- Email: [email protected]
43: Development and Validation of a Caregiver Gastroenteritis Knowledge Questionnaire
ICEM 2008 Scientific Abstract Program treatment of acute gastroenteritis focus primarily on the correction of dehydration and electrolyte abnormalities. So oral rehydration is the recommended therapy in mild to moderate dehydration secondary to acute gastroenteritis and has been proven safe and cost-effective, but it remains widely underused. Indeed, pediatric emergency physicians are more likely to choose intravenous over oral rehydration when the child vomits repeatedly. It has been estimated that oral rehydration is used in under 30% of cases of diarrhea in the US and some physicians prescribed antiemetics for treatment of children with vomiting from acute gastroenteritis. However, antiemetics use for acute gastroenteritis has not been well studied, and its use is controversial. Thus, we conducted a study to investigate potential beneficial effects of ondansetron versus placebo, in treating vomiting during acute gastroenteritis in children. Methods: A randomized, double blind, placebo-controlled trial was performed in an university and a government hospital ED. Children, 5 months to 8 years, vomiting ⱖ 4 times during the preceding 24 hours, mild/moderate dehydration were randomized to receive either oral disintegrating ondansetron tablets and placebo. Oral fluid tolerance, IV rehydration requirement, and hospitalization were evaluated at 8 and 36 hours. Those tolerating oral rehydration therapy and not vomiting were discharged. Discharged patients were evaluated by telephone at 24 hours to record vomiting, diarrhea and revisits. The primary outcome measure was the frequency of emesis during the 8 hour period after enrollment. The secondary outcomes are the rates of intravenous fluid administration or admission to hospital, and frequency of diarrhea. Results: One hundred and nine patients were enrolled; 54 received placebo and 55 received ondansetron. At baseline, age distribution, sex, frequency of emesis and diarrhea did not differ between both study groups. The ranks sum of vomiting episodes were significantly lower in the ondansetron group as compared with placebo group (⬍0.001) at both the 8- and 36-hour follow-up. During the first 8 hours, there was no statistically significant difference in the rank sum of episodes of diarrhea between the groups (⫽0.619); however, during the next 24 hours follow-up, it was significantly lower in the placebo group (⫽0.04). As compared with children who received placebo, children who received ondansetron were less likely to vomit both during the first 8 hour in the ED [relative risk (RR): 0.33, 95% confidence interval (CI): 0.19-0.56, number needed to treat (NNT): 2, 95% CI: 1.6-3.5], and during the next 24 hours follow-up (RR: 0.015, 95% CI: 0.07-0.33, NNT: 2, 95% CI: 1.3-2.1). The rate of admission (RR: 0.29, 95% CI: 0.009-1.01, NNT: 8, 95% CI: 4.9-91.7, ⫽0.07) and of return visits to the ED (RR: 0.91, 95% CI: 0.33-2.5, NNT: 2, 95% CI: 1.3-2.1, ⫽0.91) did not differ significantly between groups. Conclusion: Ondansetron may be an effective and efficient treatment that reduces the incidence of vomiting from gastroenteritis during both the first 8 hours and the next 24 hours, and is probably a useful adjunct to oral rehydration.
40
The Use of a Handheld Bladder Ultrasound Scanner in the Assessment of Dehydration and Monitoring Response to Therapy in a Pediatric Emergency Department
Enright K, Beattie TF, Taheri S/Royal Hospital for Sick Children, Edinburgh, United Kingdom
Study Objectives: 1) To investigate and characterize the utility of a handheld bladder ultrasound scanner in the assessment of children with suspected dehydration. 2) To clarify its potential role in monitoring response to therapy in the emergency department and facilitating safe discharge. Methods: Dehydration is a common concern for both parents and clinicians in paediatric emergency care and oliguria is an early physiological response to dehydration. There are few, if any, non-invasive, objective tools to aid the emergency physician in the assessment and management of dehydration. We conducted a pilot study on a convenience sample of patients attending the emergency department at a paediatric teaching hospital with a clinical presentation consistent with dehydration. Patients were recruited whenever the principal investigator was present in the emergency department. In addition to history and physical examination, a study proforma was completed detailing features of possible dehydration (including the World Health Organization guide to dehydration assessment). All patients had serial bladder ultrasounds performed by the emergency physician at half-hourly to hourly intervals but were treated independently of the results, which were analyzed following patient discharge. The handheld ultrasound device was used according to the manufacturer’s guidelines. Results: Forty-five patients aged between 4 months and 10 years with a median age of 2 years (interquartile range of 1,4) were enrolled from May to July 2007. Twenty-seven
Volume , . : April
(60%) were male. There were 8 patients (17%) aged under one year. Using WHO criteria 33 (73%), 8 (18%) & 4 (9%) were classified as having mild, moderate or severe dehydration respectively. There was a statistically significant difference in urine production between children with mild versus moderate or severe dehydration (2.3 ⫹/⫺ 1.5 mls/kg/hr vs 0.6 ⫹/⫺ 0.7 mls/kg/hr, p⫽ 0.001). Eleven (24%) were admitted. Of the 12 patients (26%) moderately or severly dehydrated, seven (58%) required admission, all (100%) of whom had documented impaired urine output (an average of 0.6ml/kg/hr). Response to fluid boluses, fluid challenges and oral rehydration programs were objectively demonstrated. In addition, 4 patients (9%) with features of possible dehydration but who appeared to be drinking well, had in fact, impaired urine production (mean of 0.42ml/kg/ hr) and this was also demonstrated by use of the handheld bladder scanner while in the emergency department. Conclusions: 1) Dehydration is a common presentation to the paediatric emergency department and yet standard clinical parameters correlate poorly with objective features of the condition. 2) Use of the handheld bladder scanner offers a convenient, non-invasive and objective adjunct to the assessment of dehydration and response to therapy in these children.
41
Normal Renal Ultrasound Predicts Low Risk of Urologic Intervention for Emergency Department Patients With Suspected Renal Colic
Sedran RJ, Yan JW, McLeod SL, Theakston KD, Edmonds ML/London Health Sciences Centre, London, Ontario, Canada
Background: Renal colic is a common emergency department (ED) diagnosis. Computed tomography (CT) is a frequently employed imaging modality for patients with suspected renal colic because of its high diagnostic accuracy. However, there is increasing concern about the lifetime cumulative radiation exposure attributed to CT. This is of particular concern for younger patients with a recurrent, non-life threatening disease such as renal colic. Ultrasound (US) is a widely available, low cost imaging modality that may also be used to diagnose renal colic without exposing the patient to radiation. Study Objectives: The objective of this study was to determine the ability of US to identify renal colic patients with a low risk of requiring urologic intervention within 90 days of their initial ED visit. Methods: A retrospective chart review was completed for all adult patients who had an ED-ordered US for suspected renal colic. Data was gathered from two tertiary care EDs with a combined annual census of 95,000 during a one-year period (January 1 to December 31, 2006). Independent, double data extraction was performed for all imaging reports and results were categorized as normal, suggestive, stone seen or nonrenal disease. The charts of all patients with a normal US were reviewed to determine if they required any urologic intervention within 90 days after their initial ED visit. Results: There were 857 ED-ordered renal ultrasounds during the study period. The study patients had a mean age of 44 years (range 18-95 years) and 53% were male. Of the 857 renal ultrasounds ordered during the study period, 373 (43.5%) were classified as normal. Of these, 49 (13%) underwent additional imaging identifying 6 (1.6%) stones, only two (⬍ 1%) of which required urologic intervention with lithotripsy. Conclusions: A normal renal US predicts a low likelihood for urologic intervention within 90 days for adult emergency department patients with suspected renal colic. The use of US may avoid the risks of radiation for many patients with suspected renal colic without adversely affecting their clinical outcomes. Further prospective research is needed to better define the role of ultrasound in the emergency management of renal colic.
42 43
Abstract Withdrawn
Development and Validation of a Caregiver Gastroenteritis Knowledge Questionnaire
Freedman SB, Deiratany S, Goldman R, Benseler S/Hospital for Sick Children, Toronto, Ontario, Canada; BC Children’s Hospital and the Child & Family Research Institute, Vancouver, British Columbia, Canada
Study Objectives: Since caregiver knowledge deficiencies are associated with the development of dehydration and nonurgent emergency department visits, we sought
Annals of Emergency Medicine 483
ICEM 2008 Scientific Abstract Program to develop and describe the reliability and validity of a Caregiver Gastroenteritis Knowledge Questionnaire. Methods: The questionnaire consists of 38 true/false questions covering signs of dehydration, indications to see a physician, oral rehydration therapy, solid intake and refeeding, medication use and disease transmission. Following validation procedures, 80 caregivers of children with gastroenteritis, 25 nurses and 22 pediatric emergency medicine physicians completed the questionnaire. One month later, participants completed the questionnaire a second time. Results: Content validity was confirmed qualitatively. Construct validity was demonstrated by incremental increases (P ⬍ 0.001) in mean total scores from caregivers to nurses to physicians. Multiple regression analysis revealed the number of prior visits for gastroenteritis was inversely associated with overall caregiver score (P ⫽ 0.02). Internal test-retest data gave a single measure intraclass correlation coefficient of 0.74 (95% Confidence Interval: 0.62, 0.83) and domain coefficients ⬎ 0.50 for all domains except “signs of dehydration.” The Pearson correlation coefficient for the test-retest score was 0.75. Internal consistency was demonstrated with a Cronbach’s alpha of 0.67 at time 0 and 0.80 at time 1 month. Conclusion: The Caregiver Gastroenteritis Knowledge Questionnaire is a reliable, valid instrument suitable for identifying knowledge gaps and measuring improvement following educational interventions. Future uses may focus on individual knowledge deficits or serve to document larger community educational needs.
44
Foreign Body Ingestion in Children
Chang YJ/Chang Gung Memorial Hospital, Taoyuan, Taiwan
Background: Foreign body ingestion is a common problem in pediatric emergency. The nature of the foreign body, the presentation, and the management may differ from those of the adult population. The study attempts to review the clinical presentation and the management of foreign body ingestion in children. Study Design: The retrospective study that evaluated foreign body ingestion in a pediatric department was conducted from January 2001 to September 2007 at a single tertiary referral center. Methods: Selection of Participants: Children under 18 years of age who had foreign body ingestion identified via International Classification of Disease, ninth revision code 938. Demographic data, the site and nature of foreign body, clinical presentation, radiographic finding, and endoscopic management were abstracted from the chart by using a standardized data collection sheet. The patients in our analysis had the following inclusion criterion: foreign bodies ingestion with radiographical or endoscopical proof or witnessed by family. Exclusion criteria: patients had incomplete medical records. Results: A total of 212 records of children with suspected foreign body were reviewed. There were 127 boys and 85 girls. The mean age was 4.52⫾3.58 years (range, 7 months to 17 year). The ingestion of foreign body was witnessed by family or the child gave the history of ingestion in 97% of cases. There was 3% no history suggestive of ingestion in the remaining case. Eighty-three percent of the admitted children had radiographically proven foreign body, 49 % of them located in esophagus, 44% in the stomach, and 7% in the intestine. The most common type of foreign bodies, proven radiographically or endoscopically, were coin (29%), disc battery (20%), and sharp metallic objects (9%). The type of sharp metallic objects is 6 screw, 5 dental reamer, 4 needle, 3 pins and 2 safety pins. Fifty-seven percent children with foreign body ingestion present asymptomatically. The main presenting symptoms were vomiting (21%), drooling (15%), anorexia (7%), and cough (5%). Endoscopic removal was attempted in and foreign body was extracted successfully in 23% of patients with disc battery or sharp metallic objects. Surgical procedure was performed in one patient with coin impacted in duodenum with failure of endoscopic removal. The complication of foreign body ingestion was 1 gastrointestinal bleeding by dental reamer, and 2 esophageal stenosis with disc battery. No mortality or bowel perforation was noted. Conclusion: Ingestion of foreign body is a common clinical problem in children. It should not be ignored in children with unexplained vomiting, anorexia, drooling or cough. Most children have a benign course and will spontaneously evacuate the foreign body. Removal of metallic sharp objects or disc battery may be safer, but careful follow-up is sufficient if they have passed into the intestine. There is no indication for prophylactic laparotomy to retrieve foreign body.
484 Annals of Emergency Medicine
45
Vulnerable Adolescents in the Emergency Department: Are We Providing Optimal Care?
Browning J, Khadr S, Cassidy J, Wilson B, Henderson A, Dunhill Z, Oglesby AJ/ Edinburgh Royal Infirmary, Edinburgh, United Kingdom; Royal Hospital for Sick Children, Edinburgh, United Kingdom
Background: The RCPCH 2003 document “Bridging The Gaps: Health care for adolescents” reports that increasing numbers of adolescents are accessing emergency departments for overdose (OD), deliberate self-harm (DSH) and substance misuse (SM) with concerns that they do not receive optimal care. The emergency department (ED) at the Royal Infirmary of Edinburgh (RIE), a large urban teaching hospital, sees adult patients aged 13 years or over. Study Objective: We examined the presentation and management of children less than (⬍) 16 years presenting to the RIE ED with OD, DSH and SM. Methods: Retrospective study of all children ⬍16 years of age who presented to the RIE ED between August 2004 and July 2005 with a diagnosis of OD, DSH or SM. Hospital notes and the ED computer system were interrogated and data was collected and analysed. Results: Over a 1 year period, 207 children presented, 56% with SM, 38% with OD and 6% with DSH. Substance Misuse: 117 adolescents presented; 56% were female. 70% presented by Emergency Ambulance, 24% self-presented and 6% in police care. 2% were triaged category 1&2, 84% triage 3 and 14% triage 4. 76% had consumed alcohol, 7% had taken drugs, the commonest being ecstasy, and 17% had taken both alcohol and drugs. 19% required IV fluids. 11% were admitted to the RIE, 4% were discharged to police custody, 6% did not wait to be seen and 79% were discharged without any follow-up. Of those discharged 93% had a responsible adult documented. Social work was involved in 14% cases. Overdose: 78 adolescents had taken an overdose. 91% were female. 58% self presented and 42% by Emergency Ambulance. 3% were triaged category 2, 81% triage 3 and 16% triage 4. Most of the drugs ingested were available over the counter: 69% paracetamol, 40% NSAIDS. 21% had ingested prescription drugs: the commonest being antibiotics (8%). 29% ingested more than 1 drug. 18% had also consumed alcohol &/or recreational drugs. Deliberate Self Harm: 12 adolescents presented: 58% had self-harmed, 42% were threatening to. 58% were female. 42% self presented, 33% by Emergency Ambulance and 25% in Police care. All those that were discharged home had a responsible adult present. Conclusion: Children ⬍16 years who attend the ED with OD, DSH and SM represent a vulnerable group of patients. This study has highlighted the extent of the problem and the results should influence health promotion. Within our ED an education programme has been instituted to improve basic knowledge of adolescent health. A proforma is now completed for every child ⬍16 years attending the RIE ED to encourage safe treatment, discharge and appropriate follow up. Improved links with Child & Adolescent Mental Health and social work will ultimately improve quality of care.
46
Children’s Weight “Guesstimates”: Could We?
Gardner S, Haber R/Ormskirk District General Hospital, Ormskirk, United Kingdom; University of Liverpool, Liverpool, United Kingdom
Study Objectives: To assess whether staff “guesstimates” of children’s weights are sufficiently accurate to be used as an approximation of children’s weights in a pediatric emergency department where the majority of children are routinely weighed. Previous studies suggested that they were inaccurate. To compare these “guesstimates” with the current Advanced Paediatric Life Support (APLS) and Luscombe’s formula for weight estimation. Methods: Medical and nursing staff at all levels of seniority were recruited to estimate the weight of children within the pediatric emergency setting by visual estimation alone. These estimates were recorded and then compared with the actual weight, with the “APLS” formula estimate and the Luscombe formula estimate. The level of seniority, and sex of the staff taking part was recorded. Results: The “APLS” formula underestimated children’s weights by 21%, clinician’s estimates underestimated by 7%. The graph of clinician estimates closely mirrored the actual weights which were non-linear in nature. “APLS” estimates were linear in nature. Within the group of clinicians those with mid-level experience were most accurate, underestimating by only 3.7%. Female staff averaged 4.8% underestimates compared to 10.7% for males. Luscombe’s formula [3(age) ⫹7] though linear, underestimated weights by 3.1%. Conclusion: In a department where weights of children are routinely measured, it
Volume , . : April
40
The Use of a Handheld Bladder Ultrasound Scanner in the Assessment of Dehydration and Monitoring Response to Therapy in a Pediatric Emergency Department
Enright K, Beattie TF, Taheri S/Royal Hospital for Sick Children, Edinburgh, United Kingdom
Study Objectives: 1) To investigate and characterize the utility of a handheld bladder ultrasound scanner in the assessment of children with suspected dehydration. 2) To clarify its potential role in monitoring response to therapy in the emergency department and facilitating safe discharge. Methods: Dehydration is a common concern for both parents and clinicians in paediatric emergency care and oliguria is an early physiological response to dehydration. There are few, if any, non-invasive, objective tools to aid the emergency physician in the assessment and management of dehydration. We conducted a pilot study on a convenience sample of patients attending the emergency department at a paediatric teaching hospital with a clinical presentation consistent with dehydration. Patients were recruited whenever the principal investigator was present in the emergency department. In addition to history and physical examination, a study proforma was completed detailing features of possible dehydration (including the World Health Organization guide to dehydration assessment). All patients had serial bladder ultrasounds performed by the emergency physician at half-hourly to hourly intervals but were treated independently of the results, which were analyzed following patient discharge. The handheld ultrasound device was used according to the manufacturer’s guidelines. Results: Forty-five patients aged between 4 months and 10 years with a median age of 2 years (interquartile range of 1,4) were enrolled from May to July 2007. Twenty-seven
Volume , . : April
(60%) were male. There were 8 patients (17%) aged under one year. Using WHO criteria 33 (73%), 8 (18%) & 4 (9%) were classified as having mild, moderate or severe dehydration respectively. There was a statistically significant difference in urine production between children with mild versus moderate or severe dehydration (2.3 ⫹/⫺ 1.5 mls/kg/hr vs 0.6 ⫹/⫺ 0.7 mls/kg/hr, p⫽ 0.001). Eleven (24%) were admitted. Of the 12 patients (26%) moderately or severly dehydrated, seven (58%) required admission, all (100%) of whom had documented impaired urine output (an average of 0.6ml/kg/hr). Response to fluid boluses, fluid challenges and oral rehydration programs were objectively demonstrated. In addition, 4 patients (9%) with features of possible dehydration but who appeared to be drinking well, had in fact, impaired urine production (mean of 0.42ml/kg/ hr) and this was also demonstrated by use of the handheld bladder scanner while in the emergency department. Conclusions: 1) Dehydration is a common presentation to the paediatric emergency department and yet standard clinical parameters correlate poorly with objective features of the condition. 2) Use of the handheld bladder scanner offers a convenient, non-invasive and objective adjunct to the assessment of dehydration and response to therapy in these children.
41
Normal Renal Ultrasound Predicts Low Risk of Urologic Intervention for Emergency Department Patients With Suspected Renal Colic
Sedran RJ, Yan JW, McLeod SL, Theakston KD, Edmonds ML/London Health Sciences Centre, London, Ontario, Canada
Background: Renal colic is a common emergency department (ED) diagnosis. Computed tomography (CT) is a frequently employed imaging modality for patients with suspected renal colic because of its high diagnostic accuracy. However, there is increasing concern about the lifetime cumulative radiation exposure attributed to CT. This is of particular concern for younger patients with a recurrent, non-life threatening disease such as renal colic. Ultrasound (US) is a widely available, low cost imaging modality that may also be used to diagnose renal colic without exposing the patient to radiation. Study Objectives: The objective of this study was to determine the ability of US to identify renal colic patients with a low risk of requiring urologic intervention within 90 days of their initial ED visit. Methods: A retrospective chart review was completed for all adult patients who had an ED-ordered US for suspected renal colic. Data was gathered from two tertiary care EDs with a combined annual census of 95,000 during a one-year period (January 1 to December 31, 2006). Independent, double data extraction was performed for all imaging reports and results were categorized as normal, suggestive, stone seen or nonrenal disease. The charts of all patients with a normal US were reviewed to determine if they required any urologic intervention within 90 days after their initial ED visit. Results: There were 857 ED-ordered renal ultrasounds during the study period. The study patients had a mean age of 44 years (range 18-95 years) and 53% were male. Of the 857 renal ultrasounds ordered during the study period, 373 (43.5%) were classified as normal. Of these, 49 (13%) underwent additional imaging identifying 6 (1.6%) stones, only two (⬍ 1%) of which required urologic intervention with lithotripsy. Conclusions: A normal renal US predicts a low likelihood for urologic intervention within 90 days for adult emergency department patients with suspected renal colic. The use of US may avoid the risks of radiation for many patients with suspected renal colic without adversely affecting their clinical outcomes. Further prospective research is needed to better define the role of ultrasound in the emergency management of renal colic.
42 43
Abstract Withdrawn
Development and Validation of a Caregiver Gastroenteritis Knowledge Questionnaire
Freedman SB, Deiratany S, Goldman R, Benseler S/Hospital for Sick Children, Toronto, Ontario, Canada; BC Children’s Hospital and the Child & Family Research Institute, Vancouver, British Columbia, Canada
Study Objectives: Since caregiver knowledge deficiencies are associated with the development of dehydration and nonurgent emergency department visits, we sought
Annals of Emergency Medicine 483
ICEM 2008 Scientific Abstract Program to develop and describe the reliability and validity of a Caregiver Gastroenteritis Knowledge Questionnaire. Methods: The questionnaire consists of 38 true/false questions covering signs of dehydration, indications to see a physician, oral rehydration therapy, solid intake and refeeding, medication use and disease transmission. Following validation procedures, 80 caregivers of children with gastroenteritis, 25 nurses and 22 pediatric emergency medicine physicians completed the questionnaire. One month later, participants completed the questionnaire a second time. Results: Content validity was confirmed qualitatively. Construct validity was demonstrated by incremental increases (P ⬍ 0.001) in mean total scores from caregivers to nurses to physicians. Multiple regression analysis revealed the number of prior visits for gastroenteritis was inversely associated with overall caregiver score (P ⫽ 0.02). Internal test-retest data gave a single measure intraclass correlation coefficient of 0.74 (95% Confidence Interval: 0.62, 0.83) and domain coefficients ⬎ 0.50 for all domains except “signs of dehydration.” The Pearson correlation coefficient for the test-retest score was 0.75. Internal consistency was demonstrated with a Cronbach’s alpha of 0.67 at time 0 and 0.80 at time 1 month. Conclusion: The Caregiver Gastroenteritis Knowledge Questionnaire is a reliable, valid instrument suitable for identifying knowledge gaps and measuring improvement following educational interventions. Future uses may focus on individual knowledge deficits or serve to document larger community educational needs.
44
Foreign Body Ingestion in Children
Chang YJ/Chang Gung Memorial Hospital, Taoyuan, Taiwan
Background: Foreign body ingestion is a common problem in pediatric emergency. The nature of the foreign body, the presentation, and the management may differ from those of the adult population. The study attempts to review the clinical presentation and the management of foreign body ingestion in children. Study Design: The retrospective study that evaluated foreign body ingestion in a pediatric department was conducted from January 2001 to September 2007 at a single tertiary referral center. Methods: Selection of Participants: Children under 18 years of age who had foreign body ingestion identified via International Classification of Disease, ninth revision code 938. Demographic data, the site and nature of foreign body, clinical presentation, radiographic finding, and endoscopic management were abstracted from the chart by using a standardized data collection sheet. The patients in our analysis had the following inclusion criterion: foreign bodies ingestion with radiographical or endoscopical proof or witnessed by family. Exclusion criteria: patients had incomplete medical records. Results: A total of 212 records of children with suspected foreign body were reviewed. There were 127 boys and 85 girls. The mean age was 4.52⫾3.58 years (range, 7 months to 17 year). The ingestion of foreign body was witnessed by family or the child gave the history of ingestion in 97% of cases. There was 3% no history suggestive of ingestion in the remaining case. Eighty-three percent of the admitted children had radiographically proven foreign body, 49 % of them located in esophagus, 44% in the stomach, and 7% in the intestine. The most common type of foreign bodies, proven radiographically or endoscopically, were coin (29%), disc battery (20%), and sharp metallic objects (9%). The type of sharp metallic objects is 6 screw, 5 dental reamer, 4 needle, 3 pins and 2 safety pins. Fifty-seven percent children with foreign body ingestion present asymptomatically. The main presenting symptoms were vomiting (21%), drooling (15%), anorexia (7%), and cough (5%). Endoscopic removal was attempted in and foreign body was extracted successfully in 23% of patients with disc battery or sharp metallic objects. Surgical procedure was performed in one patient with coin impacted in duodenum with failure of endoscopic removal. The complication of foreign body ingestion was 1 gastrointestinal bleeding by dental reamer, and 2 esophageal stenosis with disc battery. No mortality or bowel perforation was noted. Conclusion: Ingestion of foreign body is a common clinical problem in children. It should not be ignored in children with unexplained vomiting, anorexia, drooling or cough. Most children have a benign course and will spontaneously evacuate the foreign body. Removal of metallic sharp objects or disc battery may be safer, but careful follow-up is sufficient if they have passed into the intestine. There is no indication for prophylactic laparotomy to retrieve foreign body.
484 Annals of Emergency Medicine
45
Vulnerable Adolescents in the Emergency Department: Are We Providing Optimal Care?
Browning J, Khadr S, Cassidy J, Wilson B, Henderson A, Dunhill Z, Oglesby AJ/ Edinburgh Royal Infirmary, Edinburgh, United Kingdom; Royal Hospital for Sick Children, Edinburgh, United Kingdom
Background: The RCPCH 2003 document “Bridging The Gaps: Health care for adolescents” reports that increasing numbers of adolescents are accessing emergency departments for overdose (OD), deliberate self-harm (DSH) and substance misuse (SM) with concerns that they do not receive optimal care. The emergency department (ED) at the Royal Infirmary of Edinburgh (RIE), a large urban teaching hospital, sees adult patients aged 13 years or over. Study Objective: We examined the presentation and management of children less than (⬍) 16 years presenting to the RIE ED with OD, DSH and SM. Methods: Retrospective study of all children ⬍16 years of age who presented to the RIE ED between August 2004 and July 2005 with a diagnosis of OD, DSH or SM. Hospital notes and the ED computer system were interrogated and data was collected and analysed. Results: Over a 1 year period, 207 children presented, 56% with SM, 38% with OD and 6% with DSH. Substance Misuse: 117 adolescents presented; 56% were female. 70% presented by Emergency Ambulance, 24% self-presented and 6% in police care. 2% were triaged category 1&2, 84% triage 3 and 14% triage 4. 76% had consumed alcohol, 7% had taken drugs, the commonest being ecstasy, and 17% had taken both alcohol and drugs. 19% required IV fluids. 11% were admitted to the RIE, 4% were discharged to police custody, 6% did not wait to be seen and 79% were discharged without any follow-up. Of those discharged 93% had a responsible adult documented. Social work was involved in 14% cases. Overdose: 78 adolescents had taken an overdose. 91% were female. 58% self presented and 42% by Emergency Ambulance. 3% were triaged category 2, 81% triage 3 and 16% triage 4. Most of the drugs ingested were available over the counter: 69% paracetamol, 40% NSAIDS. 21% had ingested prescription drugs: the commonest being antibiotics (8%). 29% ingested more than 1 drug. 18% had also consumed alcohol &/or recreational drugs. Deliberate Self Harm: 12 adolescents presented: 58% had self-harmed, 42% were threatening to. 58% were female. 42% self presented, 33% by Emergency Ambulance and 25% in Police care. All those that were discharged home had a responsible adult present. Conclusion: Children ⬍16 years who attend the ED with OD, DSH and SM represent a vulnerable group of patients. This study has highlighted the extent of the problem and the results should influence health promotion. Within our ED an education programme has been instituted to improve basic knowledge of adolescent health. A proforma is now completed for every child ⬍16 years attending the RIE ED to encourage safe treatment, discharge and appropriate follow up. Improved links with Child & Adolescent Mental Health and social work will ultimately improve quality of care.
46
Children’s Weight “Guesstimates”: Could We?
Gardner S, Haber R/Ormskirk District General Hospital, Ormskirk, United Kingdom; University of Liverpool, Liverpool, United Kingdom
Study Objectives: To assess whether staff “guesstimates” of children’s weights are sufficiently accurate to be used as an approximation of children’s weights in a pediatric emergency department where the majority of children are routinely weighed. Previous studies suggested that they were inaccurate. To compare these “guesstimates” with the current Advanced Paediatric Life Support (APLS) and Luscombe’s formula for weight estimation. Methods: Medical and nursing staff at all levels of seniority were recruited to estimate the weight of children within the pediatric emergency setting by visual estimation alone. These estimates were recorded and then compared with the actual weight, with the “APLS” formula estimate and the Luscombe formula estimate. The level of seniority, and sex of the staff taking part was recorded. Results: The “APLS” formula underestimated children’s weights by 21%, clinician’s estimates underestimated by 7%. The graph of clinician estimates closely mirrored the actual weights which were non-linear in nature. “APLS” estimates were linear in nature. Within the group of clinicians those with mid-level experience were most accurate, underestimating by only 3.7%. Female staff averaged 4.8% underestimates compared to 10.7% for males. Luscombe’s formula [3(age) ⫹7] though linear, underestimated weights by 3.1%. Conclusion: In a department where weights of children are routinely measured, it
Volume , . : April