- Email: [email protected]
Impact of a new booster seat law
RESEARCH FORUM ABSTRACTS
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Sports Injuries, A Common Pediatric Problem
older than 6 months. The use of these criteria for evaluating patients at risk for urinary tract infection is limited by the sensitivity and specificity of this factor.
Llovera IA, Ward MF, Falitz S, Miele D, Sama A, Trimarco T, Lukin M, Yaghoubian S, Sison C/North Shore University Hospital, Manhasset, NY Study objectives: We determine the frequency and demographics of all pediatric sports-related injuries presenting to our emergency department (ED) during 1 year (2002 to 2003), the particular sports causing specific injuries, and the disposition of these patients. Methods: This was a retrospective medical record review of all ED patients. We included only those patients with a sports-related injury documented on the ED record as the reason for the visit. We recorded demographic information, the sport, injury, treatment, and disposition. Results: Our ED census from July 2002 to 2003 was 60,873 (11,941 were pediatric patients). We reviewed 53,568 records (88%) and identified 1,087 pediatric sportsrelated injuries. Nine percent of all our pediatric visits were for sports-related injuries (mean age 11.8 years, 69% male patients, 73% white). Most of the injuries were from basketball (17%), playground/backyard activities (11%), biking (8%), football (8%), soccer (7%), and baseball/softball (6%). They had the following dispositions: admitted (4.4%) and the rest discharged to follow-up with orthopedics/hand (44%), their primary physician or ED (44%), plastic surgery (2%), dental (1%), ophthalmology (1%), neurology (0.5%), and other (3%). The most common sports resulting in admission were playground/backyard activities (18%), biking (16%), and basketball (9%; mean age 9.9 years, 69% male patients, 73% white). The children sustained the following fractures: a fracture or dislocation to an extremity 356 (21%), facial/skull fractures 15 (1%), fractured ribs or clavicle 7 (0.6%), neck fractures 5 (.3%), and fractured back 1 (\0.1%). The part of the body affected by the sports-related injuries was the following: arm 39%, leg 28%, head 25%, chest 3%, back 2%, neck 2%, and abdomen 1%. Conclusion: Nine percent of all our pediatic visits are from sports-related injuries (mean age 9.9 years). Of those, 4.4% are admitted to the hospital, mainly from injuries sustained in playground/backyard activities, biking, and basketball. The upper and lower extremities and the head are most often injured.
123
Does the WBC Count, Age, or Sex Predict Which Febrile Children From 90 Days to 36 Months of Age Will Have a Positive Urine Culture?
Ryan JG, Barata I, Ward MF, Hormozdi S, Shenkman A, Sama AE, Roit Z/New York Hospital–Queens, Flushing, NY; North Shore University Hospital, Manhasset, NY Study objectives: The purpose of this study is to determine whether the WBC count, age, or sex is predictive of a positive urine culture in children aged 90 days to 36 months who present to the emergency department (ED) with fever. Methods: This prospective study was conducted at an academic ED that treats 16,000 pediatric patients per year. Consecutive enrollment of subjects was performed by the principal investigator when the principal investigator was present. Patients were eligible if they were aged 3 to 36 months, had a rectal temperature of 103oF (39.4oC) or greater, were immunocompetent, did not receive antibiotics before evaluation, and did not have otitis media or pneumonia on physical examination. Eligible patients were evaluated by physical examination, CBC count, blood culture, catheter-obtained urine analysis and culture, and chest radiography. Results: Over a 17-month period, 119 patients were enrolled. Eight patients (6.7%) had a positive urine culture result. Six (9.7%) of the 62 male patients had a positive urine culture result compared with 2 (3.5%) of the 57 female patients. This was not significant. The mean WBC count in the group with a positive culture result was slightly lower than the group with a negative culture result (12.6 versus 13.5; P=not significant). Of the 8 patients with a positive urine culture result, 5 (63%) had a WBC count less than 15,000, and all had a WBC count less than 20,000. Patients younger than 6 months had a higher rate of urinary tract infection than those older than 6 months (16.6% versus 4.2%; P=.029). However, the sensitivity, specificity, and likelihood ratios showed that age was not very useful as a discriminatory test to predict urinary tract infection (sensitivity 62.5, specificity 74.8, positive likelihood ratio 2.48, negative likelihood ratio .50). Conclusion: There was no significant difference in the rate of urinary tract infection according to WBC count or sex. There was a significantly higher rate of urinary tract infection in patients younger than 6 months compared with patients
OCTOBER 2004
44:4
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124
Effects of Initial Pain Treatment on Sedation Recovery Time in a Pediatric Emergency Department
Losek JD, Reid SR/Medical University of South Carolina, Charleston, SC; Children’s Hospitals and Clinics, St. Paul, MN Study objectives: The purpose of this study is to compare the sedation recovery times for children receiving ketamine/midazolam (K/M) versus K/M plus an opiate (morphine or meperidine) analgesic in a pediatric emergency department (ED). Methods: This was a retrospective cross-sectional study performed at an urban children’s hospital pediatric ED with a yearly census of 36,000. Descriptive statistics and confidence intervals (CIs) were used to analyze the data. Results: During an 18-month period (July 1, 2002, to December 31, 2003), 136 children received ketamine for procedural sedation in the ED. Of these, 116 also received midazolam. For the purpose of this study, the following number of patients were excluded: 9 with altered mental status, 11 with level of sedation not recorded, 6 with inadequate sedation, 6 with ketamine dose greater than 2 mg/kg or less than 0.3 mg/kg, 1 given reversal agents (Narcan and flumazenil), 2 with medical records not available for review, and 1 with morphine given more than 4 hours before ketamine and midazolam. Of the remaining 80 patients, 33 patients received K/M only, 32 received K/M and morphine, and 15 received K/M and meperidine. Of the 80 patients, the mean age was 91.8 months (SD 47.2, range 12 to 215 months). There were 47 (58%) male patients. Indication for procedural sedation and analgesia was an injury in 70 (87.5%) of the patients. Injuries included 64 fractures (60 forearm fractures), 3 lacerations, and 3 joint dislocations. Other indications were 3 foreign body removals, 2 incision and drainage procedures, 2 vaginal examinations, 2 computed tomographic scans, and 1 hernia reduction. The mean ketamine dose for the study population was 1.08 mg/kg (SD 0.4l, range 0.3 to 2 mg/ kg). The mean midazolam dose was 0.08 (SD 0.03, range 0.02 to 0.21 mg/kg). The mean recovery time was 38.1 minutes (SD 21.6, range 8 to 96 minutes). For the 32 children who received intravenous morphine, the mean dose was 0.09 mg/kg (SD 0.04, range 0.03 to 0.2 mg/kg). For the 15 children who received intramuscular meperidine, the mean dose was 1.01 (SD 0.1, range 0.85 to 1.19 mg/kg). Minor complications occurred in 5 (6%) patients. In the K/M-only group, 2 patients had transient hypoxia (room air pulse oximeter #92%), 1 patient required a neck roll to maintain a patent airway, and 1 patient had agitation for less than 1 minute. In the K/M morphine group, 1 patient had transient hypoxia. In comparing the K/M-only group with the K/M morphine, K/M meperidine, and K/M morphine or meperidine groups, the mean ketamine and midazolam doses (mg/kg) were not significantly different. In comparing the recovery times for the K/M-only group with the K/M morphine, K/M meperidine, and the K/M morphine or meperidine groups, there was a significant difference. The mean recovery times were 29.7 minutes (SD 15.7), 41.1 minutes (SD 22.4; 95% CI for differences –20.9 to –1.76); 50.1 minutes (SD 24.9; 95% CI for differences –32.2 to –8.4) and 44 minutes (SD 23.4; 95% CI for differences –23.5 to –4.9), respectively. Conclusion: Presedation analgesia (morphine or meperidine) is associated with a significantly longer recovery time for procedural sedation with ketamine and midazolam. This finding is not to suggest a discontinuation of presedation analgesia treatment but to help in estimating resources (staff time) for providing procedural sedation in a pediatric ED.
125
Impact of a New Booster Seat Law
Vilke GM, Murrin P, Gardina L, Upledger Ray L, Stepanski B, Chan TC/University of California–San Diego, San Diego, CA; San Diego County EMS, San Diego, CA Study objectives: The National Highway Traffic Safety Administration has currently estimated infant and toddler safety seat use at 91%, up 31% from 1996, in part because of child safety seat legislation. However, with no booster seat law in place for children who were too small or young for adult vehicle safety belts, booster seat use was estimated at 10%. Local data showed that before January 2002, boosters composed 5.6% (59/1,046) of seats inspected. Child safety seat legislation has historically been
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RESEARCH FORUM ABSTRACTS
more effective than public education. California extended the child restraint law to provide protection for children up to age 6 years or 60 lbs in January 2002. Methods: This was a cross-sectional study of child safety seats inspected at communitybased child safety seat inspection events and was conducted in a large metropolitan county. Child safety seat inspection events consisted of an intensive inspection of each child restraint for proper installation and adjustment. A standard collection form was used to record errors encountered and recommendations made to parents or caregivers about proper restraint adjustment and appropriate type of restraint. Descriptive analysis was performed on data collected both pre- and postlegislation. Periods were compared on booster seat use, misuse or error by booster type, age, weight, sibling seats inspected, and vehicle type. Geographic analysis examined spatial implications of inspection location, participants’ travel distance, and socioeconomic status. Results: Before January 2002, boosters composed 5.6% of seats inspected, and 37% of these demonstrated at least 1 error. There was a significant difference in misuse by booster type: 80% of shield and 28% of belt positioning boosters had at least 1 misuse (relative risk 2.96). Seventy-five percent of children for whom boosters were inspected also had a sibling’s seat inspected. The majority of siblings were younger and in rearfacing or forward-facing seats. Sixty percent of children in shield and 11% of children in belt positioning boosters weighed less than 40 lbs. Preliminary post-January 2002 data show that booster seats inspected increased to 11% and no shield booster seats were inspected. Conclusion: Results demonstrate an increase in the use of booster seats; however, there also remains a need for comprehensive parental education.
126
Intussusception Incidence Relative to Rotavirus Vaccine Use in Honolulu
Lee YY, Lee R, Yamamoto LG/University of Hawaii John A. Burns School of Medicine, Honolulu, HI Study objectives: Rotavirus vaccine was in use during August 1998 to October 1999. Epidemics of intussusception during this period were allegedly caused by rotavirus vaccine, which prompted the vaccine to be withdrawn. Hawaii’s geographic location between Asia and the mainland United States may subject it to infectious disease epidemic periods midway between occurrence in Asia and occurrence in the mainland United States. In contrast, immunization recommendations are temporally identical across all 50 states. The purpose of this study is to determine whether an epidemic of intussusception was experienced in Honolulu during the period of Rotavirus vaccine use. Methods: This is a retrospective study of data obtained from inpatient and emergency department discharge diagnosis codes of intussusception for children up to 36 months of age. The incidence data were plotted by time periods to identify possible epidemic periods. Results: Among those younger than 36 months old, the incidence of intussusception (in 4-month blocks) during the rotavirus vaccine use period was 4, 4, 2, 4 and 2 cases during each of the 4-month blocks beginning July 1998 and ending December 1999. This compares to an incidence of 2 to 4 cases per 4-month block before the rotavirus vaccine period from May 1994 to June 1998. From January 2000, the incidence per 4month block has been 4, 4, 6, 6, 5, 4, 6, 4, 5, 4, 4, and 1. This suggests a small epidemic of intussusception cases well after the period of rotavirus vaccine use. Conclusion: These incidence data are inconsistent with the allegation that rotavirus vaccine caused an epidemic of intussusception in Honolulu.
127
Clarifying Needs of the Pediatric Disaster Patient: A Descriptive Analysis of Pediatric Patient Encounters From Four Disaster Medical Assistance Team Deployments
Nufer KE, Gnauck K/University of New Mexico, Albuquerque, NM Study objectives: Disaster preparedness enhanced to meet children’s needs has become a growing priority, especially in light of recent world events. In the wake of a catastrophic disaster, children can be a significant part of the surviving population in need of disaster medical assistance teams (DMAT) aid. Pediatric patients represented approximately a third of all patients treated in New Mexico DMAT (NMDMAT) field clinics in the days and weeks after 4 recent natural disasters. We have no information on the specific needs of pediatric patients who present to DMAT field clinics. The purpose of this study is to describe pediatric patient encounters in 4 natural disaster DMAT deployments.
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Methods: We conducted a retrospective cohort review of pediatric patient encounter forms from NMDMAT field clinics during deployments to hurricanes Andrew (Florida, August 1991) and Iniki (Hawaii, September 1991), the Northridge earthquake (California, January 1994) and the Houston flood caused by Tropical Storm Allison (Texas, June 2001). All patients 18 years and younger were included. Data abstracted included age, sex, triage level, chief complaint, diagnosis, treatment, and disposition. For analysis, patients were placed by age into 5 groups: 2 months and younger; 3 months to 1 year; 1 to 5 years; 5 to 12 years; and 12 to 18 years. Simple descriptive statistics were used to describe patient variables. Results: Six hundred sixty-one patients were 18 years or younger, ranging from 0 to 18 years. The median age was 4 years. Children aged 1 year to 5 years represented the largest patient group (\2 months, 5.9%; 3 months to 1 year, 10.3%; 1 to 5 years, 40.4%; 5 to 12 years, 18.3%; 12 to 18 years, 10.3%). The female to male ratio was 1:1.2. Triage levels for all age groups were 57% green; 10% yellow; 2% red; 31% no documentation. Omission of triage level documentation on encounter forms decreased as patient age increased (\2 months, 51%; 3 months to 1 year, 37%; 1 to 5 years, 33%; 5 years to 12 years, 29%; 12 years to 18 years, 16%). The most common chief complaints by age category follow: less than 2 months, upper respiratory infection symptoms (URI) (30.8%), wounds, rash, and medication refill (all 10.3%), and abdominal complaints (7.7%); 3 months to 1 year, URI 66.2%, abdominal complaints 11.8%, rash 10.3%; 1 to 5 years, URI 53.6%, abdominal complaints 11.2%, rash 9.4%, and wounds 7.5%; 5 to 12 years URI 30.1%, wounds 25.7%, rash and abdominal complaints 7.7%, and musculoskeletal pain 7.1%; 12 to 18 years, wounds 35.9%, URI 12.6%, musculoskeletal pain 11.7%, and rash 8.7%. The most common discharge diagnoses by age group were younger than 2 months, wounds and URI 10.5% and otitis media 7.9%; 3 months to 1 year, otitis media 23.9%, URI 22.4%, viral syndrome and gastroenteritis 8.5%; 1 to 5 years, otitis media 22.4%, URI 16.2%, gastroenteritis 8.3%, otitis media 6.7%; 12 to 18 years, wounds 27.1%, musculoskeletal pain 8.4%, and cellulitis 6.5%. The most common treatments administered across all age groups included antibiotics, pain relievers, tetanus boosters, and wound care. The vast majority of patients’ disposition was home (92%). The youngest children were referred to the hospital more frequently than the older children (\2 months, 13%; 3 months to 1 year, 4.6%; 1 to 5 years, 5.3%; 5 to 12 years, 5.5%; 12 to 18 years, 1%). Conclusion: DMATs should be prepared to treat pediatric patients of all ages, particularly young children and infants, and anticipate medical and minor injury complaints. Field teams must be prepared to care for the infrequent pediatric patient in yellow and red triage categories who may need stabilization and hospital transfer. This unique study yields several interesting trends. First, minor trauma complaints and diagnoses (wounds and msk) increase in frequency as the children get older, whereas the medical complaints are more common in younger children. Next, the youngest children (0 to 2 months) were sent to hospitals more frequently than the other age groups. Finally, triage category was missing more often in the younger age groups. These latter 2 observations may indicate a lack of provider comfort in evaluating and treating young children. Further work is indicated: to improve field documentation, especially of younger children; to plan and implement postdisaster parent and pediatric injury prevention interventions; and to enhance the pediatric capability of DMATs. This first report of DMAT deployments specifically focused on children clarifies the specific needs of pediatric disaster victims and can serve as an important guide to future DMAT deployments.
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Relationship of Incidence of Otitis Media to Weather, Air Pollutants, Airborne Allergens, and Upper Respiratory Tract Infection Incidence
Shahidi H, Rickerhauser-Krall M, Barricella R, Chan YY, Zinzuwadia SN, Low RB/ University of Medicine and Dentistry of New Jersey, Newark, NJ Study objectives: We study the effects of air pollutants, weather, airborne allergens, incidence of upper respiratory tract infection (URI), and the September 11, 2001, attack on the incidence of otitis media in the 11 public hospitals and 6 clinics run by the New York City Health and Hospital Corporation (HHC). Methods: This was a retrospective study of electronic records of all patients treated in 11 HHC Hospitals and 5 clinics in New York City with a diagnosis of otitis media. We obtained airborne pollutant levels from the Environmental Protection Agency, weather information from the National Weather Service, and otitis media
ANNALS OF EMERGENCY MEDICINE
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Sports Injuries, A Common Pediatric Problem
older than 6 months. The use of these criteria for evaluating patients at risk for urinary tract infection is limited by the sensitivity and specificity of this factor.
Llovera IA, Ward MF, Falitz S, Miele D, Sama A, Trimarco T, Lukin M, Yaghoubian S, Sison C/North Shore University Hospital, Manhasset, NY Study objectives: We determine the frequency and demographics of all pediatric sports-related injuries presenting to our emergency department (ED) during 1 year (2002 to 2003), the particular sports causing specific injuries, and the disposition of these patients. Methods: This was a retrospective medical record review of all ED patients. We included only those patients with a sports-related injury documented on the ED record as the reason for the visit. We recorded demographic information, the sport, injury, treatment, and disposition. Results: Our ED census from July 2002 to 2003 was 60,873 (11,941 were pediatric patients). We reviewed 53,568 records (88%) and identified 1,087 pediatric sportsrelated injuries. Nine percent of all our pediatric visits were for sports-related injuries (mean age 11.8 years, 69% male patients, 73% white). Most of the injuries were from basketball (17%), playground/backyard activities (11%), biking (8%), football (8%), soccer (7%), and baseball/softball (6%). They had the following dispositions: admitted (4.4%) and the rest discharged to follow-up with orthopedics/hand (44%), their primary physician or ED (44%), plastic surgery (2%), dental (1%), ophthalmology (1%), neurology (0.5%), and other (3%). The most common sports resulting in admission were playground/backyard activities (18%), biking (16%), and basketball (9%; mean age 9.9 years, 69% male patients, 73% white). The children sustained the following fractures: a fracture or dislocation to an extremity 356 (21%), facial/skull fractures 15 (1%), fractured ribs or clavicle 7 (0.6%), neck fractures 5 (.3%), and fractured back 1 (\0.1%). The part of the body affected by the sports-related injuries was the following: arm 39%, leg 28%, head 25%, chest 3%, back 2%, neck 2%, and abdomen 1%. Conclusion: Nine percent of all our pediatic visits are from sports-related injuries (mean age 9.9 years). Of those, 4.4% are admitted to the hospital, mainly from injuries sustained in playground/backyard activities, biking, and basketball. The upper and lower extremities and the head are most often injured.
123
Does the WBC Count, Age, or Sex Predict Which Febrile Children From 90 Days to 36 Months of Age Will Have a Positive Urine Culture?
Ryan JG, Barata I, Ward MF, Hormozdi S, Shenkman A, Sama AE, Roit Z/New York Hospital–Queens, Flushing, NY; North Shore University Hospital, Manhasset, NY Study objectives: The purpose of this study is to determine whether the WBC count, age, or sex is predictive of a positive urine culture in children aged 90 days to 36 months who present to the emergency department (ED) with fever. Methods: This prospective study was conducted at an academic ED that treats 16,000 pediatric patients per year. Consecutive enrollment of subjects was performed by the principal investigator when the principal investigator was present. Patients were eligible if they were aged 3 to 36 months, had a rectal temperature of 103oF (39.4oC) or greater, were immunocompetent, did not receive antibiotics before evaluation, and did not have otitis media or pneumonia on physical examination. Eligible patients were evaluated by physical examination, CBC count, blood culture, catheter-obtained urine analysis and culture, and chest radiography. Results: Over a 17-month period, 119 patients were enrolled. Eight patients (6.7%) had a positive urine culture result. Six (9.7%) of the 62 male patients had a positive urine culture result compared with 2 (3.5%) of the 57 female patients. This was not significant. The mean WBC count in the group with a positive culture result was slightly lower than the group with a negative culture result (12.6 versus 13.5; P=not significant). Of the 8 patients with a positive urine culture result, 5 (63%) had a WBC count less than 15,000, and all had a WBC count less than 20,000. Patients younger than 6 months had a higher rate of urinary tract infection than those older than 6 months (16.6% versus 4.2%; P=.029). However, the sensitivity, specificity, and likelihood ratios showed that age was not very useful as a discriminatory test to predict urinary tract infection (sensitivity 62.5, specificity 74.8, positive likelihood ratio 2.48, negative likelihood ratio .50). Conclusion: There was no significant difference in the rate of urinary tract infection according to WBC count or sex. There was a significantly higher rate of urinary tract infection in patients younger than 6 months compared with patients
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
124
Effects of Initial Pain Treatment on Sedation Recovery Time in a Pediatric Emergency Department
Losek JD, Reid SR/Medical University of South Carolina, Charleston, SC; Children’s Hospitals and Clinics, St. Paul, MN Study objectives: The purpose of this study is to compare the sedation recovery times for children receiving ketamine/midazolam (K/M) versus K/M plus an opiate (morphine or meperidine) analgesic in a pediatric emergency department (ED). Methods: This was a retrospective cross-sectional study performed at an urban children’s hospital pediatric ED with a yearly census of 36,000. Descriptive statistics and confidence intervals (CIs) were used to analyze the data. Results: During an 18-month period (July 1, 2002, to December 31, 2003), 136 children received ketamine for procedural sedation in the ED. Of these, 116 also received midazolam. For the purpose of this study, the following number of patients were excluded: 9 with altered mental status, 11 with level of sedation not recorded, 6 with inadequate sedation, 6 with ketamine dose greater than 2 mg/kg or less than 0.3 mg/kg, 1 given reversal agents (Narcan and flumazenil), 2 with medical records not available for review, and 1 with morphine given more than 4 hours before ketamine and midazolam. Of the remaining 80 patients, 33 patients received K/M only, 32 received K/M and morphine, and 15 received K/M and meperidine. Of the 80 patients, the mean age was 91.8 months (SD 47.2, range 12 to 215 months). There were 47 (58%) male patients. Indication for procedural sedation and analgesia was an injury in 70 (87.5%) of the patients. Injuries included 64 fractures (60 forearm fractures), 3 lacerations, and 3 joint dislocations. Other indications were 3 foreign body removals, 2 incision and drainage procedures, 2 vaginal examinations, 2 computed tomographic scans, and 1 hernia reduction. The mean ketamine dose for the study population was 1.08 mg/kg (SD 0.4l, range 0.3 to 2 mg/ kg). The mean midazolam dose was 0.08 (SD 0.03, range 0.02 to 0.21 mg/kg). The mean recovery time was 38.1 minutes (SD 21.6, range 8 to 96 minutes). For the 32 children who received intravenous morphine, the mean dose was 0.09 mg/kg (SD 0.04, range 0.03 to 0.2 mg/kg). For the 15 children who received intramuscular meperidine, the mean dose was 1.01 (SD 0.1, range 0.85 to 1.19 mg/kg). Minor complications occurred in 5 (6%) patients. In the K/M-only group, 2 patients had transient hypoxia (room air pulse oximeter #92%), 1 patient required a neck roll to maintain a patent airway, and 1 patient had agitation for less than 1 minute. In the K/M morphine group, 1 patient had transient hypoxia. In comparing the K/M-only group with the K/M morphine, K/M meperidine, and K/M morphine or meperidine groups, the mean ketamine and midazolam doses (mg/kg) were not significantly different. In comparing the recovery times for the K/M-only group with the K/M morphine, K/M meperidine, and the K/M morphine or meperidine groups, there was a significant difference. The mean recovery times were 29.7 minutes (SD 15.7), 41.1 minutes (SD 22.4; 95% CI for differences –20.9 to –1.76); 50.1 minutes (SD 24.9; 95% CI for differences –32.2 to –8.4) and 44 minutes (SD 23.4; 95% CI for differences –23.5 to –4.9), respectively. Conclusion: Presedation analgesia (morphine or meperidine) is associated with a significantly longer recovery time for procedural sedation with ketamine and midazolam. This finding is not to suggest a discontinuation of presedation analgesia treatment but to help in estimating resources (staff time) for providing procedural sedation in a pediatric ED.
125
Impact of a New Booster Seat Law
Vilke GM, Murrin P, Gardina L, Upledger Ray L, Stepanski B, Chan TC/University of California–San Diego, San Diego, CA; San Diego County EMS, San Diego, CA Study objectives: The National Highway Traffic Safety Administration has currently estimated infant and toddler safety seat use at 91%, up 31% from 1996, in part because of child safety seat legislation. However, with no booster seat law in place for children who were too small or young for adult vehicle safety belts, booster seat use was estimated at 10%. Local data showed that before January 2002, boosters composed 5.6% (59/1,046) of seats inspected. Child safety seat legislation has historically been
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RESEARCH FORUM ABSTRACTS
more effective than public education. California extended the child restraint law to provide protection for children up to age 6 years or 60 lbs in January 2002. Methods: This was a cross-sectional study of child safety seats inspected at communitybased child safety seat inspection events and was conducted in a large metropolitan county. Child safety seat inspection events consisted of an intensive inspection of each child restraint for proper installation and adjustment. A standard collection form was used to record errors encountered and recommendations made to parents or caregivers about proper restraint adjustment and appropriate type of restraint. Descriptive analysis was performed on data collected both pre- and postlegislation. Periods were compared on booster seat use, misuse or error by booster type, age, weight, sibling seats inspected, and vehicle type. Geographic analysis examined spatial implications of inspection location, participants’ travel distance, and socioeconomic status. Results: Before January 2002, boosters composed 5.6% of seats inspected, and 37% of these demonstrated at least 1 error. There was a significant difference in misuse by booster type: 80% of shield and 28% of belt positioning boosters had at least 1 misuse (relative risk 2.96). Seventy-five percent of children for whom boosters were inspected also had a sibling’s seat inspected. The majority of siblings were younger and in rearfacing or forward-facing seats. Sixty percent of children in shield and 11% of children in belt positioning boosters weighed less than 40 lbs. Preliminary post-January 2002 data show that booster seats inspected increased to 11% and no shield booster seats were inspected. Conclusion: Results demonstrate an increase in the use of booster seats; however, there also remains a need for comprehensive parental education.
126
Intussusception Incidence Relative to Rotavirus Vaccine Use in Honolulu
Lee YY, Lee R, Yamamoto LG/University of Hawaii John A. Burns School of Medicine, Honolulu, HI Study objectives: Rotavirus vaccine was in use during August 1998 to October 1999. Epidemics of intussusception during this period were allegedly caused by rotavirus vaccine, which prompted the vaccine to be withdrawn. Hawaii’s geographic location between Asia and the mainland United States may subject it to infectious disease epidemic periods midway between occurrence in Asia and occurrence in the mainland United States. In contrast, immunization recommendations are temporally identical across all 50 states. The purpose of this study is to determine whether an epidemic of intussusception was experienced in Honolulu during the period of Rotavirus vaccine use. Methods: This is a retrospective study of data obtained from inpatient and emergency department discharge diagnosis codes of intussusception for children up to 36 months of age. The incidence data were plotted by time periods to identify possible epidemic periods. Results: Among those younger than 36 months old, the incidence of intussusception (in 4-month blocks) during the rotavirus vaccine use period was 4, 4, 2, 4 and 2 cases during each of the 4-month blocks beginning July 1998 and ending December 1999. This compares to an incidence of 2 to 4 cases per 4-month block before the rotavirus vaccine period from May 1994 to June 1998. From January 2000, the incidence per 4month block has been 4, 4, 6, 6, 5, 4, 6, 4, 5, 4, 4, and 1. This suggests a small epidemic of intussusception cases well after the period of rotavirus vaccine use. Conclusion: These incidence data are inconsistent with the allegation that rotavirus vaccine caused an epidemic of intussusception in Honolulu.
127
Clarifying Needs of the Pediatric Disaster Patient: A Descriptive Analysis of Pediatric Patient Encounters From Four Disaster Medical Assistance Team Deployments
Nufer KE, Gnauck K/University of New Mexico, Albuquerque, NM Study objectives: Disaster preparedness enhanced to meet children’s needs has become a growing priority, especially in light of recent world events. In the wake of a catastrophic disaster, children can be a significant part of the surviving population in need of disaster medical assistance teams (DMAT) aid. Pediatric patients represented approximately a third of all patients treated in New Mexico DMAT (NMDMAT) field clinics in the days and weeks after 4 recent natural disasters. We have no information on the specific needs of pediatric patients who present to DMAT field clinics. The purpose of this study is to describe pediatric patient encounters in 4 natural disaster DMAT deployments.
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Methods: We conducted a retrospective cohort review of pediatric patient encounter forms from NMDMAT field clinics during deployments to hurricanes Andrew (Florida, August 1991) and Iniki (Hawaii, September 1991), the Northridge earthquake (California, January 1994) and the Houston flood caused by Tropical Storm Allison (Texas, June 2001). All patients 18 years and younger were included. Data abstracted included age, sex, triage level, chief complaint, diagnosis, treatment, and disposition. For analysis, patients were placed by age into 5 groups: 2 months and younger; 3 months to 1 year; 1 to 5 years; 5 to 12 years; and 12 to 18 years. Simple descriptive statistics were used to describe patient variables. Results: Six hundred sixty-one patients were 18 years or younger, ranging from 0 to 18 years. The median age was 4 years. Children aged 1 year to 5 years represented the largest patient group (\2 months, 5.9%; 3 months to 1 year, 10.3%; 1 to 5 years, 40.4%; 5 to 12 years, 18.3%; 12 to 18 years, 10.3%). The female to male ratio was 1:1.2. Triage levels for all age groups were 57% green; 10% yellow; 2% red; 31% no documentation. Omission of triage level documentation on encounter forms decreased as patient age increased (\2 months, 51%; 3 months to 1 year, 37%; 1 to 5 years, 33%; 5 years to 12 years, 29%; 12 years to 18 years, 16%). The most common chief complaints by age category follow: less than 2 months, upper respiratory infection symptoms (URI) (30.8%), wounds, rash, and medication refill (all 10.3%), and abdominal complaints (7.7%); 3 months to 1 year, URI 66.2%, abdominal complaints 11.8%, rash 10.3%; 1 to 5 years, URI 53.6%, abdominal complaints 11.2%, rash 9.4%, and wounds 7.5%; 5 to 12 years URI 30.1%, wounds 25.7%, rash and abdominal complaints 7.7%, and musculoskeletal pain 7.1%; 12 to 18 years, wounds 35.9%, URI 12.6%, musculoskeletal pain 11.7%, and rash 8.7%. The most common discharge diagnoses by age group were younger than 2 months, wounds and URI 10.5% and otitis media 7.9%; 3 months to 1 year, otitis media 23.9%, URI 22.4%, viral syndrome and gastroenteritis 8.5%; 1 to 5 years, otitis media 22.4%, URI 16.2%, gastroenteritis 8.3%, otitis media 6.7%; 12 to 18 years, wounds 27.1%, musculoskeletal pain 8.4%, and cellulitis 6.5%. The most common treatments administered across all age groups included antibiotics, pain relievers, tetanus boosters, and wound care. The vast majority of patients’ disposition was home (92%). The youngest children were referred to the hospital more frequently than the older children (\2 months, 13%; 3 months to 1 year, 4.6%; 1 to 5 years, 5.3%; 5 to 12 years, 5.5%; 12 to 18 years, 1%). Conclusion: DMATs should be prepared to treat pediatric patients of all ages, particularly young children and infants, and anticipate medical and minor injury complaints. Field teams must be prepared to care for the infrequent pediatric patient in yellow and red triage categories who may need stabilization and hospital transfer. This unique study yields several interesting trends. First, minor trauma complaints and diagnoses (wounds and msk) increase in frequency as the children get older, whereas the medical complaints are more common in younger children. Next, the youngest children (0 to 2 months) were sent to hospitals more frequently than the other age groups. Finally, triage category was missing more often in the younger age groups. These latter 2 observations may indicate a lack of provider comfort in evaluating and treating young children. Further work is indicated: to improve field documentation, especially of younger children; to plan and implement postdisaster parent and pediatric injury prevention interventions; and to enhance the pediatric capability of DMATs. This first report of DMAT deployments specifically focused on children clarifies the specific needs of pediatric disaster victims and can serve as an important guide to future DMAT deployments.
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Relationship of Incidence of Otitis Media to Weather, Air Pollutants, Airborne Allergens, and Upper Respiratory Tract Infection Incidence
Shahidi H, Rickerhauser-Krall M, Barricella R, Chan YY, Zinzuwadia SN, Low RB/ University of Medicine and Dentistry of New Jersey, Newark, NJ Study objectives: We study the effects of air pollutants, weather, airborne allergens, incidence of upper respiratory tract infection (URI), and the September 11, 2001, attack on the incidence of otitis media in the 11 public hospitals and 6 clinics run by the New York City Health and Hospital Corporation (HHC). Methods: This was a retrospective study of electronic records of all patients treated in 11 HHC Hospitals and 5 clinics in New York City with a diagnosis of otitis media. We obtained airborne pollutant levels from the Environmental Protection Agency, weather information from the National Weather Service, and otitis media
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004