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412: An Observational Study of Cutaneous Abscess Management in a Pediatric Emergency Department Setting
Research Forum Abstracts
411
Correlation of Pediatric Asthma Severity Score and End Tidal CO2 Values With Asthma Severity in the Pediatric Population
Dhillon RK, Bellolio M, Anderson JL/Mayo Clinic, Rochester, MN
Study Objectives: To investigate the relationship between end-tidal CO2, clinical severity measured by Pediatric Asthma Severity Score (PASS) and admission rate in children between ages 3 and 18 years presenting with acute asthma in the emergency department (ED). Methods: This was a prospective, observational study in children with an acute asthma exacerbation. Asthma was defined as two or more previous episodes of wheezing requiring albuterol. An acute exacerbation was defined as worsening of typical asthma symptoms, such as coughing or wheezing or increased difficulty breathing requiring a change in regular medications. Children with a chronic disease affecting respiratory function (eg, cardiac disease or cystic fibrosis), an airway abnormality (eg, laryngomalacia or stridor), a medical condition that would contraindicate the use of albuterol, or any condition needing immediate resuscitation or airway intervention were excluded. Results: Twenty-three patients were enrolled over an 8-month period. The median age was 10 years (IQR 6 to 13), 56.5% were males, and 61% Caucasians. There were a total of 16 patients (69.6%) on medications for asthma. A total of 12 (52.2%) patients presented with wheezing, 13 (56.5%) with cough, 7 (30.4%) with difficulty breathing, 6 (26.1%) with shortness of breath, and 3 (13.0%) with respiratory distress. A total of 15 (68.2%) children received medications prior coming to the ED, the most common of all was albuterol. The initial end-tidal CO2 median was 33 mm Hg (IQR 29 –36). Total initial PASS median was 2 (IQR 0 to 3, range 0 to 6). Only 9 patients were able to do peak expiratory flow rate. There was no relationship between total initial PASS and age (p⫽0.71), sex (p⫽0.59), peak expiratory flow rate (p⫽0.47), pulse rate (p⫽0.3), end-tidal CO2 (p⫽0.22), or respiratory rate (p⫽0.6). There was a negative linear correlation between total initial PASS and oxygen saturation (p⫽0.015, R-square 35.3%). There was an improvement of 1 point between the initial and second PASS, and improvement in 2 points between initial and third measurement, which were taken at 20-minute intervals after the treatment. There was no relationship between improvement in PASS and age, sex, symptoms at presentation, pulse rate, oxygen saturation, end-tidal CO2 or peak expiratory flow rate. There was a significant relationship between respiratory rate and improvement in PASS after nebulization (p⫽0.029, R-square 36.4% for initial respiratory rate, and p⫽0.011, R-square 53.3% for second respiratory rate). Three patients were admitted. The initial and second PASS were not predictors of hospital admission (p⫽0.40 for initial PASS, and p⫽0.089 for second PASS). Patients admitted had worse 3rd PASS (after 2 courses of nebulization), with a median score of 1 for those dismissed home, and median PASS of 3 for those admitted to the hospital (p⫽0.0507). The poor improvement in PASS from initial to 3rd measurement was related to admission (p⫽0.038). Conclusion: The clinical severity calculated with PASS was a predictor of admission to the hospital in this cohort. Improvement in PASS did not correlate with end tidal CO2.
412
An Observational Study of Cutaneous Abscess Management in a Pediatric Emergency Department Setting
Ramirez J, Ellis M, Papa L/Orlando Health: Arnold Palmer Hospital for Children, Orlando, FL; Orlando Health, Orlando, FL
Background: The presentation of pediatric patients with cutaneous abscesses is a common occurrence. In order to provide care in the most pain-free manner possible, a number of agents are used to achieve this, including lidocaine/prilocaine cream, a commonly used topical anesthetic in the pediatric emergency department (ED). It has been observed that the application of lidocaine/prilocaine cream to an abscess prior to incision and drainage (I&D) has led to the spontaneous rupture of some abscesses. Study Objective: To assess if application of lidocaine/prilocaine cream to a cutaneous abscess prior to I&D is associated with a higher rate of spontaneous drainage compared to those on which no lidocaine/prilocaine cream is applied in a pediatric ED population. Methods: This prospective observational study assessed a convenience sample of children aged 6 months to 18 years who presented to the ED of an urban Level I pediatric trauma center with a cutaneous abscess involving the torso, buttocks or extremities. Patients were consented prior to enrollment and were treated per usual
S130 Annals of Emergency Medicine
care by the emergency physician so that patient care was not altered by the study. Lidocaine/prilocaine cream as an adjunctive anesthetic is routinely used by many of our emergency physicians. When used, lidocaine/prilocaine cream was applied by the ED nurse by coating the surface and surrounding skin of the abscess and covered with an occlusive dressing for on average of 90 minutes. Data collection included a description of the abscess (size, location, degree of erythema, induration), ED length of stay, admission rate and complications. The main outcome was rate of spontaneous drainage. Other endpoints included time to spontaneous drainage, length of stay, degree of pain, need for I&D, improvement in symptoms and admission rate. Results: Of the 41 patients who were enrolled in the study, 31 had lidocaine/ prilocaine cream applied prior to intended I&D and 10 did not. Participants were a mean age of 3.3 years (SD 3.7) with 69% females and 31% males, mean temperature was 99.5F (SD 1.7) and 51% had a previous history of abscess. There were no significant differences between groups with respect to age (p⫽0.41) or sex (p⫽⫽0.40). Fifty one (51%) of abscesses were located on the buttocks, 37% on the extremities, 7% on the trunk, and 5% on the face. Spontaneous rupture occurred in 17 (51%) of patients in the lidocaine/prilocaine cream application group and in 0 cases in the non-lidocaine/prilocaine cream application group (p⫽0.002). Of the 17 abscesses that spontaneously ruptured 5 (31%) required subsequent I&D and the remaining 12 (79%) were managed expectantly. Conclusions: There was a significant number of abscesses that ruptured spontaneously following the application of lidocaine/prilocaine cream prior to I&D. A randomized trial is needed to assess the utility of lidocaine/prilocaine cream in managing abscesses in the pediatric ED.
413
Assessing Competency of the Broselow-Luten Pediatric Resuscitation Tape: A Prospective, Cross Sectional, Analytical Study of 15,000 South Indian School Children
Cattamanchi S, Banala SR, S P, Trichur RV/Sri Ramchandra Medical College & Research Institute, Chennai, India
Study Objective: ● To determines accuracy of Broselow pediatric emergency tape in Indian pediatric population. ● To find out standard deviation of weight from Broselow pediatric emergency tape to Indian population. ● To determine usefulness of Broselow pediatric emergency tape in Indian settings. Methods: A prospective, cross-sectional study of 15,000 South Indian school children in three weight-based groups of ⬎10 kg, 10 –18 kg and ⬍18 kg. Children above 2 months of age and below 12 years were eligible to participate in this study. Data was collected from patients attending Sri Ramachandra Paediatric outpatient department and school children in and around Chittoor Municipality, in South India. Age, sex, body length, actual weight, & Broselow weight were recorded in proforma between September 15th, 2008 and November 15th, 2008. Measured weight was compared to Broselow predicted weight and percent difference was calculated. A cross-validated correction factor was derived by non linear regression. Analysis was done using SPSS Ver. 15.0. Results: A total of 13, 214 school children from 8 different schools in and around Chittoor Municipality, S. India were enrolled in study. And also 1,786 children below age of 3 years who presented to Sri Ramachandra Hospital Paediatric outpatient department were included in study. Every child’s body weight and body length were measured to nearest 0.1 kg and 0.1 cm, respectively. A total of 8,609 males and 6,391 (42.6%) females were enrolled. 58% of children were aged between 3 and 6 years of age; and 1% was younger than 3 years of age. Median age was 5.6 years of age. Weights ranged from 3 to 36.0 kg, with a mean of 12.6 kgs. Subjects were divided into three weight-based groups comprising of 4,256 (28.3%) children less than 10kgs, 6,076 (40.5%) children between 10 –18kgs and 4,668 (31.15%) children above 18kgs. The mean percentage differences were ⫺2.4, ⫺13.3, and ⫺17.9% for each weight-based group respectively. Body weight was estimated using Broselow tape while measuring height of child at school or in outpatient department, and was compared with measured body weight. Using a Bland-Altman plot, mean bias and limits of agreement were determined. There was a statistically significant mean bias of ⫺1.72 kg (P 18 kg was ⫺5.9 kg (limits of agreement ⫺9.2/8.6 kg). Broselow weight was found to be within a 10% error for 63% and a 15% error for 85% of children. The 10% error for children 18 kg was 57%. Differences between these groups were pronounced above the 15% error range (18 kg: 45%). There was a good correlation between Broselow weight and measured weight
Volume , . : September
411
Correlation of Pediatric Asthma Severity Score and End Tidal CO2 Values With Asthma Severity in the Pediatric Population
Dhillon RK, Bellolio M, Anderson JL/Mayo Clinic, Rochester, MN
Study Objectives: To investigate the relationship between end-tidal CO2, clinical severity measured by Pediatric Asthma Severity Score (PASS) and admission rate in children between ages 3 and 18 years presenting with acute asthma in the emergency department (ED). Methods: This was a prospective, observational study in children with an acute asthma exacerbation. Asthma was defined as two or more previous episodes of wheezing requiring albuterol. An acute exacerbation was defined as worsening of typical asthma symptoms, such as coughing or wheezing or increased difficulty breathing requiring a change in regular medications. Children with a chronic disease affecting respiratory function (eg, cardiac disease or cystic fibrosis), an airway abnormality (eg, laryngomalacia or stridor), a medical condition that would contraindicate the use of albuterol, or any condition needing immediate resuscitation or airway intervention were excluded. Results: Twenty-three patients were enrolled over an 8-month period. The median age was 10 years (IQR 6 to 13), 56.5% were males, and 61% Caucasians. There were a total of 16 patients (69.6%) on medications for asthma. A total of 12 (52.2%) patients presented with wheezing, 13 (56.5%) with cough, 7 (30.4%) with difficulty breathing, 6 (26.1%) with shortness of breath, and 3 (13.0%) with respiratory distress. A total of 15 (68.2%) children received medications prior coming to the ED, the most common of all was albuterol. The initial end-tidal CO2 median was 33 mm Hg (IQR 29 –36). Total initial PASS median was 2 (IQR 0 to 3, range 0 to 6). Only 9 patients were able to do peak expiratory flow rate. There was no relationship between total initial PASS and age (p⫽0.71), sex (p⫽0.59), peak expiratory flow rate (p⫽0.47), pulse rate (p⫽0.3), end-tidal CO2 (p⫽0.22), or respiratory rate (p⫽0.6). There was a negative linear correlation between total initial PASS and oxygen saturation (p⫽0.015, R-square 35.3%). There was an improvement of 1 point between the initial and second PASS, and improvement in 2 points between initial and third measurement, which were taken at 20-minute intervals after the treatment. There was no relationship between improvement in PASS and age, sex, symptoms at presentation, pulse rate, oxygen saturation, end-tidal CO2 or peak expiratory flow rate. There was a significant relationship between respiratory rate and improvement in PASS after nebulization (p⫽0.029, R-square 36.4% for initial respiratory rate, and p⫽0.011, R-square 53.3% for second respiratory rate). Three patients were admitted. The initial and second PASS were not predictors of hospital admission (p⫽0.40 for initial PASS, and p⫽0.089 for second PASS). Patients admitted had worse 3rd PASS (after 2 courses of nebulization), with a median score of 1 for those dismissed home, and median PASS of 3 for those admitted to the hospital (p⫽0.0507). The poor improvement in PASS from initial to 3rd measurement was related to admission (p⫽0.038). Conclusion: The clinical severity calculated with PASS was a predictor of admission to the hospital in this cohort. Improvement in PASS did not correlate with end tidal CO2.
412
An Observational Study of Cutaneous Abscess Management in a Pediatric Emergency Department Setting
Ramirez J, Ellis M, Papa L/Orlando Health: Arnold Palmer Hospital for Children, Orlando, FL; Orlando Health, Orlando, FL
Background: The presentation of pediatric patients with cutaneous abscesses is a common occurrence. In order to provide care in the most pain-free manner possible, a number of agents are used to achieve this, including lidocaine/prilocaine cream, a commonly used topical anesthetic in the pediatric emergency department (ED). It has been observed that the application of lidocaine/prilocaine cream to an abscess prior to incision and drainage (I&D) has led to the spontaneous rupture of some abscesses. Study Objective: To assess if application of lidocaine/prilocaine cream to a cutaneous abscess prior to I&D is associated with a higher rate of spontaneous drainage compared to those on which no lidocaine/prilocaine cream is applied in a pediatric ED population. Methods: This prospective observational study assessed a convenience sample of children aged 6 months to 18 years who presented to the ED of an urban Level I pediatric trauma center with a cutaneous abscess involving the torso, buttocks or extremities. Patients were consented prior to enrollment and were treated per usual
S130 Annals of Emergency Medicine
care by the emergency physician so that patient care was not altered by the study. Lidocaine/prilocaine cream as an adjunctive anesthetic is routinely used by many of our emergency physicians. When used, lidocaine/prilocaine cream was applied by the ED nurse by coating the surface and surrounding skin of the abscess and covered with an occlusive dressing for on average of 90 minutes. Data collection included a description of the abscess (size, location, degree of erythema, induration), ED length of stay, admission rate and complications. The main outcome was rate of spontaneous drainage. Other endpoints included time to spontaneous drainage, length of stay, degree of pain, need for I&D, improvement in symptoms and admission rate. Results: Of the 41 patients who were enrolled in the study, 31 had lidocaine/ prilocaine cream applied prior to intended I&D and 10 did not. Participants were a mean age of 3.3 years (SD 3.7) with 69% females and 31% males, mean temperature was 99.5F (SD 1.7) and 51% had a previous history of abscess. There were no significant differences between groups with respect to age (p⫽0.41) or sex (p⫽⫽0.40). Fifty one (51%) of abscesses were located on the buttocks, 37% on the extremities, 7% on the trunk, and 5% on the face. Spontaneous rupture occurred in 17 (51%) of patients in the lidocaine/prilocaine cream application group and in 0 cases in the non-lidocaine/prilocaine cream application group (p⫽0.002). Of the 17 abscesses that spontaneously ruptured 5 (31%) required subsequent I&D and the remaining 12 (79%) were managed expectantly. Conclusions: There was a significant number of abscesses that ruptured spontaneously following the application of lidocaine/prilocaine cream prior to I&D. A randomized trial is needed to assess the utility of lidocaine/prilocaine cream in managing abscesses in the pediatric ED.
413
Assessing Competency of the Broselow-Luten Pediatric Resuscitation Tape: A Prospective, Cross Sectional, Analytical Study of 15,000 South Indian School Children
Cattamanchi S, Banala SR, S P, Trichur RV/Sri Ramchandra Medical College & Research Institute, Chennai, India
Study Objective: ● To determines accuracy of Broselow pediatric emergency tape in Indian pediatric population. ● To find out standard deviation of weight from Broselow pediatric emergency tape to Indian population. ● To determine usefulness of Broselow pediatric emergency tape in Indian settings. Methods: A prospective, cross-sectional study of 15,000 South Indian school children in three weight-based groups of ⬎10 kg, 10 –18 kg and ⬍18 kg. Children above 2 months of age and below 12 years were eligible to participate in this study. Data was collected from patients attending Sri Ramachandra Paediatric outpatient department and school children in and around Chittoor Municipality, in South India. Age, sex, body length, actual weight, & Broselow weight were recorded in proforma between September 15th, 2008 and November 15th, 2008. Measured weight was compared to Broselow predicted weight and percent difference was calculated. A cross-validated correction factor was derived by non linear regression. Analysis was done using SPSS Ver. 15.0. Results: A total of 13, 214 school children from 8 different schools in and around Chittoor Municipality, S. India were enrolled in study. And also 1,786 children below age of 3 years who presented to Sri Ramachandra Hospital Paediatric outpatient department were included in study. Every child’s body weight and body length were measured to nearest 0.1 kg and 0.1 cm, respectively. A total of 8,609 males and 6,391 (42.6%) females were enrolled. 58% of children were aged between 3 and 6 years of age; and 1% was younger than 3 years of age. Median age was 5.6 years of age. Weights ranged from 3 to 36.0 kg, with a mean of 12.6 kgs. Subjects were divided into three weight-based groups comprising of 4,256 (28.3%) children less than 10kgs, 6,076 (40.5%) children between 10 –18kgs and 4,668 (31.15%) children above 18kgs. The mean percentage differences were ⫺2.4, ⫺13.3, and ⫺17.9% for each weight-based group respectively. Body weight was estimated using Broselow tape while measuring height of child at school or in outpatient department, and was compared with measured body weight. Using a Bland-Altman plot, mean bias and limits of agreement were determined. There was a statistically significant mean bias of ⫺1.72 kg (P 18 kg was ⫺5.9 kg (limits of agreement ⫺9.2/8.6 kg). Broselow weight was found to be within a 10% error for 63% and a 15% error for 85% of children. The 10% error for children 18 kg was 57%. Differences between these groups were pronounced above the 15% error range (18 kg: 45%). There was a good correlation between Broselow weight and measured weight
Volume , . : September