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Fatal bicycle accidents in children: A plea for prevention
Abstracts
bidity. These three cases made up 1% of all patients without pain or positive physical exam. Charges for pelvic xrays in patients without pain or tenderness totalled $88,000 [Merle Miller, MD] or $29,000 per fracture detected. Editor’s Comment: This study supports the selective use of pelvic x-rays in the evaluation of blunt trauma. Pelvic x-rays should be performed in patients who are symptomatic, intoxicated, obtunded, unconscious, hypotensive, or have distracting injuries.
0 DURATION OF APNEA IN ANESTHETIZED INFANTS AND CHILDREN REQUIRED FOR DESATURATION OF HEMOGLOBIN TO 95%: THE INFLUENCE OF UPPER RESPIRATORY INFECTION. Kinouchi K, Tanigami H, Tashiro C, Nishimura M, Fukumitsu K, Takauchi Y. Anesthesiology. 1992;77: 1105 1107. Theoretically, younger children are at greater risk for hypoxemia than other patients, given their higher rates of oxygen consumption per kilogram and lower functional residual capacity (FRC). To test this hypothesis, and to further assess the risk of hypoxemia from pediatric upper respiratory infection (URI), sixty one elective surgery patients were selected. All were between 1 month and 12 years of age; their ASA physical status was either 1 or 2. Two cohorts were identified, based on the presence or absence of URI symptoms (rhinorrhea, congestion, cough, and/ or fever). After induction with sevoflurane/nitrous oxide mixtures, paralysis with vecuronium, and endotracheal intubation, all patients were ventilated with 3% sevoflurane/ oxygen mixtures until endtidal nitrous oxide was less than 5% and arterial hemoglobin oxygen saturation @p/O’) was 100% by pulse oximetry. Under continuous monitoring, the breathing circuit was then disconnected, and time to Sp/O* of 95% was measured. Patients were then reventilated to 100%. Both URI-symptomatic and asymptomatic groups yielded nearly linear relationships between desaturation and decreasing age; neonates desaturated over two and a half times faster than did the older children. Further, the URI-symptomatic cohort showed an independent effect, with desaturation occurring 40 to 50 seconds faster in all age groups when compared to the asymptomatic cohort. [W. S. Ernoehazy, Jr., MD] Editor’s Comment: Yet another good reason to beware of pediatric asthmatics and pneumonia patients. This study supports the clinical intuition that pediatric patients with respiratory problems get into trouble swiftly, and may require early ventilatory assistance.
? ?ACUTE EPIGLOTTITIS - 25 YEARS EXPERIENCE WITH NASOTRACHEAL INTUBATION, CURRENT MANAGEMENT POLICY AND FUTURE TRENDS. Andreassen UK, Baer S, Nielsen TG, et al. J Laryg Oto. 1992;106:1072-1075.
651
This retrospective study examined data collected on the incidence, treatment and morbidity of acute epiglottitis (AE) in both children and adults. During a 25-year period, 168 adults and 111 children were treated for AE. Of these patients four died, three of whom died of a cardiac arrest upon arrival at the hospital. Diagnosis was established via direct visualization utilizing a tongue depressant, indirect laryngoscopy. or fibreoptic nasolaryngoscopy. All patients received antibiotics and most were observed in an intensive care unit. The study found that in children the majority of AE is due to Haemophilus influenzae type b (Hib) while in adults, Hib is responsible for approximately one third of the total number of cases seen. Of the adults, 37 (22%) required intubation or tracheostomy, while in the pediatric group 78 (70%) were intubated or underwent tracheostomy. The infrequency of AE warrants a preplanned departmental protocol. Obstruction can occur suddenly and unexpectedly, therefore consideration for intubation should remain paramount during evaluation and observation. In this study, the incidence of AE in children was calculated at 3.2/100,000 and as the vaccination for Hib becomes more prevalent, it is expected that the incidence will be markedly reduced in children. [Bold R. Hood, MD]
Cl FATAL BICYCLE ACCIDENTS IN CHILDREN: A PLEA FOR PREVENTION. Spence LJ, Dykes EH, Bohn DJ, Wesson DE. Pediatr Surg. 1993;28:214-216. A retrospective study reviewing coroner records of fatal bicycle accidents occurring in the 0 to 15 age group in Ontario Canada between January 1985 and December 1989, to document the frequency of cycling deaths and determine the degree to which death could have been prevented by optimal post injury treatment. Documented injuries were scored using the Abbreviated Injury Score (AIS) and classified as survivable or unsurvivable (AIS of 6 or head/neck injury with AIS of 5). The causes and circumstances of the accidents were also obtained from police records. During the 4-year study, of 540 children who died secondary to blunt injury, 81 (15%) were bicycle related. 74 deaths (91%) were considered unsurvivable of which 89% were head injuries. 78 (96%) were due to motor vehicle collision. Police investigation concluded cyclists caused the collision in 70% of cases either due to poor judgement or violation of traffic law. Motorists were responsible for 18%. In all cases no helmets were present. Results suggested that primary and secondary prevention would be more likely to reduce cycling deaths in children than improvements in post injury treatment. In light of recent studies noting a significant association between helmet use and the decrease in severity of head injury, it was felt the most effective strategy would be manditory helmet use. Current helmet use in children is less than 1%. Other prevention strategies mentioned included: 1) separation of bicycle and vehicular traffic, 2) restriction of certain roads from bicycle use, 3) educational programs for both bicyclist and motorists. [Teresa M. Mazur]
The Journal of Emergency Medicine
652
Editor’s Comment: We may be uniquely qualified to participate strategies.
in educating the public about these prevention
0 ACUTE CONJUNCTIVITIS IN CHILDHOOD. Weiss A, Brinser JH, Nazar-Stewart V. J of Pediatr. 1993;122: 10-14. This paper was designed to study the efficacy of Gram staining, Giemsa staining and bacterial cultures of the conjunctiva and eyelids in children with acute conjunctivitis. The authors obtained cultures from the eyelids and conjunctiva of 95 patients ranging in age from 4 months to 12 years diagnosed with acute conjunctivitis. The control group consisted of 91 patients of similar age. By obtaining separate specimens from the lids and the conjunctiva, the authors could distinguish blepheritis from conjunctivitis. The results confirmed previous data suggesting that acute conjunctivitis is bacterial in origin 78% (76 patients) of the time, as proven by positive culture results. A viral etiology was suspected in 12% (12 patients) of the patients by a negative bacterial culture and a Giemsa stain revealing lymphocyte predominance. In the remaining children, allergic conjunctivitis was suspected in 2, and no etiology was found in 5. The predominant organism causing an acute conjunctivitis was identified as Hemophilus influenza, isolated in 43 of the patients. Streptococcus pneumoniae and Moraxella catarrhalis were also frequent causes of acute conjunctivitis. The predominant organisms found to cause an acute blepheritis were Staphylococci, corynebacteria, and alpha-hemolytic streptococci. The Gram staining proved to be a valuable diagnostic tool and correlated well with the culture results. The majority of the control group had normal conjunctival cytologic findings. Clinically, it is difficult to distinguish viral from bacterial conjunctivitis. Of the clinical findings observed, a purulent discharge was seen in 80% of the confirmed bacterial infections, but was also seen in 25% of the culture negative (suspected viral) infections. The results of this study confirm that the early use of antibiotic therapy for acute conjunctivitis is war[Susan Taylor, MD] ranted.
0 MIDAZOLAM ENHANCES ANTEROGRADE BUT NOT RETROGRADE AMNESIA IN PEDIATRIC PATIENTS. Twersky R, Hartung J, Berger B, McClain J, Beaton C. Anesthesiology. 1993;78:51-55. This article investigates the effect of aerosolized intranasal midazolam on both anterograde and retrograde memory in children. Forty children, aged 4-10 years, were randomized to receive either midazolam (0.2 mg/kg) or placebo intranasally via an atomizer. They were then given general anesthesia with nitrous oxide and halothane as well as a muscle relaxant. Memory testing was performed prior to any treatments, 10 minutes after receiving midazolam or placebo, and again postoperatively using picture cards.
Six patients were excluded from the study due to low baseline memory scores, clerical errors, or complicated operation. Results showed that there was a significant difference between the midazolam group versus placebo group in both recall and recognition when assessing postoperative memory occurring subsequent to the administration of treatment with midazolam or placebo (anterograde effect). There was no significant difference between the groups in memory prior to treatment (retrograde effect). The authors conclude that midazolam significantly reduces a child’s postoperative ability to recall and recognize cards shown subsequent to its administration without affecting pretreatment memory. Therefore midazolam is an excellent choice for premeditation in children. [Kenneth Ahonen, MD]
0 ACUTE APPENDICITIS IN CHILDREN: VALUE OF SONOGRAPHY IN DETECTING PERFORATION. Quillin SP, Siegel MJ, Coffin CM. Am J Roentgenol. 1992; 159:1265-1268. The use of sonography as a sensitive modality in the diagnosis of acute appendicitis is well established. However, there is some controversy over its usefulness in differentiating perforating from nonperforating appendicitis. This study reports sonographic signs identified retrospectively in children with appendicitis and correlates these with surgical and pathologic findings. Statistical analysis was performed using a Fisher exact two-tailed test. Sonograms of 79 children with surgically-proved appendicitis were reviewed. The sonographic signs evaluated included the presence or absence of an appendix, an echogenic submucosal layer, increased periappendiceal echogenicity, free or loculated periappendiceal or pelvic fluid collections, and appendicoliths. Abnormal signs were identified in 71 of the 79 patients; surgery was performed within 36 hours of sonographic evaluation in all but two patients. Appendiceal perforations were found in 26 of these patients. A visible appendix with a diameter greater than 6 mm was seen in all 45 patients with non-complicated appendicitis but only 38% of patients with perforation. An echogenic submucosa was present sonographically in 60% with nonperforated appendicitis and 33% with perforation and a recognizable appendix @ < 0.05). Loculated periappendiceal or pelvic fluid collections were visualized in 73% of patients with perforated appendix but in none of the patients with nonperforating appendicitis (p < 0.05). No statistically significant association was found between presence or absence of perforation and free pelvic fluid, prominent periappendiceal fat, or an appendicolith. These results support the value of sonography in distinguishing perforating versus nonperforating appendicitis and suggest that the presence of loculated fluid collection and absence of echogenic submucosal layer are the most sensitive sonographic findings. [Gordon Hardenbergh, MD]
bidity. These three cases made up 1% of all patients without pain or positive physical exam. Charges for pelvic xrays in patients without pain or tenderness totalled $88,000 [Merle Miller, MD] or $29,000 per fracture detected. Editor’s Comment: This study supports the selective use of pelvic x-rays in the evaluation of blunt trauma. Pelvic x-rays should be performed in patients who are symptomatic, intoxicated, obtunded, unconscious, hypotensive, or have distracting injuries.
0 DURATION OF APNEA IN ANESTHETIZED INFANTS AND CHILDREN REQUIRED FOR DESATURATION OF HEMOGLOBIN TO 95%: THE INFLUENCE OF UPPER RESPIRATORY INFECTION. Kinouchi K, Tanigami H, Tashiro C, Nishimura M, Fukumitsu K, Takauchi Y. Anesthesiology. 1992;77: 1105 1107. Theoretically, younger children are at greater risk for hypoxemia than other patients, given their higher rates of oxygen consumption per kilogram and lower functional residual capacity (FRC). To test this hypothesis, and to further assess the risk of hypoxemia from pediatric upper respiratory infection (URI), sixty one elective surgery patients were selected. All were between 1 month and 12 years of age; their ASA physical status was either 1 or 2. Two cohorts were identified, based on the presence or absence of URI symptoms (rhinorrhea, congestion, cough, and/ or fever). After induction with sevoflurane/nitrous oxide mixtures, paralysis with vecuronium, and endotracheal intubation, all patients were ventilated with 3% sevoflurane/ oxygen mixtures until endtidal nitrous oxide was less than 5% and arterial hemoglobin oxygen saturation @p/O’) was 100% by pulse oximetry. Under continuous monitoring, the breathing circuit was then disconnected, and time to Sp/O* of 95% was measured. Patients were then reventilated to 100%. Both URI-symptomatic and asymptomatic groups yielded nearly linear relationships between desaturation and decreasing age; neonates desaturated over two and a half times faster than did the older children. Further, the URI-symptomatic cohort showed an independent effect, with desaturation occurring 40 to 50 seconds faster in all age groups when compared to the asymptomatic cohort. [W. S. Ernoehazy, Jr., MD] Editor’s Comment: Yet another good reason to beware of pediatric asthmatics and pneumonia patients. This study supports the clinical intuition that pediatric patients with respiratory problems get into trouble swiftly, and may require early ventilatory assistance.
? ?ACUTE EPIGLOTTITIS - 25 YEARS EXPERIENCE WITH NASOTRACHEAL INTUBATION, CURRENT MANAGEMENT POLICY AND FUTURE TRENDS. Andreassen UK, Baer S, Nielsen TG, et al. J Laryg Oto. 1992;106:1072-1075.
651
This retrospective study examined data collected on the incidence, treatment and morbidity of acute epiglottitis (AE) in both children and adults. During a 25-year period, 168 adults and 111 children were treated for AE. Of these patients four died, three of whom died of a cardiac arrest upon arrival at the hospital. Diagnosis was established via direct visualization utilizing a tongue depressant, indirect laryngoscopy. or fibreoptic nasolaryngoscopy. All patients received antibiotics and most were observed in an intensive care unit. The study found that in children the majority of AE is due to Haemophilus influenzae type b (Hib) while in adults, Hib is responsible for approximately one third of the total number of cases seen. Of the adults, 37 (22%) required intubation or tracheostomy, while in the pediatric group 78 (70%) were intubated or underwent tracheostomy. The infrequency of AE warrants a preplanned departmental protocol. Obstruction can occur suddenly and unexpectedly, therefore consideration for intubation should remain paramount during evaluation and observation. In this study, the incidence of AE in children was calculated at 3.2/100,000 and as the vaccination for Hib becomes more prevalent, it is expected that the incidence will be markedly reduced in children. [Bold R. Hood, MD]
Cl FATAL BICYCLE ACCIDENTS IN CHILDREN: A PLEA FOR PREVENTION. Spence LJ, Dykes EH, Bohn DJ, Wesson DE. Pediatr Surg. 1993;28:214-216. A retrospective study reviewing coroner records of fatal bicycle accidents occurring in the 0 to 15 age group in Ontario Canada between January 1985 and December 1989, to document the frequency of cycling deaths and determine the degree to which death could have been prevented by optimal post injury treatment. Documented injuries were scored using the Abbreviated Injury Score (AIS) and classified as survivable or unsurvivable (AIS of 6 or head/neck injury with AIS of 5). The causes and circumstances of the accidents were also obtained from police records. During the 4-year study, of 540 children who died secondary to blunt injury, 81 (15%) were bicycle related. 74 deaths (91%) were considered unsurvivable of which 89% were head injuries. 78 (96%) were due to motor vehicle collision. Police investigation concluded cyclists caused the collision in 70% of cases either due to poor judgement or violation of traffic law. Motorists were responsible for 18%. In all cases no helmets were present. Results suggested that primary and secondary prevention would be more likely to reduce cycling deaths in children than improvements in post injury treatment. In light of recent studies noting a significant association between helmet use and the decrease in severity of head injury, it was felt the most effective strategy would be manditory helmet use. Current helmet use in children is less than 1%. Other prevention strategies mentioned included: 1) separation of bicycle and vehicular traffic, 2) restriction of certain roads from bicycle use, 3) educational programs for both bicyclist and motorists. [Teresa M. Mazur]
The Journal of Emergency Medicine
652
Editor’s Comment: We may be uniquely qualified to participate strategies.
in educating the public about these prevention
0 ACUTE CONJUNCTIVITIS IN CHILDHOOD. Weiss A, Brinser JH, Nazar-Stewart V. J of Pediatr. 1993;122: 10-14. This paper was designed to study the efficacy of Gram staining, Giemsa staining and bacterial cultures of the conjunctiva and eyelids in children with acute conjunctivitis. The authors obtained cultures from the eyelids and conjunctiva of 95 patients ranging in age from 4 months to 12 years diagnosed with acute conjunctivitis. The control group consisted of 91 patients of similar age. By obtaining separate specimens from the lids and the conjunctiva, the authors could distinguish blepheritis from conjunctivitis. The results confirmed previous data suggesting that acute conjunctivitis is bacterial in origin 78% (76 patients) of the time, as proven by positive culture results. A viral etiology was suspected in 12% (12 patients) of the patients by a negative bacterial culture and a Giemsa stain revealing lymphocyte predominance. In the remaining children, allergic conjunctivitis was suspected in 2, and no etiology was found in 5. The predominant organism causing an acute conjunctivitis was identified as Hemophilus influenza, isolated in 43 of the patients. Streptococcus pneumoniae and Moraxella catarrhalis were also frequent causes of acute conjunctivitis. The predominant organisms found to cause an acute blepheritis were Staphylococci, corynebacteria, and alpha-hemolytic streptococci. The Gram staining proved to be a valuable diagnostic tool and correlated well with the culture results. The majority of the control group had normal conjunctival cytologic findings. Clinically, it is difficult to distinguish viral from bacterial conjunctivitis. Of the clinical findings observed, a purulent discharge was seen in 80% of the confirmed bacterial infections, but was also seen in 25% of the culture negative (suspected viral) infections. The results of this study confirm that the early use of antibiotic therapy for acute conjunctivitis is war[Susan Taylor, MD] ranted.
0 MIDAZOLAM ENHANCES ANTEROGRADE BUT NOT RETROGRADE AMNESIA IN PEDIATRIC PATIENTS. Twersky R, Hartung J, Berger B, McClain J, Beaton C. Anesthesiology. 1993;78:51-55. This article investigates the effect of aerosolized intranasal midazolam on both anterograde and retrograde memory in children. Forty children, aged 4-10 years, were randomized to receive either midazolam (0.2 mg/kg) or placebo intranasally via an atomizer. They were then given general anesthesia with nitrous oxide and halothane as well as a muscle relaxant. Memory testing was performed prior to any treatments, 10 minutes after receiving midazolam or placebo, and again postoperatively using picture cards.
Six patients were excluded from the study due to low baseline memory scores, clerical errors, or complicated operation. Results showed that there was a significant difference between the midazolam group versus placebo group in both recall and recognition when assessing postoperative memory occurring subsequent to the administration of treatment with midazolam or placebo (anterograde effect). There was no significant difference between the groups in memory prior to treatment (retrograde effect). The authors conclude that midazolam significantly reduces a child’s postoperative ability to recall and recognize cards shown subsequent to its administration without affecting pretreatment memory. Therefore midazolam is an excellent choice for premeditation in children. [Kenneth Ahonen, MD]
0 ACUTE APPENDICITIS IN CHILDREN: VALUE OF SONOGRAPHY IN DETECTING PERFORATION. Quillin SP, Siegel MJ, Coffin CM. Am J Roentgenol. 1992; 159:1265-1268. The use of sonography as a sensitive modality in the diagnosis of acute appendicitis is well established. However, there is some controversy over its usefulness in differentiating perforating from nonperforating appendicitis. This study reports sonographic signs identified retrospectively in children with appendicitis and correlates these with surgical and pathologic findings. Statistical analysis was performed using a Fisher exact two-tailed test. Sonograms of 79 children with surgically-proved appendicitis were reviewed. The sonographic signs evaluated included the presence or absence of an appendix, an echogenic submucosal layer, increased periappendiceal echogenicity, free or loculated periappendiceal or pelvic fluid collections, and appendicoliths. Abnormal signs were identified in 71 of the 79 patients; surgery was performed within 36 hours of sonographic evaluation in all but two patients. Appendiceal perforations were found in 26 of these patients. A visible appendix with a diameter greater than 6 mm was seen in all 45 patients with non-complicated appendicitis but only 38% of patients with perforation. An echogenic submucosa was present sonographically in 60% with nonperforated appendicitis and 33% with perforation and a recognizable appendix @ < 0.05). Loculated periappendiceal or pelvic fluid collections were visualized in 73% of patients with perforated appendix but in none of the patients with nonperforating appendicitis (p < 0.05). No statistically significant association was found between presence or absence of perforation and free pelvic fluid, prominent periappendiceal fat, or an appendicolith. These results support the value of sonography in distinguishing perforating versus nonperforating appendicitis and suggest that the presence of loculated fluid collection and absence of echogenic submucosal layer are the most sensitive sonographic findings. [Gordon Hardenbergh, MD]