertiary pediatric trauma center/sexual abuse clinic. PARTICIPANTS: Male patients evaluated in the emergency department for rectal/genital trauma from 9/1/89 through 10/31/93 ("accidental group"). Male patients referred to Child Protection Services for suspected sexual abuse from 1/1/93 through 12/31/95 who had abnormal genital physical findings ("sexual abuse group"). MAIN OUTCOME MEASURES: Outcomes measured included age, mechanism of injury, category of diagnosis, location of injury, and type of injury. RESULTS: Forty-four male patients comprised the accidental group, aged six months to 17 years. The most common mechanism was a fall onto an object (34%). The most common injuries were lacerations/perforations of the scrotum (36%) followed by penile lacerations/perforations (25%). No patient had an isolated rectal laceration. Forty-four male patients with positive physical findings comprised the sexual abuse group. Ages ranged from seven months to 18 years. All patients had rectal lesions. Penile lacerations/perforations were the only other injuries documented, occurring in two patients. CONCLUSIONS: Accidental rectal/genital trauma in the pediatric population is uncommon; scrotal trauma occurs much more frequently than rectal trauma. Rectal/genital injury in the sexual abuse group typically involves only the rectal area. Sexual assault should be considered in patients with isolated rectal injury or whenever the alleged history does not correlate with physical findings.

Using the hand to estimate the surface area of a burn in children.

OBJECTIVE: Estimation of the surface area involved is vital to evaluation and treatment of burns. Common teaching suggests the palm approximates 1% of the total body surface area (TBSA). However, early century literature suggests the palmar surface of the entire hand approximates 1% of the TBSA. We sought to determine whether the palm or the entire palmar surface of the hand approximates 1% TBSA in children. DESIGN: A prospective, convenience sample. MATERIALS AND METHODS: Using height, weight, and standard nomograms, body surface area was determined. A photocopy of the hand was used to determine the surface area of the palm and the entire palmar surface of the hand. RESULTS: In 91 children, the mean percent of the TBSA represented by the entire palmar surface was 0.94% (95% confidence interval (C.I.) 0.93-0.97), and the mean percent of the TBSA represented by the palm was 0.52% (95% C.I. 0.51-0.53). CONCLUSION: The entire palmar surface of a child's hand more closely approximates 1% TBSA, while the palm approximate 0.5% TBSA.

Treatment of convulsive status epilepticus with propofol: case report.

INTRODUCTION: Convulsive status epilepticus (CSE) refractory to treatment with benzodiazepines, phenobarbital, and phenytoin presents a challenge to pediatric emergency and critical care specialists. Prompt seizure control may prevent mortality and morbidity. CASE: A nine-month-old girl with hereditary fructose intolerance had prolonged, refractory CSE. Her seizures promptly stopped after administration of propofol (3 mg/kg bolus followed by infusion of 100 micrograms/kg/min). This dose resulted in electroencephalographic burst suppression. She required endotracheal intubation, invasive hemodynamic monitoring, and pressor support. DISCUSSION: This is the first pediatric case of prolonged, refractory CSE treated with propofol. The adult experience is reviewed. Propofol should be used only in a setting where definitive airway control and hemodynamic support is possible.

Laboratory presentation in diabetic ketoacidosis and duration of therapy.

OBJECTIVE: To determine if initial emergency department (ED) laboratory parameters in children with diabetic ketoacidosis (DKA) can predict the minimum duration of continuous insulin therapy and aid in ED triage. DESIGN: Retrospective chart review, over a four-year period. SETTING: Tertiary care pediatric center ED. PATIENTS: All patients in DKA, managed with a standard hospital protocol were included. Standard therapy consisted of an intravenous infusion over an hour of normal saline or Ringer's lactate, followed by 0.45% saline (potassium acetate/ phosphate added) at 1.5 times maintenance and insulin infusion (0.1 units/kg/h). New-onset diabetic patients were excluded. MAIN RESULTS: One hundred thirty-two visits (45 patients, 55.5% female) were reviewed. Three of 60 (5%) patient-visits with moderate to severe DKA (serum pH < 7.20 and serum bicarbonate concentration < 10 mmol/L) had their acidosis corrected (serum pH > or = 7.30 or serum bicarbonate concentration > or = 15 mmol/L) within four hours compared to 33 of 72 (46%) patient-visits with mild DKA (serum pH > or = 7.20 or serum bicarbonate concentration > or = 10 mmol/L) (P < 0.0001). The acidosis was corrected within six hours in 69 and 11% of the mild and moderate-severe DKA group, respectively (P < 0.0001). CONCLUSIONS: Initial laboratory presentation can help predict the minimum necessary duration of therapy in pediatric patient with DKA, aid early triage decision in the ED, and select a subgroup of patients who may be considered for outpatient management.

Cyclizine abuse by teenagers in Utah.

Substance abuse by teenagers is common, often involving use of alcohol and illicit drugs. Ingestion of cyclizine hydrochloride, a nonprescription medication, was noted to occur frequently in Utah for abuse reasons. A retrospective review was conducted of patients younger than 18 years of age over a 3-year period who intentionally ingested cyclizine identified from Utah Poison Control Center records. Eighty patients were included; 42 patients underwent hospital record review. Abuse accounted for 89% of cyclizine ingestions; hallucinations (70%) and confusion/disorientation (40%) were the most notable symptoms. Tachycardia (52%) and systolic hypertension (69%) were frequently present in patients who presented to a hospital. No serious complications occurred. This study illustrates teenage abuse of one nonprescription antihistamine presumably to induce hallucinations. Abuse of over-the-counter medications by adolescents may be more appealing than illicit drug use for numerous reasons, and may be more common than appreciated.

Delayed diagnosis of injury in pediatric trauma.

OBJECTIVE: To define the frequency and nature of delayed diagnosis of injury (DDI) in pediatric trauma. DESIGN: Retrospective review. SETTING: Tertiary pediatric trauma center. METHODS: Medical records of 1175 pediatric trauma admissions from July 1, 1989, through June 30, 1992, were reviewed. RESULTS: Fifty (4.3%) patients had 53 DDI. Fractures accounted for 38 DDI, most commonly of the extremities (total, 16). The delay until injury diagnosis ranged from 1 to 55 (median, 3) days. Patients with DDI had lower scores on the Glasgow Coma Scale, higher injury severity scores, and longer pediatric intensive care unit and hospital stays than patients without DDI. Patients with DDI more frequently required medical transport, emergent intubation, admission to the pediatric intensive care unit, and surgery. The DDI altered treatment for 68% of patients; 10 required surgery, including second operations for 6 children. CONCLUSIONS: DDI represents a failure of pediatric trauma care at all levels. The severely injured child is at the greatest risk of DDI. All pediatric patients with trauma warrant ongoing evaluation to identify initially unrecognized injuries.

The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department.

Head injury is a frequent cause of morbidity and mortality in pediatric trauma. Guidelines for obtaining computed tomographic (CT) scans in the child with mild head injury are poorly defined. This study investigated the utility of head CT scanning in the pediatric patient presenting with normal neurologic examination. All patients undergoing head CT scanning for trauma in the emergency department (ED) at a tertiary care pediatric trauma center during 1992 were identified (508). Charts were reviewed for historical and physical examination findings, CT results, and need for neurosurgical intervention. Patients were excluded if they had an abnormal neurologic examination (179), known depressed skull fracture (11), bleeding diathesis (3), age older than 18 years (1), or developmental delay (1). Included were 313 patients (median 5.5 years) who presented with clinical variables including sleepiness (38%), vomiting (34%), headache (30%), loss of consciousness (LOC) (25%), irritability (22%), amnesia (20%), and seizures (8%). An abnormal head CT was noted in 88 cases (28%); 79 (25%) were traumatic abnormalities involving the skull and/or contents. Thirteen patients (4%) had intracranial injuries (ICI); all had either a linear (10), basilar (2), or depressed (1) skull fracture noted on CT. Four patients required neurosurgery, three for epidural hematoma, and one for a complicated orbital fracture (without ICI). No clinical variables (seizure, LOC, vomiting, headache, confusion, irritability, sleepiness, amnesia) were associated with ICI (P > 0.05). In pediatric head trauma patients, with normal neurologic examinations in the ED, ICI occurs < 5% of the time and neurosurgery is needed in 1% of the cases. Commonly used clinical variables are not associated with ICI in these children.

Felbamate overdose: a case report and discussion of a new antiepileptic drug.

Felbamate was approved in July 1993 for use alone or in combination with other antiepileptic drugs for partial seizures and Lennox-Gastaut syndrome. We report an overdose of felbamate in a teenage female patient who, in a suicide gesture, ingested eight times her maximum dose and suffered only mild side effects. This first report of a felbamate overdose is presented and followed by a discussion of felbamate's effectiveness, pharmacology, adverse effects, and drug interactions.

Pediatric basilar skull fracture: do children with normal neurologic findings and no intracranial injury require hospitalization?

STUDY OBJECTIVE: To delineate complications in patients with basilar skull fractures (BSFs) and normal neurologic findings, including computed tomography (CT) scans without intracranial injury, and to assess the need for hospitalization. DESIGN: Retrospective chart review. PARTICIPANTS: All emergency department patients with the ED diagnosis or hospital discharge diagnosis of BSF. Patients were included if they had a clinical or radiographic diagnosis of BSF. A subgroup of patients ("simple BSF") with normal neurologic examination findings in the ED, Glasgow Coma Scale scores of 15, and cranial CT scans without intracranial pathology was specifically analyzed. RESULTS: We included 239 patients in the study. One hundred fourteen patients (48%) were included in the "simple BSF" subgroup. In this subgroup, vomiting (6%) was the most common complication, meningitis (1%) the most serious. There were no cases of delayed intracranial hemorrhage, and no patient with "simple BSF" required surgery. CONCLUSION: Given the relatively low frequency of serious complications, our study suggests that some patients with BSFs may not require hospital admission.