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Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations
viewed. Eligibility criteria were set in an effort to consider only occult bacteremia. Children who had received sponge baths, who had serious acute or chronic illnesses, or who were currently on antibiotic or steroid therapy were excluded. Only 1,028 (26%) of the patient charts had both blood cultures done and met eligibility requirements. Children were given acetaminophen at a dose of 10 mg/kg. Temperature was rechecked within two hours. Nonresponse was defined as decrease in temperature of 0.8 C or less. Thirty-five patients with positive blood cultures were identified and paired to a control group of patients with negative blood cultures. The two groups were found to be similar in age, gender, ethnieity, month of presentation, initial temperature, and dose of acetaminophen. The temperature decrease of the group with positive blood cultures averaged 1.0 +_ 0.6 C versus 1.5 +- 0.5 C in the control subjects. The temperature difference was significant (P = .0005). A univariable risk estimate showed a 9.2-fold increased risk of occult bacteremia in nonresponders. A m u l t i v a r i a b l e risk e s t i m a t e w i t h a d j u s t m e n t for a c e t a m i n o p h e n dose and time to repeat t e m p e r a t u r e showed a 9.4-fold increase in risk of occult bacteremia. The authors conclude that children who do not respond to acetaminophen by at least a 0.8-C decrease in temperature have an increased risk of occult bacteremia. They warn, however, that a response to acetaminophen does not eliminate the possibility of occult bacteremia.
Jeff Bernstein, MD
A p r o s p e c t i v e , r a n d o m i z e d , double-blind study to e v a l u a t e the e f f e c t of d e x a m e t h a s o n e in a c u t e l a r y n g o t r a c h e i t i s Super DM, Cartelli NA, Brooks LJ, et al Ped Pharm & Therap 115:323-328 Aug 1989
Viral infection, especially parainfluenza, is a major cause of laryngotracheitis (croup) and can result in airway compromise. To assess the benefit of a single-dose dexamethasone injection in the treatment of croup, the authors undertook a prospective, double-blind, placebo-controlled, randomized clinical trial. Using strict study inclusion criteria, 29 patients admitted to a metropolitan hospital with acute laryngotracheitis were studied. Severity of illness was determined by a croup score that involved rating inspiratory stridor, retractions, air entry, cyanosis, and level of consciousness. Clinical assessments were made using the croup score, respiratory rate, pulse rate, and ear oximetry. Evaluations were performed on admission, followed by 12-hour serial observations following injection of dexamethasone versus placebo until the patient was discharged from the hospital. All patients were cultured for respiratory viruses. Supplemental treatments were administered concomitantly in a standardized fashion and consisted of mist for a croup score above 2, racemic epinephrine aerosols for a croup score above 4, and supplemental oxygen for oxygen saturation of less than 19:6 June 1990
88%. Twelve and 24 hours after injection, the dexamethasone group had marked diminution in retractions and stridor, resulting in a clinically significant improvement of the total croup score of more than 2 in 81% of the dexamethasone group versus 33% in the placebo group. The dexamethasone group also required fewer eointerventions. No statistically significant difference in duration of hospital stay or respiratory rate and oxygen saturation at 12 and 24 hours was found. Nine percent of patients developed pneumonia. The authors concluded that a single injection of dexamethasone as an adjunctive therapy, but not in the place of standard treatment in acute laryngotracheitis, does reduce severity of illness during the first 24 hours of patients hospitalized with moderate to severe disease. Fifty percent of children with croup develop increased airway hyperactivity and abnormal pulmonary function tests. The authors recommend that further studies be performed assessing the role of dexarnethasone in blunting the acute processes in croup and in ameliorating the longterm sequelae.
Riemke M Brakema, MD
lacerations, pediatric, topical anesthetics
I n f l u e n c e of t o p i c a l a n e s t h e s i a on the sedation of p e d i a t r i c e m e r g e n c y department patients with lacerations Pierluisi GJ, Terndrup TE Pediatric Emergency Care 5:211-215 Dec 1989
Laceration repair is a frequent surgical procedure performed on pediatric patients. Infiltration of local anesthetic is painful, often causing greater anxiety and combativeness requiring restraint and/or sedation. The use of a nonpainful topical anesthetic containing 0.5% tetracaine, 1:2,000 epinephrine, and 11.8% cocaine (TAC) was studied to determine if this alternative would redude the need for sedation. A retrospective chart review was performed, comparing patients who presented during the first eight months of the use of TAC with those presenting during a preTAC period. Indications for the use of the intramuscular sedative combination Demerol ®, Phenergan ®, and Thorazine ® (DPT) were identified. These included lacerations, fractures, abscesses, burns, foreign bodies, and head injuries. In these subgroups, only those presenting with lacerations had a significant decrease in the use of DPT during the TAC period, 12% to 7.6%. There were no differences between laceration frequency, length, location, or complexity between the two groups. The authors note that the use of TAC is contraindicated in burns, on mucous membranes including the lips, infected wounds, and in end arteriole areas. They conclude that the appropriate use of TAC may reduce the need for sedation, thereby avoiding the complications of these medications, reducing emergency department times and improving patient ac-
Annals of EmergencyMedicine
728/179
ABSTRACTS
ceptance of procedures. [Editor's note: The use of TAC remains controversial due to a potential delay of healing, an increase in bacterial count to the wounds, and systemic cocaine concentrations that may occur.]
Lynn Keating, MD
thrombolytic therapy, prehospital
E a r l y t h r o m b o l y t i c t h e r a p y in a c u t e m y o c a r d i a l i n f a r c t i o n a n d t h e role of prehospital management Gotsman MS, Weiss AT, Mosseri M, et al JEUR 2:170-183 1989
Ron Genova, MD aortic dissection, angiography; aortic dissection, computed tomography
The authors attempt to show that early thrombolytic therapy in acute myocardial infarction, less than two hours, enhances increased myocardial salvage and reduction in infarction size, and that "home" therapy reduces the amount of time to initiation of therapy. Comparisons were made in therapy administered by a physician-monitored mobile coronary care unit versus that initiated in an emergency department or hospital. Rapid IV streptokinase (1.5 mu) or APSAC (30 rag) was given to 300 patients within four hours of the onset of chest pain. Sixtytwo of 300 patients received treatment at home. Mean time to streptokinase administration was 1.2 + 0.6 hours in patients treated at home versus 2.1 + 1.0 hours in patients treated in a hospital or ED. Myocardial salvage and infarct size were measured by QRS score, cumulative CPK curves, and LV dysfunction index (LV ejection fraction/index). Results suggested that anterior infarct size was reduced by 25% in patients receiving home versus hospital thrombolytic therapy, as well as that a linear increase in infarct size occurs with increased time elapsed from onset of chest pain. Dysfunction index (infarct size) studies suggest that all patients receiving streptokinase or APSAC after two hours' pain duration had significantly "larger" infarcts compared with the patient group treated within two hours. Patients with more than 75% residual stenosis after therapy always had large infarcts regardless of time onset of treatment (<75% residual stenosis had markedly improved outcome). Thrombolytic therapy started at more than two hours after onset of symptoms showed large infarcts regardless of less than 75% or more than 75% stenosis, suggesting a higher myocardial salvage rate in the
180/729
less than 75% residual stenosis group. Mortality and morbidity differences were not analyzed in this study, nor were statistical analyses performed to establish significance of findings. The authors conclude that mobile home thrombolytic therapy reduces time to initiation of treatment and that this may benefit patients experiencing an acute myocardial infarction. [Editor's note: This study of prehospital thrombolytic therapy shows a significant improvement of myocardial infarction when initiated early. The mobile coronary care unit was physician staffed. The European Journal of Emergencies (JEUR) is written in French and English and is recommended as a significant contribution to the emergency medicine literature.]
A c u t e a o r t i c d i s s e c t i o n of t h e a o r t a : W h i c h test? Waiters NA, Rhomson KR Aust NZ J Surg 59:617-620
The authors studied 42 patients suspected of having an acute aortic dissection by angiography, computed tomography (CT), or a combination of these in order to determine which test is optimal. The investigators used dynamic CT scanning, a technique using ten rapid scans at three aortic levels following IV contrast injection. Twelve p a t i e n t s u n d e r w e n t a n g i o g r a p h y alone; six s h o w e d changes of dissection. Thirteen underwent CT alone; two had changes compatible with dissection. Angiography and CT were used in 17 patients; 12 had changes compatible with dissection. The dissection was evident on both CT and angiography in all 12. In all cases in which both CT and angiography were used, the CT correctly classified the type (A or B). The authors conclude that dynamic CT scanning should be used first in suspected dissection because it is sensitive, noninvasive, and can allow classification. Angiography should follow in cases in which more information is required. [Editor's note: Studies to determine existence, size, and leakage of aneurysms of the thoracic aorta m u s t be done in concert with the operative technicians who will decide ff an operation is necessary and the optimal approach. Angiography in most centers is still the option of choice for suspected acute dissection.]
Annals of Emergency Medicine
Tim Hutchinson, MD
19:6 June 1990
Jeff Bernstein, MD
A p r o s p e c t i v e , r a n d o m i z e d , double-blind study to e v a l u a t e the e f f e c t of d e x a m e t h a s o n e in a c u t e l a r y n g o t r a c h e i t i s Super DM, Cartelli NA, Brooks LJ, et al Ped Pharm & Therap 115:323-328 Aug 1989
Viral infection, especially parainfluenza, is a major cause of laryngotracheitis (croup) and can result in airway compromise. To assess the benefit of a single-dose dexamethasone injection in the treatment of croup, the authors undertook a prospective, double-blind, placebo-controlled, randomized clinical trial. Using strict study inclusion criteria, 29 patients admitted to a metropolitan hospital with acute laryngotracheitis were studied. Severity of illness was determined by a croup score that involved rating inspiratory stridor, retractions, air entry, cyanosis, and level of consciousness. Clinical assessments were made using the croup score, respiratory rate, pulse rate, and ear oximetry. Evaluations were performed on admission, followed by 12-hour serial observations following injection of dexamethasone versus placebo until the patient was discharged from the hospital. All patients were cultured for respiratory viruses. Supplemental treatments were administered concomitantly in a standardized fashion and consisted of mist for a croup score above 2, racemic epinephrine aerosols for a croup score above 4, and supplemental oxygen for oxygen saturation of less than 19:6 June 1990
88%. Twelve and 24 hours after injection, the dexamethasone group had marked diminution in retractions and stridor, resulting in a clinically significant improvement of the total croup score of more than 2 in 81% of the dexamethasone group versus 33% in the placebo group. The dexamethasone group also required fewer eointerventions. No statistically significant difference in duration of hospital stay or respiratory rate and oxygen saturation at 12 and 24 hours was found. Nine percent of patients developed pneumonia. The authors concluded that a single injection of dexamethasone as an adjunctive therapy, but not in the place of standard treatment in acute laryngotracheitis, does reduce severity of illness during the first 24 hours of patients hospitalized with moderate to severe disease. Fifty percent of children with croup develop increased airway hyperactivity and abnormal pulmonary function tests. The authors recommend that further studies be performed assessing the role of dexarnethasone in blunting the acute processes in croup and in ameliorating the longterm sequelae.
Riemke M Brakema, MD
lacerations, pediatric, topical anesthetics
I n f l u e n c e of t o p i c a l a n e s t h e s i a on the sedation of p e d i a t r i c e m e r g e n c y department patients with lacerations Pierluisi GJ, Terndrup TE Pediatric Emergency Care 5:211-215 Dec 1989
Laceration repair is a frequent surgical procedure performed on pediatric patients. Infiltration of local anesthetic is painful, often causing greater anxiety and combativeness requiring restraint and/or sedation. The use of a nonpainful topical anesthetic containing 0.5% tetracaine, 1:2,000 epinephrine, and 11.8% cocaine (TAC) was studied to determine if this alternative would redude the need for sedation. A retrospective chart review was performed, comparing patients who presented during the first eight months of the use of TAC with those presenting during a preTAC period. Indications for the use of the intramuscular sedative combination Demerol ®, Phenergan ®, and Thorazine ® (DPT) were identified. These included lacerations, fractures, abscesses, burns, foreign bodies, and head injuries. In these subgroups, only those presenting with lacerations had a significant decrease in the use of DPT during the TAC period, 12% to 7.6%. There were no differences between laceration frequency, length, location, or complexity between the two groups. The authors note that the use of TAC is contraindicated in burns, on mucous membranes including the lips, infected wounds, and in end arteriole areas. They conclude that the appropriate use of TAC may reduce the need for sedation, thereby avoiding the complications of these medications, reducing emergency department times and improving patient ac-
Annals of EmergencyMedicine
728/179
ABSTRACTS
ceptance of procedures. [Editor's note: The use of TAC remains controversial due to a potential delay of healing, an increase in bacterial count to the wounds, and systemic cocaine concentrations that may occur.]
Lynn Keating, MD
thrombolytic therapy, prehospital
E a r l y t h r o m b o l y t i c t h e r a p y in a c u t e m y o c a r d i a l i n f a r c t i o n a n d t h e role of prehospital management Gotsman MS, Weiss AT, Mosseri M, et al JEUR 2:170-183 1989
Ron Genova, MD aortic dissection, angiography; aortic dissection, computed tomography
The authors attempt to show that early thrombolytic therapy in acute myocardial infarction, less than two hours, enhances increased myocardial salvage and reduction in infarction size, and that "home" therapy reduces the amount of time to initiation of therapy. Comparisons were made in therapy administered by a physician-monitored mobile coronary care unit versus that initiated in an emergency department or hospital. Rapid IV streptokinase (1.5 mu) or APSAC (30 rag) was given to 300 patients within four hours of the onset of chest pain. Sixtytwo of 300 patients received treatment at home. Mean time to streptokinase administration was 1.2 + 0.6 hours in patients treated at home versus 2.1 + 1.0 hours in patients treated in a hospital or ED. Myocardial salvage and infarct size were measured by QRS score, cumulative CPK curves, and LV dysfunction index (LV ejection fraction/index). Results suggested that anterior infarct size was reduced by 25% in patients receiving home versus hospital thrombolytic therapy, as well as that a linear increase in infarct size occurs with increased time elapsed from onset of chest pain. Dysfunction index (infarct size) studies suggest that all patients receiving streptokinase or APSAC after two hours' pain duration had significantly "larger" infarcts compared with the patient group treated within two hours. Patients with more than 75% residual stenosis after therapy always had large infarcts regardless of time onset of treatment (<75% residual stenosis had markedly improved outcome). Thrombolytic therapy started at more than two hours after onset of symptoms showed large infarcts regardless of less than 75% or more than 75% stenosis, suggesting a higher myocardial salvage rate in the
180/729
less than 75% residual stenosis group. Mortality and morbidity differences were not analyzed in this study, nor were statistical analyses performed to establish significance of findings. The authors conclude that mobile home thrombolytic therapy reduces time to initiation of treatment and that this may benefit patients experiencing an acute myocardial infarction. [Editor's note: This study of prehospital thrombolytic therapy shows a significant improvement of myocardial infarction when initiated early. The mobile coronary care unit was physician staffed. The European Journal of Emergencies (JEUR) is written in French and English and is recommended as a significant contribution to the emergency medicine literature.]
A c u t e a o r t i c d i s s e c t i o n of t h e a o r t a : W h i c h test? Waiters NA, Rhomson KR Aust NZ J Surg 59:617-620
The authors studied 42 patients suspected of having an acute aortic dissection by angiography, computed tomography (CT), or a combination of these in order to determine which test is optimal. The investigators used dynamic CT scanning, a technique using ten rapid scans at three aortic levels following IV contrast injection. Twelve p a t i e n t s u n d e r w e n t a n g i o g r a p h y alone; six s h o w e d changes of dissection. Thirteen underwent CT alone; two had changes compatible with dissection. Angiography and CT were used in 17 patients; 12 had changes compatible with dissection. The dissection was evident on both CT and angiography in all 12. In all cases in which both CT and angiography were used, the CT correctly classified the type (A or B). The authors conclude that dynamic CT scanning should be used first in suspected dissection because it is sensitive, noninvasive, and can allow classification. Angiography should follow in cases in which more information is required. [Editor's note: Studies to determine existence, size, and leakage of aneurysms of the thoracic aorta m u s t be done in concert with the operative technicians who will decide ff an operation is necessary and the optimal approach. Angiography in most centers is still the option of choice for suspected acute dissection.]
Annals of Emergency Medicine
Tim Hutchinson, MD
19:6 June 1990