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Abdominal injuries in restrained pediatric passengers
Abstracts
of ST elevation was found in 51 home electrocardiograms (sensitivity 55%) and in 49 admission electrocardiograms (sensitivity 53%). In patients with ST elevation, 6 of the 57 home electrocardiograms (specificity 86Vo) and 2 of the 51 admission electrocardiograms (specificity 95%) did not have infarction. Of the 93 with myocardial infarction, 27 showed a change in classification between home and admission readings. These data suggest that ST elevation is a transient abnormality with high specificity and low sensitivity for predicting acute myocardial infarction. [Mark S. McIntosh] Editor’s Comment: Clearly, more sensitive criteria need to be developed for the initiation of thrombolytic therapy. Preferably, these criteria would be amenable to data gathering in the field.
0 CAUDA EQUINA SYNDROME SECONDARY TO LUMBAR DISK HERNIATION. Shapiro S. Neurosurgery. 1993;32:743-7. A retrospective review of 14 patients presenting with cauda equina syndrome secondary to lumbar disc herniation between 1986 and 1991 is presented. The patients’ presenting complaints consisted of bilateral sciatica, bilateral severe foot weakness, occasional quadriceps weakness, and stool or urinary incontinence. Three patients developed these complaints gradually over a period of weeks. Of 11 patients developing symptoms acutely over 24 hours, 2 presented over 4 days after the onset of symptoms and 9 sought immediate attention. The 11 acute-onset patients were emergently evaluated with myelogram, CT scan, or both. All 11 acute-onset patients were operated on emergently, and the other 3 were operated on within 24 hours. Follow-up ranged from 6 months to 5 years. All of the patients were ambulatory, 6 were normal, 4 had chronic pain and numbness, and 4 had persistent incontinence and weakness. All of the patients operated on less than 48 hours after the onset of symptoms regained unassisted ambulation, continence, and sexual activity. Of the patients operated on after 48 hours, 3 of 7 had permanent weakness, 2 of 6 regained continence, and 2 of 4 men resumed sexual activity. The authors state ,that cauda equina syndrome secondary to lumbar disc herniation should be treated as a surgical emergency, and every effort should be made to [John Long] operate within 24 to 48 hours.
Cl AMINOPWLLINE IN THE TREATMENT OF ACUTE ASTHMA WHEN B-2 ADRENERGICS AND STEROIDS ARE PROVIDED. Murphy DG, McDermott MF, Rydman RJ. Arch Intern Med. 1993;153:1784-88. The investigators conducted a prospective, randomized, double-blind, placebo controlled trial to address aminophylline use in acute asthma exacerbations when used in combination with metaproterenol and steroid therapy. The
119
measured end point was change in peak expiratory flow rate (PEFR). This trial was conducted at a municipal city emergency department. Inclusion criteria for the trial were acute exacerbation of previously diagnosed asthma, age 18 to 43, subtherapeutic theophylline level, and failure to achieve a PEFR of 40% predicted after one metaproterenol nebulizer and 125 mg intravenous methylprednlsolone. Those participants who were febrile, pregnant, on oral steroids, or with exacerbation severe enough to require continuous nebulizer or epinephrine were excluded from the study. A loading dose followed by a maintenance drip from randomized drug vials containing either 20 mg/ml amlnophylline/DSW solution or DSW solution alone were administered to 44 consenting participants. The participant and investigator were blind as to the content of the vials. Metaproterenol treatments were continued every hour for a total of six treatments. Outcome was determined by the best of three measured PEFR performed 15 minutes after each metaproterenol treatment. The data collected showed no difference in PEFR, and the time of documented improvement was the same for both groups. Furthermore, the group receiving the aminophylline suffered more tremor, palpitation, nausea, and vomiting. [Kelly R. Gray] Editor’s Comment: Severe asthmatics were excluded from this study, but the group of patients that was already on theophylline showed no benefit from acute administration of aminophylline and a high cost in terms of drug side effects.
0 ABDOMINAL INJURIES IN RESTRAINED PEDIATIUC PASSENGERS. Tso EL, Beaver BL, Haller JA, Jr. Journal of Pediatric Surgery. 1993;28:915-9. The authors report a retrospective chart review analysis of 42 pediatric patients admitted to a pediatric Level 1 trauma center for injuries sustained as restrained passengers in motor vehicle accidents over a Cyear period. Among the 9 children using 3-point lap-shoulder belts, there were 4 solid-organ, 1 hollow-organ, and 4 abdominalwall injuries. There were no vertebral injuries and no deaths in this group. Among the 24 children using lap belts only, there were 6 solid-visceral, 3 hollow-visceral, 14 minor abdominal-wall, and 6 vertebral-column injuries. There was 1 death in this group. Of the 5 patients restrained in a car seat, 2 suffered solid-organ injuries and 1 suffered an abdominal-wall contusion. There was 1 vertebral fracture and 1 death due to massive head injuries in this group. The authors note that 4 of 6 children who required extrication at the scene and 5 of 7 children with vertebral fractures were diagnosed with intra-abdominal injuries. They point out that, although the history of seatbelt use by motor vehicle accident victims is generally reassuring, serious injuries do occur despite seat-belt use. The physician must remain vigilant for belt-related abdominal injuries, especially in children who required extrication at the scene or in those with vertebral fractures. [Glen A. Hebel, MD]
120
Editor’s Comment: In addition, such injur :s are more frequently seen when a seat-belt sign is present.
0 TAXICABS AND CHILD RESTRAINT. Walter RS, Kuo AR. Am J Dis Child. 1993;147:561-4. Taxicab transportation of children less than 4 years of age was studied with regard to child restraint devices (CRDs) in this investigation conducted by the Department of Pediatrics, University of Maryland Medic *l Systems, Baltimore. In the pediatrics clinic, 108 families with children less than 4 years of age were surveyed during the fall of 1991. The authors report that 76% of families rode in taxicabs at least monthly (n = 28), weekly (n = 27), or daily (n = 9), all without CRDs. Additionally, the authors noted that, despite 11 pediatric deaths among the 106 reported taxicab occupant fatalities from 1986 to 1990 in the United States, 35 (70%) of 50 states and Washington, DC, exempt taxicabs from child restraint laws. Of 50 taxicab fleets surveyed in 4 states (Delaware, Maryland, New Jersey, and Pennsylvania), only 3 (6Vo) offered CRD availability. The authors maintain that physicians must act as child advocates by encouraging the use of CRDs among their patients when using taxicabs and by endorsing legislative efforts to mandate the availability of CRDs in taxi[Neal R. Abarbanell, MD] cabs.
Cl PREVALENCE OF URINARY TRACT INFECTION IN FEBRILE INFANTS. Hoberman A, Chao H, Keller D. The Journal of Pediatrics. 1993;123:17-23. The study assessed the prevalence of urinary tract infections (UTI) in febrile infants (temperature over 38.3 “C) and the usefulness of urinalysis in diagnosing UTI. Of 945 febrile infants included in the study, 50 infants (5.3%) were diagnosed with a UTI. UT1 was diagnosed if there were more than 10000 colony-forming units of a single pathogen per milliliter in a urine specimen obtained by catheterization. The prevalence of UT1 was similar among infants under 2 months of age undergoing a sepsis workup (4.6010)~ infants over 2 months of age where UT1 was suspected (5.9%), and infants with no suspected UT1 (5.1%). White and female infants had significantly more UTIs than Black and male infants. Overall, White female infants with a temperature above 39 OC had significantly more UTIs (17%) than any other group of infants. Infants with no apparent source of fever were more likely to have a UT1 (7.5%) than those with a possible source of fever (3.5%). Pyuria and bacteruria had sensitivities of 54% and 86% and specificities of 96% and 63%, respectively, as indicators of UTI. Since UT1 is a relatively common source of fever in infancy and can cause permanent renal damage, physicians should consider it as a potential source and consider a urinalysis and urine culture as part of the evaluation. [Tracy Martis]
The Journal of Emergency
Medicine
Editor’s Comment: Urine laboratory evaluation should be performed in those instances in which the results will influence patient management. I doubt that it is cost effective to perform such evaluations on patients when another infectious source has been identified and therapy initiated.
0 EFFICACY OF COUGH SUPPRESSANTS IN CHILDREN. Taylor JA, Novack AH, Almquist JR, Rogers JE. The Journal of Pediatrics. 1993;122:799-802. This study was a randomized, blinded study designed to determine the efficacy of cough suppressants in the pediatric population. Fifty-seven children selected were between the ages of 18 months and 12 years. Candidates were excluded if they had an underlying lung disease, reactive airway disease, or if other medications such as antibiotics or bronchodilators were necessary during the study period. Only those children with frequent coughing throughout the night as described by the parent or a cough that kept the child awake during the night were included. Each child was randomized into one of the following categories: guaifenesin 100 mg/5 ml + dextromethorphan 15 mg/5ml, guaifenesin 100 mg/5 ml + codeine 10 mg/5 ml, or placebo. The parents were asked to rate the frequency of coughing, loss of sleep, and post-tussive emesis each night for 3 consecutive nights as well as the night preceding the study. There was no difference between dextromethorphan, codeine, and placebo for cough suppression. Cough and composite symptom scores improved in each group every day of the study and, regardless of the group, the cough score decreased significantly on Day 3 of the study. The authors speculate on the efficacy of giving children a medication with potential for abuse when cough suppressants appear to be of little value in the pediatric population. [Susan Taylor, MD] Editor’s Comment: The same can probably be said for the adult population.
0 ADVICE SEEKING AND APPROPRIATE USE OF A PEDIATRIC EMERGENCY DEPARTMENT. Oberlander TF, Pless IB, Dougherty GE. AJDA. 1993;147: 863-7. Emergency departments have become the front door into today’s medical system and a source of primary care for most people. Many visits to emergency departments are for non-acute, non-emergent conditions. The authors proposed to evaluate whether parents who sought advice prior to coming to the hospital tended to make more appropriate visits than those who did not. At Montreal Children’s Hospital, parents were queried as to whether they had spoken to anyone prior to their visit and, if so, what advice had been given. They were also asked if the patient had a regular physician; date of last visit; patient’s age, sex, and birth order; and parents’ age and level of education.
of ST elevation was found in 51 home electrocardiograms (sensitivity 55%) and in 49 admission electrocardiograms (sensitivity 53%). In patients with ST elevation, 6 of the 57 home electrocardiograms (specificity 86Vo) and 2 of the 51 admission electrocardiograms (specificity 95%) did not have infarction. Of the 93 with myocardial infarction, 27 showed a change in classification between home and admission readings. These data suggest that ST elevation is a transient abnormality with high specificity and low sensitivity for predicting acute myocardial infarction. [Mark S. McIntosh] Editor’s Comment: Clearly, more sensitive criteria need to be developed for the initiation of thrombolytic therapy. Preferably, these criteria would be amenable to data gathering in the field.
0 CAUDA EQUINA SYNDROME SECONDARY TO LUMBAR DISK HERNIATION. Shapiro S. Neurosurgery. 1993;32:743-7. A retrospective review of 14 patients presenting with cauda equina syndrome secondary to lumbar disc herniation between 1986 and 1991 is presented. The patients’ presenting complaints consisted of bilateral sciatica, bilateral severe foot weakness, occasional quadriceps weakness, and stool or urinary incontinence. Three patients developed these complaints gradually over a period of weeks. Of 11 patients developing symptoms acutely over 24 hours, 2 presented over 4 days after the onset of symptoms and 9 sought immediate attention. The 11 acute-onset patients were emergently evaluated with myelogram, CT scan, or both. All 11 acute-onset patients were operated on emergently, and the other 3 were operated on within 24 hours. Follow-up ranged from 6 months to 5 years. All of the patients were ambulatory, 6 were normal, 4 had chronic pain and numbness, and 4 had persistent incontinence and weakness. All of the patients operated on less than 48 hours after the onset of symptoms regained unassisted ambulation, continence, and sexual activity. Of the patients operated on after 48 hours, 3 of 7 had permanent weakness, 2 of 6 regained continence, and 2 of 4 men resumed sexual activity. The authors state ,that cauda equina syndrome secondary to lumbar disc herniation should be treated as a surgical emergency, and every effort should be made to [John Long] operate within 24 to 48 hours.
Cl AMINOPWLLINE IN THE TREATMENT OF ACUTE ASTHMA WHEN B-2 ADRENERGICS AND STEROIDS ARE PROVIDED. Murphy DG, McDermott MF, Rydman RJ. Arch Intern Med. 1993;153:1784-88. The investigators conducted a prospective, randomized, double-blind, placebo controlled trial to address aminophylline use in acute asthma exacerbations when used in combination with metaproterenol and steroid therapy. The
119
measured end point was change in peak expiratory flow rate (PEFR). This trial was conducted at a municipal city emergency department. Inclusion criteria for the trial were acute exacerbation of previously diagnosed asthma, age 18 to 43, subtherapeutic theophylline level, and failure to achieve a PEFR of 40% predicted after one metaproterenol nebulizer and 125 mg intravenous methylprednlsolone. Those participants who were febrile, pregnant, on oral steroids, or with exacerbation severe enough to require continuous nebulizer or epinephrine were excluded from the study. A loading dose followed by a maintenance drip from randomized drug vials containing either 20 mg/ml amlnophylline/DSW solution or DSW solution alone were administered to 44 consenting participants. The participant and investigator were blind as to the content of the vials. Metaproterenol treatments were continued every hour for a total of six treatments. Outcome was determined by the best of three measured PEFR performed 15 minutes after each metaproterenol treatment. The data collected showed no difference in PEFR, and the time of documented improvement was the same for both groups. Furthermore, the group receiving the aminophylline suffered more tremor, palpitation, nausea, and vomiting. [Kelly R. Gray] Editor’s Comment: Severe asthmatics were excluded from this study, but the group of patients that was already on theophylline showed no benefit from acute administration of aminophylline and a high cost in terms of drug side effects.
0 ABDOMINAL INJURIES IN RESTRAINED PEDIATIUC PASSENGERS. Tso EL, Beaver BL, Haller JA, Jr. Journal of Pediatric Surgery. 1993;28:915-9. The authors report a retrospective chart review analysis of 42 pediatric patients admitted to a pediatric Level 1 trauma center for injuries sustained as restrained passengers in motor vehicle accidents over a Cyear period. Among the 9 children using 3-point lap-shoulder belts, there were 4 solid-organ, 1 hollow-organ, and 4 abdominalwall injuries. There were no vertebral injuries and no deaths in this group. Among the 24 children using lap belts only, there were 6 solid-visceral, 3 hollow-visceral, 14 minor abdominal-wall, and 6 vertebral-column injuries. There was 1 death in this group. Of the 5 patients restrained in a car seat, 2 suffered solid-organ injuries and 1 suffered an abdominal-wall contusion. There was 1 vertebral fracture and 1 death due to massive head injuries in this group. The authors note that 4 of 6 children who required extrication at the scene and 5 of 7 children with vertebral fractures were diagnosed with intra-abdominal injuries. They point out that, although the history of seatbelt use by motor vehicle accident victims is generally reassuring, serious injuries do occur despite seat-belt use. The physician must remain vigilant for belt-related abdominal injuries, especially in children who required extrication at the scene or in those with vertebral fractures. [Glen A. Hebel, MD]
120
Editor’s Comment: In addition, such injur :s are more frequently seen when a seat-belt sign is present.
0 TAXICABS AND CHILD RESTRAINT. Walter RS, Kuo AR. Am J Dis Child. 1993;147:561-4. Taxicab transportation of children less than 4 years of age was studied with regard to child restraint devices (CRDs) in this investigation conducted by the Department of Pediatrics, University of Maryland Medic *l Systems, Baltimore. In the pediatrics clinic, 108 families with children less than 4 years of age were surveyed during the fall of 1991. The authors report that 76% of families rode in taxicabs at least monthly (n = 28), weekly (n = 27), or daily (n = 9), all without CRDs. Additionally, the authors noted that, despite 11 pediatric deaths among the 106 reported taxicab occupant fatalities from 1986 to 1990 in the United States, 35 (70%) of 50 states and Washington, DC, exempt taxicabs from child restraint laws. Of 50 taxicab fleets surveyed in 4 states (Delaware, Maryland, New Jersey, and Pennsylvania), only 3 (6Vo) offered CRD availability. The authors maintain that physicians must act as child advocates by encouraging the use of CRDs among their patients when using taxicabs and by endorsing legislative efforts to mandate the availability of CRDs in taxi[Neal R. Abarbanell, MD] cabs.
Cl PREVALENCE OF URINARY TRACT INFECTION IN FEBRILE INFANTS. Hoberman A, Chao H, Keller D. The Journal of Pediatrics. 1993;123:17-23. The study assessed the prevalence of urinary tract infections (UTI) in febrile infants (temperature over 38.3 “C) and the usefulness of urinalysis in diagnosing UTI. Of 945 febrile infants included in the study, 50 infants (5.3%) were diagnosed with a UTI. UT1 was diagnosed if there were more than 10000 colony-forming units of a single pathogen per milliliter in a urine specimen obtained by catheterization. The prevalence of UT1 was similar among infants under 2 months of age undergoing a sepsis workup (4.6010)~ infants over 2 months of age where UT1 was suspected (5.9%), and infants with no suspected UT1 (5.1%). White and female infants had significantly more UTIs than Black and male infants. Overall, White female infants with a temperature above 39 OC had significantly more UTIs (17%) than any other group of infants. Infants with no apparent source of fever were more likely to have a UT1 (7.5%) than those with a possible source of fever (3.5%). Pyuria and bacteruria had sensitivities of 54% and 86% and specificities of 96% and 63%, respectively, as indicators of UTI. Since UT1 is a relatively common source of fever in infancy and can cause permanent renal damage, physicians should consider it as a potential source and consider a urinalysis and urine culture as part of the evaluation. [Tracy Martis]
The Journal of Emergency
Medicine
Editor’s Comment: Urine laboratory evaluation should be performed in those instances in which the results will influence patient management. I doubt that it is cost effective to perform such evaluations on patients when another infectious source has been identified and therapy initiated.
0 EFFICACY OF COUGH SUPPRESSANTS IN CHILDREN. Taylor JA, Novack AH, Almquist JR, Rogers JE. The Journal of Pediatrics. 1993;122:799-802. This study was a randomized, blinded study designed to determine the efficacy of cough suppressants in the pediatric population. Fifty-seven children selected were between the ages of 18 months and 12 years. Candidates were excluded if they had an underlying lung disease, reactive airway disease, or if other medications such as antibiotics or bronchodilators were necessary during the study period. Only those children with frequent coughing throughout the night as described by the parent or a cough that kept the child awake during the night were included. Each child was randomized into one of the following categories: guaifenesin 100 mg/5 ml + dextromethorphan 15 mg/5ml, guaifenesin 100 mg/5 ml + codeine 10 mg/5 ml, or placebo. The parents were asked to rate the frequency of coughing, loss of sleep, and post-tussive emesis each night for 3 consecutive nights as well as the night preceding the study. There was no difference between dextromethorphan, codeine, and placebo for cough suppression. Cough and composite symptom scores improved in each group every day of the study and, regardless of the group, the cough score decreased significantly on Day 3 of the study. The authors speculate on the efficacy of giving children a medication with potential for abuse when cough suppressants appear to be of little value in the pediatric population. [Susan Taylor, MD] Editor’s Comment: The same can probably be said for the adult population.
0 ADVICE SEEKING AND APPROPRIATE USE OF A PEDIATRIC EMERGENCY DEPARTMENT. Oberlander TF, Pless IB, Dougherty GE. AJDA. 1993;147: 863-7. Emergency departments have become the front door into today’s medical system and a source of primary care for most people. Many visits to emergency departments are for non-acute, non-emergent conditions. The authors proposed to evaluate whether parents who sought advice prior to coming to the hospital tended to make more appropriate visits than those who did not. At Montreal Children’s Hospital, parents were queried as to whether they had spoken to anyone prior to their visit and, if so, what advice had been given. They were also asked if the patient had a regular physician; date of last visit; patient’s age, sex, and birth order; and parents’ age and level of education.