Skull fractures in infants and predictors of associated intracranial injury.

BACKGROUND: Emergency department (ED) management of skull fractures in children remains controversial. Because infants incurring head trauma have a high incidence of skull fracture, we chose to describe fractures in this subset of patients and to determine if there are clinical predictors of associated intracranial injury (ICI) that may have utility in developing more efficient management schemes in these patients. METHODS: A retrospective medical record review was conducted on all awake patients < 13 months of age with an acute skull fracture from non-birth trauma, presenting to the ED of a university-affiliated children's hospital during a three-year period. Clinical and radiographic data extracted were used to describe skull fractures in these patients. The ability of various characteristics to determine the presence of ICI was assessed by calculating sensitivity, specificity, positive predictive value, and negative predictive value for each. RESULTS: The predominant mechanism of injury for the 102 infants was falls (91%). Suspicion of abuse was found in only one case. The parietal bone was fractured in 87 infants, and 34 had nonparietal fractures. The most prevalent fracture type was linear (92 infants), and 31 had > 1 cranial bone fractured. CT scans obtained on 32 infants (CT group) revealed 21 ICIs in 15 patients. Two with temporoparietal fractures required emergent evacuation of epidural blood. In the CT group, seven of the 15 (47%) with ICI (ICI group) were lethargic compared to two of the 17 (12%) without ICI (No ICI group) (P = 0.035). Five (33%) in the ICI group had temporal bone fractures compared to 0 in the No ICI group (P = 0.015). The presence of any sign or symptom had a sensitivity and negative predictive value of 100%, but only a specificity of 35%. The presence of lethargy had a positive predictive value of 78%. The presence of temporal and frontal bone fractures had positive predictive values of 100 and 75%, respectively. CONCLUSION: This study reports a high prevalence of fracture characteristics often associated with inflicted injury in other studies when virtually all injuries in our sample were accidental. Several clinical characteristics were demonstrated to be potentially useful in predicting ICI associated with skull fracture; however, prospective study is recommended to validate these findings prior to clinical application.

Efficacy of rectal midazolam for the sedation of preschool children undergoing laceration repair.

STUDY OBJECTIVE: To determine the efficacy of rectal midazolam as sedation for laceration repair in preschool children in the pediatric emergency department. DESIGN: Randomized, double-blind, placebo-controlled trial. PARTICIPANTS: Thirty-four anxious children aged 14 to 51 months with face or scalp lacerations 3 cm or less in length requiring two or more sutures and behavior scores of 3 or more. INTERVENTIONS: Subjects received 0.45 mg/kg rectal midazolam or saline placebo rectally followed by a topical anesthetic 15 minutes before repair. RESULTS: Sixteen patients received rectal midazolam, and 18 received placebo. The groups were similar in age, race, gender, laceration length and location, entry behavior score, and entry anxiety score. Ten patients in the rectal midazolam group and 1 in the placebo group achieved adequate sedation (P < .001). Median behavior scores during suturing were more favorable in the rectal midazolam group (P = .003 and P = .08, respectively). Two patients in the rectal midazolam group experienced inconsolable agitation after the repair. None of the patients suffered cardiopulmonary complications. CONCLUSION: Rectal midazolam is an effective method of sedation for facilitating uncomplicated laceration repair in preschool children. However, physicians must be aware of the possibility of paradoxical reactions when using midazolam in children.

Herpes simplex dissemination following glucocorticoids for upper airway obstruction in an adolescent girl.

A previously healthy adolescent female suddenly developed a severe febrile pharyngitis and impending upper airway obstruction. Her Monospot test was positive, and her throat culture grew group A beta-hemolytic streptococcus. After treatment with antibiotics and glucocorticoids, she developed a fulminant course dominated by disseminated intravascular coagulation and hepatic necrosis. At autopsy, herpes simplex virus type-1 was cultured from lung, liver, and spleen tissue. We believe this is the first report of disseminated herpes simplex infection after steroid use for upper airway obstruction.

Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma.

BACKGROUND: Recent studies have shown that the use of parenteral corticosteroids in the emergency department decreases the hospitalization rate for patients with acute asthma. We studied the efficacy of oral corticosteroids in the emergency department treatment of moderately ill children with acute asthma. METHODS: Emergency department patients aged 1 through 17 years whose chief complaint was acute asthma were assigned a pulmonary index, based on clinical evaluation. Those with a moderate exacerbation (pulmonary index = 9 through 13) received either 2 mg/kg of oral prednisone or placebo in a randomized, double-blind fashion. Patients in each group were then treated with an identical regimen of frequent aerosolized albuterol, for up to a maximum of 4 hours. RESULTS: Seventy-five patients were assessed. Overall, 11 (31%) of 36 in the prednisone group required hospitalization compared with 19 (49%) of 39 in the placebo group (P = .10). Among the sickest patients (initial pulmonary index > 10), 7 (32%) of 22 prednisone-treated patients required hospitalization compared with 13 (72%) of 18 placebo-treated patients (P < .05). Among patients who had a suboptimal response to initial beta 2-agonist therapy and who therefore would have been hospitalized had treatment been restricted to 2 hours, 9 (45%) of 20 in the prednisone group ultimately required hospitalization when duration of care was extended 2 additional hours compared with 15 (83%) of 18 in the placebo group (P < .05). In addition, prednisone-treated patients had a significantly greater improvement in median pulmonary index (5.0 vs 3.0, P < .001). CONCLUSIONS: These data demonstrate that oral prednisone, within 4 hours of its administration, reduced the need for hospitalization among a subset of children treated in the emergency department for acute asthma.