Efficacy of topical anesthesia in children.

OBJECTIVES: To compare the efficacy of three formulations of a topical anesthetic solution composed of various concentrations of tetracaine hydrochloride, adrenaline (epinephrine), and cocaine hydrochloride (TAC), and to compare the cost of the topical anesthetic solutions with the cost of lidocaine infiltration. DESIGN: Randomized, double-blind clinical trial. SETTING: Urban pediatric emergency department. PARTICIPANTS: One hundred fifty-six children 3 to 18 years of age and older requiring topical anesthesia for suturing of lacerations. INTERVENTION: Children received 3 mL of one of the following study solutions: TAC 1 consisting of 0.5% tetracaine, 1:2000 dilution of adrenaline, 11.8% cocaine; TAC 2 that contained 1% tetracaine, 1:2000 dilution of adrenaline, 4% cocaine; or TAC 3 made up of 1% tetracaine and 4% cocaine, without adrenaline. MEASUREMENTS OR MAIN RESULTS: Patients were randomized to group 1 (n = 49), group 2 (n = 49), or group 3 (n = 58), and received TAC 1, TAC 2, or TAC 3, respectively. Patients in the three study groups were similar for age, gender, anatomic location and length of the laceration, and history of sutures or use of topical anesthesia. Based on the physician assessment of achievement of complete, partial, or no anesthesia, solutions containing 11.8% cocaine (TAC 1) and 4% cocaine with adrenaline (TAC 2) were more likely to produce complete anesthesia than the solution with 4% cocaine without adrenaline (TAC 3) (P < .001, chi 2). This difference was only noted when the laceration involved the face or scalp. A second dose of the TAC 3 solution was more often required to produce anesthesia when compared with the other two study drugs (P < .003, chi 2). The final cost to produce 3 mL of the study drugs, including the vials, was $16.39 for TAC 1, $8.67 for TAC 2, and $8.41 for TAC 3. CONCLUSIONS: The application of a TAC solution containing 4% cocaine is as effective as a TAC solution containing 11.8% cocaine. Use of the 4% solution decreases the cost of the agent. Adrenaline is a necessary ingredient in the anesthetic solution.

Dental concerns unrelated to trauma in the pediatric emergency department: barriers to care.

OBJECTIVES: To describe patients with nontraumatic dental problems treated in our pediatric emergency department (PED) and to determine if barriers to access prompted seeking care in the PED rather than from a dentist or dental clinic. DESIGN: Questionnaire administered to a convenience sample of patients with nontraumatic dental complaints. SETTING: An urban PED. MAIN OUTCOME MEASURES: Insurance status, primary medical and dental care, duration of symptoms, diagnosis, and reason for seeking care in the PED. RESULTS: Two hundred patients were enrolled. Median age was 17 years (range, 1-22 years). Forty-five percent were African American. Forty-nine percent had Medicaid. Fifty percent identified a regular dentist, whereas 71% had a primary care physician. Thirty-four percent of patients 4 years and older had not seen a dentist in more than a year. Children younger than 13 years were more likely than teenagers to identify a regular dentist (odds ratio [OR] = 2.8; 95% confidence interval [CI], 1.3-6.1). Those with a regular medical provider were more likely to have a regular dentist (OR = 7.7; 95% CI, 3.4-18). The most common reasons for not going to a dentist were as follows: dentist closed, 34%; lack of dental insurance or money, 17%; and lack of a dentist, 16%. Patients with symptoms for more than 72 hours were more likely to cite lack of a dentist as their reason for coming to the PED (OR = 7.4; 95% CI, 1.9-33). CONCLUSIONS: Many pediatric patients do not have regular dental care, and this is associated with a lack of primary medical care. Access barriers to acute dental care include lack of insurance or funds, lack of a dentist, and limited hours of dental care sites. Improved insurance reimbursement, active enrollment of adolescents into preventive dental care, and expansion of provider hours may limit PED dental visits and improve the health of patients.

The role of serial radiographs in the management of pediatric torus fractures.

OBJECTIVES: To assess the utility of radiographs taken immediately after the application of a cast in the management of pediatric torus (or buckle) fractures and to determine the need for serial radiographs taken at follow-up visits. DESIGN: Retrospective medical record review; survey questionnaire of a panel of experts. SETTING: The pediatric emergency department (PED) and the pediatric orthopedic clinic at an urban, tertiary care hospital. PATIENTS: All children with torus fractures referred to the pediatric orthopedic clinic for follow-up visits between February 1995 and February 1997. MAIN OUTCOME MEASURES: The number of patients whose postcast studies was obtained in the PED; number of follow-up visits and studies conducted at the pediatric orthopedic clinic; usual regional practices as extracted from a panel of experts by survey questionnaire. RESULTS: Of 70 patients, 46 (66%) were evaluated by a single, precast study in the PED, and 24 (34%) were evaluated by both precast and postcast studies in the PED. The time range of the first follow-up study was the first to fifth week after the patient's injury. The range of the number of follow-up studies for each patient was 0 to 5. Our cohort's total radiology charges for 70 patients were $27251. Regional directors of pediatric orthopedic surgery unanimously agreed that postcast studies in the PED are unnecessary. The range of the number of follow-up studies they obtained is 0 to 3 per patient. CONCLUSIONS: Postcast studies of torus fractures are unnecessary. Multiple radiographs taken during follow-up visits, especially early in the healing process, do not change fracture management. Relying on the clinical examination, perhaps combined with a single follow-up study, is a more appropriate regimen for the management of pediatric torus fractures and translates into a cost savings of over $ 10000 for our 70 patients.

Prehospital management of pediatric asthma requiring hospitalization.

Our objective was to evaluate the quality of prehospital assessment and management in pediatric asthma requiring hospitalization via a retrospective chart review. Charts were obtained from a pediatric emergency department (ED) with 24,000 annual visits. Included in the study were 27 patients less than 18 years of age with asthma requiring hospitalization, transported to the Boston City Hospital Pediatric ED by Boston Emergency Medicine Services (EMS). We found that 12 patients admitted to the pediatric intensive care unit over an 18-month period, and 15 patients admitted to the ward over a six-month period, received prehospital care from Boston EMS. Only 63% of cases (17/27) had a physical examination marker of asthma severity noted on the EMS record. Twenty-six percent of cases (7/27) did not receive O2 in the field. Thirty percent of cases (8/27) were hypoxic at ED presentation. None of the hypoxic patients had received albuterol in the field, and one did not receive O2. We conclude that further study of the prehospital assessment and management of pediatric asthma is warranted.

Cocaine absorption after application of a viscous cocaine-containing TAC solution.

STUDY OBJECTIVES: We sought to measure plasma cocaine and benzoylecgonine levels in children after application of a solution of a topical anesthetic containing tetracaine 0.5%, epinephrine 1:2, 000, and viscous cocaine 5.9% (TAC) to lacerations requiring suture repair. Previous reports demonstrating cocaine absorption used aqueous cocaine. The purpose of this study is to determine whether systemic absorption occurs with viscous cocaine. METHODS: We used a convenience sample of children in a pediatric emergency department during the summer months of 1994 and 1995. Participants were pediatric patients less than 15 years of age with simple lacerations requiring suturing. RESULTS: Twenty-five patients were enrolled in the study. The mean age of the patients was 8.5 years (range, 3 to 13 years). Lacerations tended to be small, with a mean length of 2.2 cm (range, 1 to 8 cm). Plasma cocaine and benzoylecgonine levels were measured by means of high-performance liquid chromatography. The mean time for obtaining the plasma sample for cocaine analysis was 67.2+/-23.9 minutes (range, 28 to 130 minutes) after application of the viscous cocaine-containing TAC solution. Qualitative assay results, which were accurate to 50 ng/mL, were negative in all 25 patients for both plasma cocaine and benzoylecgonine. No child demonstrated any signs or symptoms suggestive of cocaine toxicity. CONCLUSION: In our study, application of viscous cocaine-containing TAC solutions to small lacerations did not produce clinically important cocaine absorption.

Pediatric pre-hospital advanced life support care in an urban setting.

OBJECTIVE: To describe pediatric advanced life support (PALS) in a single urban environment and clarify educational priorities for ALS pre-hospital providers and pediatric medical control physicians. METHODS: Retrospective observational review of all pediatric pre-hospital PALS transport and medical control records of the two-tiered, unified, municipal emergency medical service of the City of Boston (catchment area 590,000) over a 1-year period. RESULTS: Of the 555 pediatric patients receiving ALS transport, 38% were for respiratory emergencies, 24% for nonrespiratory medical emergencies, 19% for traffic-related blunt trauma, and 10% for penetrating trauma. Two percent involved cardiac arrests. The most frequent procedures performed were intravenous (IV) cannulation (n = 184, 33%), bag-mask ventilation (n = 28, 5%) and intubation (n = 15, 3%). Intraosseous access was only performed in three patients (0.5%). Fifty ALS providers in the EMS system averaged pediatric IV cannulation 3.7 times, intubation 0.3 times, and intraosseous access 0.06 times per provider per year. On-line medical control was requested in 28 % of PALS transports. The chief complaints managed by medical control closely mirrored the distribution of all ALS transports. The most frequent medication ordered by on-line medical control was additional nebulized albuterol after standing orders (off-line medical control) had been exhausted. CONCLUSIONS: A limited number of chief complaints make up the majority of PALS transports. Initial and continuing education for ALS providers needs to reflect the importance of these critical entities. Education for urban pre-hospital providers should reflect that certain procedures will be only executed every few years (eg, pediatric intubation) or once in the career of an ALS pre-hospital provider (eg, intraosseous access). With a limited amount of pediatric teaching time, paramedic education will have to strike a careful balance between teaching about the chief complaints most frequently encountered and teaching rare, high-risk procedures that could provide maximal support for the uncommon critically ill child. On-line medical control physicians need to be prepared to direct and support the management by ALS pre-hospital providers for the chief complaints most frequently seen in pediatric patients.

Violence-related injuries in a pediatric emergency department.

BACKGROUND: Since the 1980s, violence has emerged as a leading public health concern in the United States. Recent studies have begun to address the impact of interpersonal violence specifically on young children. The purpose of this study was to describe the epidemiology of violence-related injuries (VRI) in an urban pediatric emergency department (ED). METHODS: A six-month retrospective chart review was conducted. The records of 11,000 patients 17 years of age and younger who were seen in an urban pediatric ED were accessed for VRI. VRI were defined as purposefully inflicted with intent to harm. Patients discharged from the ED with VRI were compared to patients admitted with VRI. RESULTS: Three hundred seventeen (3%) of patients were categorized as having VRI during the six-month study period. Eighty-three percent were discharged, and 17% were admitted. The majority of injuries was the result of interpersonal conflict with a friend or acquaintance. Patients discharged were more likely to involve: younger children, female victims, and blunt instruments. Thirteen percent of discharged patients, however, involved potentially lethal weapons (knife or firearm). CONCLUSIONS: The vast majority of patients with VRI are discharged from the ED. Females and young children were frequently evaluated for VRI in the pediatric ED. Identification of these patients can be used to initiate service protocols directed at violence prevention.

The routine use of radiography and arterial blood gases in the evaluation of blunt trauma in children.

STUDY OBJECTIVE: To evaluate the usefulness of routine radiographs and arterial blood gases in children with blunt trauma. DESIGN: Retrospective chart review. TYPE OF PARTICIPANTS: Ninety patients who met triage criteria for our trauma team evaluation and who were less than 15 years old were evaluated. Patients with a Glasgow Coma Scale score (GCS) of 15 (lie, mild to moderately injured children) were the focus of this study. METHODS: Children seen from May 1991 through August 1992 had charts reviewed systematically and within 24 hours of emergency department evaluation. Standard radiologic evaluation, including cervical-spine, chest, and pelvic radiographs, as well as arterial blood gas analysis, were obtained. The severity of injury was graded according to the Modified Injury Severity Scale. RESULTS: The mean age of patients was 6.4 years, and the injuries observed were exclusively extremity fractures. The correlation between physical examination findings and radiologic evaluation was assessed. Forty-three patients had an abnormal physical examination (ie, gross deformity, limitation of motion, or pain), and 26 had a fracture identified on radiograph. Forty-seven patients had a normal physical examination and none had a fracture identified on radiograph (P < .001; sensitivity of positive signs and symptoms, 100%; false-negative findings, 0%). Four patients with abnormal blood gases are described. No patient had any vascular or solid organ injury identified. CONCLUSION: In children with a GCS score of 15, selected radiologic and laboratory tests based on clinical findings are recommended. Careful observation and repeat examinations by trained clinicians can select a group of children at low risk for occult injury.

Prehospital fentanyl analgesia in air-transported pediatric trauma patients.

OBJECTIVE: To review the 5.5-year safety record of a protocol guiding fentanyl administration to pediatric trauma patients undergoing aeromedical transport. METHODS: Retrospective review of an urban aeromedical program's trauma scene responses from October 1991 to March 1997 identified the study population as all pediatric patients (age <15 years) receiving fentanyl for analgesia during air transport. Patients receiving fentanyl concurrently with other agents, eg, paralytics, were not studied. The air transport team consisted of a flight nurse and flight paramedic who provided protocol-driven patient care with off-line medical control. Study patients' flight records were reviewed to determine vital signs (systolic blood pressure [SBP], heart rate [HR], and oxygen saturation [SAT]) before and after fentanyl administration. Postfentanyl vital signs were reviewed for evidence of hemodynamic or ventilatory compromise. Pre- and postfentanyl vital signs were compared with the paired t test (P < 0.05). Flight records were also analyzed for narrative information, eg, naloxone administration and assisted ventilation, indicative of fentanyl side effects. RESULTS: Fentanyl (0.33-5.0 microg/kg) was administered 211 times to 131 patients who had a median age of 6.2 years (0.1-14 years), median Glasgow coma score (GCS) of 9 (3-15), and a mean pediatric trauma score of 8.3+/-2.4. Seventy-nine (60.3%) patients were intubated; these patients received 139 (65.9 %) of the 211 total fentanyl doses. No adverse effects from fentanyl were noted in flight record narratives. The median interval between fentanyl administration and postfentanyl vital sign assessment was 9.5 minutes (1-35 minutes). Median postfentanyl changes in SBP and HR were -4.7 and -2.9%, respectively. No patient became hypotensive after fentanyl administration. In nonintubated patients, mean postfentanyl SAT (99.2+/-1.3%) was not significantly different (P = 0.70) from prefentanyl SAT (99.1+/-1.3%), and no patient was noted to have clinically significant SAT decrement after fentanyl. CONCLUSION: Retrospective review of more than five years of prehospital fentanyl administration revealed no untoward events. Although prospective definitive demonstration of fentanyl's field use is pending, it is reasonable to continue discretionary fentanyl administration to injured pediatric children in pain.