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Is the Combination of Ibuprofen and Acetaminophen a Better Pediatric Antipyretic Than Ibuprofen Alone?
Research Forum Abstracts
191
What a Bite: Review of Snakebites in Children
Feng S, Stephan M, UT Southwestern Medical Center/Children’s Medical Center of Dallas, Dallas, TX
Study Objectives: Approximately 2000 children less than 17 years of age are victims of crotalid envenomation each year. Multiple controversies exist in the management of these bites. We present the largest pediatric review of snakebite envenomations. Methods: This is a retrospective chart review of pediatric patients presenting with venomous snakebites. Data was abstracted for; demographics, the severity of the bite, circumstances of the snakebite, lab values, method and dose of antivenom administered, VS, length of hospital stay, adverse outcomes, cost and disposition. Results: 49 patients were identified. Ages ranged 22 mos -16.8 years, 67.3% male. The envenomations consisted of: 65% copperheads, 8% cottonmouth, 27% unknown. 47% were moderate level 2 envenomations, 36.7% were mild level 1. Systemic symptoms were found in 26.8% with predominance of vomiting. Initial coagulation evaluation revealed 26.5% abnormal CBCs: 7 pts had WBCO15K, 4 had thrombocytopenia. 30.6% had abnormal PT, 10.1% abnormal PTT. 1 patient had abnormal fibrinogen and d-dimer results (cottonmouth envenomation). 31.6% had other labs performed predominantly renal group(35%). Subsequent labs were significant for persistently abnormal percentage PTT and d-dimer (16.3%, 4.1%) Antivenin was used in 34.6%: 82.3% received CroFab (CF) with 1 adverse reaction described as facial flushing. Vital signs remained stable during all infusions. 18.4% received subsequent CF dosing. No reactions were noted on subsequent dosing. 22% had progression of symptoms described as edema during hospitalization. 49% had a tox consult. Antivenin use in all snakebites with tox consult (62.5%) is statistically significant (p\0.004) using Pearson Chi-Square. 50% of copperhead bites with tox consult received no antivenin. 43% had 2 day hospital stay. 59% received antibiotics. 2 patients were readmitted for surgical debridement of hemorrhagic blisters on digits. Conclusion: Copperhead envenomations are prevalent in Northeast Texas as reflected in our data. The use of Wyeth Polyvalent Antivenin and CF appear to be safe and effective. Antivenom use still remains controversial in copperhead envenomations. We present the largest descriptive analysis of snakebite envenomations in the pediatric population.
192
Is the Combination of Ibuprofen and Acetaminophen a Better Pediatric Antipyretic Than Ibuprofen Alone?
Tenison M, Eberhardt M, Pellett N, Heller M, St Lukes Hospital, Bethlehem, PA
Study Objectives: Acetaminophen and ibuprofen are often combined for the treatment of pediatric fever despite the lack of data to support or refute this practice. The purpose of this prospective, controlled, randomized, double-blind clinical investigation is to determine whether the use of these two agents in combination is a more effective antipyretic than ibuprofen alone. Methods: Febrile (O101 C) children age 3 to 10 were enrolled during a visit to a community hospital ED or its affiliated pediatric clinic. Subjects were randomized to treatment with one of two regimens: a combination of oral ibuprofen (10mg/kg) and acetaminophen (15mg/kg) (study) or ibuprofen (10mg/kg) and identically-appearing placebo (control). Initial oral temperatures were recorded during the visit; 2, 4 and 6-hour oral temperatures were later reported via phone or mail-in form by the patient’s caregiver. Results: In this predefined interim analysis 28 febrile children were enrolled with at least 2 and 4-hour temperatures available for 20 subjects. Initial temperatures ranged from 101.2 to 104.2 (mean 102.5) and were similar between groups (p=0.42). Mean temperature change between 0 and 2 hours was also similar (-3.1 degC for the both groups; p=0.66). Mean temperature decrease between 0 and 4 hours however, was significantly greater in the study group (-4.4 deg C for the study group and -3.7 deg C for controls; p=0.05). At 6 hours this difference was even more pronounced (-4.8 deg C for the study group versus -1.3 deg C for controls; p=0.02). Conclusion: Although the combination of ibuprofen and acetaminophen was no more effective than ibuprofen alone at 2 hours, it may offer a more prolonged antipyretic effect.
S54 Annals of Emergency Medicine
193
Attitudes and Practices of Emergency Medicine Residents Regarding Family Presence During Pediatric Procedural and Resuscitation Scenarios
Barata IA, LaMantia J, Riccardi D, Mayerhoff RM, Litroff A, D’Abbracci P, Livote E, Ward MF, Sama A, North Shore University Hospital, Manhasset, NY
Objective: Determine attitudes and practices of emergency medicine (EM) residents regarding family presence (FP) during hypothetical pediatric procedural and resuscitation scenarios. Methods: This was a prospective, anonymous survey of residents in ACGME accredited residency programs. Surveys were mailed in September 2004 for completion by residents. Descriptive statistics were employed. Results: Responses were received from 61 programs with the following geographic distribution: 38% Northeast, 37% Midwest, 18% South and 5% West Coast. A total of 521 surveys were completed by EM residents: 193 EM-1, 170 EM2, 133 EM-3, 16 EM-4, 8 other or missing; 129 residents completed an internship year other than EM: 52 IM, 18 General Surgery, 13 Family Practice, 5 Pediatrics, 41 other; 169 (32%) residents see pediatric patients primarily at a children’s hospital. EM residents reported that FP during selected procedures would interfere with their ability to perform the interventions: 25% conscious sedation, 45% spinal tap, 48% intubation, 50% resuscitation. In addition, only a small percentage of residents would always allow FP during certain procedures: 31% conscious sedation, 19% spinal tap, 11% resuscitation, 10% intubation. EM-1 residents that have completed a prior internship year or residency were as likely as EM-1 residents without prior experience to report that FP would interfere with their performance, especially in the case scenarios of intubation (59% vs.49%; p value 0.2505) and resuscitation (51% vs. 40%; p value 0.1827). When comparing the practices of emergency medicine residents regarding FP during pediatric resuscitation at children’s hospitals ED vs. a general ED it seems that a greater number of families would be allowed to be present during resuscitation at children’s hospitals: 17% vs. 9% (p value 0.0108) (7 yr old major resuscitation), 23% vs.15% (p value 0.0375) (2 month old major resuscitation with death); however, overall it is still a small percentage. Many residents felt that FP benefits parents. Conclusions: A high percentage of EM residents report FP as an interfering factor with performance of certain procedures especially intubation and resuscitation. Residents with prior internship or residency were as likely to report FP as an interfering factor in those situations. It seems that a greater number of families would be allowed to be present during resuscitation at children’s hospital ED vs. a general ED. However, overall it is still a small percentage. Complexity of the procedures performed appears to be a significant factor in decreasing residents’ acceptance of FP. However, EM residents expressed that FP benefits parents.
194
Potential Adverse Events in Children Treated in the Emergency Department
Vega RM, Mayerhoff RM, Livote E, Argota E, Ward MF, Sama A, North Shore University Hospital, Manhasset, NY; Institute for Medical Research at North Shore-Long Island Jewish, Manhasset, NY
Objective: To determine the rate of PAEs in pediatric emergency department patients over the course of a six-week period. Methods: A retrospective review of medical records of all pediatric patients admitted through the emergency department (ED) during an approximately six-week period in June and July of 2003. Variables to be studied included documentation of patient’s weight, use of milligram per kilogram (mg/kg) dosing, type of medication ordered including intravenous fluids. Study setting was a suburban Level I Trauma Center with an annual census of approximately 60,000 total and 15,000 pediatric patients. Inclusion criteria: All patients \18 years old seen in the ED and for whom at least one weight-based medication was ordered. Exclusion criteria: Patients greater than or equal to 18 years old or patients for whom no weight-based medications were ordered. Statistical analysis: A power analysis determined that the sample size needed to show a difference of 0.1 (0.23 to 0.33) was 1973. A total of 1132 medical records were reviewed with a total of 809 medications or fluids orders prescribed. Medications were categorized as to whether they required weight based dosing or not, and classified into the following categories: antibiotics, narcotics, none-narcotic analgesics, sedatives, steroids and other. Patients ages were divided into the following groups: infants, pre-school, school age, and teenage. Results: The total number of patients for whom weight-based medications were ordered was 440. The rate of PAEs within this group were as follows: overall 36.4%; by age group: infants 12.2%, pre-school 21.2%, school age 33.8%, teenage 80%. The potential adverse event rate by drug category were as follows: antibiotics 31.3%, narcotics 38.5%, non-narcotic analgesics 32.5%, sedatives 10%, and steroids 21.3%.
Volume 46, no. 3 : September 2005
191
What a Bite: Review of Snakebites in Children
Feng S, Stephan M, UT Southwestern Medical Center/Children’s Medical Center of Dallas, Dallas, TX
Study Objectives: Approximately 2000 children less than 17 years of age are victims of crotalid envenomation each year. Multiple controversies exist in the management of these bites. We present the largest pediatric review of snakebite envenomations. Methods: This is a retrospective chart review of pediatric patients presenting with venomous snakebites. Data was abstracted for; demographics, the severity of the bite, circumstances of the snakebite, lab values, method and dose of antivenom administered, VS, length of hospital stay, adverse outcomes, cost and disposition. Results: 49 patients were identified. Ages ranged 22 mos -16.8 years, 67.3% male. The envenomations consisted of: 65% copperheads, 8% cottonmouth, 27% unknown. 47% were moderate level 2 envenomations, 36.7% were mild level 1. Systemic symptoms were found in 26.8% with predominance of vomiting. Initial coagulation evaluation revealed 26.5% abnormal CBCs: 7 pts had WBCO15K, 4 had thrombocytopenia. 30.6% had abnormal PT, 10.1% abnormal PTT. 1 patient had abnormal fibrinogen and d-dimer results (cottonmouth envenomation). 31.6% had other labs performed predominantly renal group(35%). Subsequent labs were significant for persistently abnormal percentage PTT and d-dimer (16.3%, 4.1%) Antivenin was used in 34.6%: 82.3% received CroFab (CF) with 1 adverse reaction described as facial flushing. Vital signs remained stable during all infusions. 18.4% received subsequent CF dosing. No reactions were noted on subsequent dosing. 22% had progression of symptoms described as edema during hospitalization. 49% had a tox consult. Antivenin use in all snakebites with tox consult (62.5%) is statistically significant (p\0.004) using Pearson Chi-Square. 50% of copperhead bites with tox consult received no antivenin. 43% had 2 day hospital stay. 59% received antibiotics. 2 patients were readmitted for surgical debridement of hemorrhagic blisters on digits. Conclusion: Copperhead envenomations are prevalent in Northeast Texas as reflected in our data. The use of Wyeth Polyvalent Antivenin and CF appear to be safe and effective. Antivenom use still remains controversial in copperhead envenomations. We present the largest descriptive analysis of snakebite envenomations in the pediatric population.
192
Is the Combination of Ibuprofen and Acetaminophen a Better Pediatric Antipyretic Than Ibuprofen Alone?
Tenison M, Eberhardt M, Pellett N, Heller M, St Lukes Hospital, Bethlehem, PA
Study Objectives: Acetaminophen and ibuprofen are often combined for the treatment of pediatric fever despite the lack of data to support or refute this practice. The purpose of this prospective, controlled, randomized, double-blind clinical investigation is to determine whether the use of these two agents in combination is a more effective antipyretic than ibuprofen alone. Methods: Febrile (O101 C) children age 3 to 10 were enrolled during a visit to a community hospital ED or its affiliated pediatric clinic. Subjects were randomized to treatment with one of two regimens: a combination of oral ibuprofen (10mg/kg) and acetaminophen (15mg/kg) (study) or ibuprofen (10mg/kg) and identically-appearing placebo (control). Initial oral temperatures were recorded during the visit; 2, 4 and 6-hour oral temperatures were later reported via phone or mail-in form by the patient’s caregiver. Results: In this predefined interim analysis 28 febrile children were enrolled with at least 2 and 4-hour temperatures available for 20 subjects. Initial temperatures ranged from 101.2 to 104.2 (mean 102.5) and were similar between groups (p=0.42). Mean temperature change between 0 and 2 hours was also similar (-3.1 degC for the both groups; p=0.66). Mean temperature decrease between 0 and 4 hours however, was significantly greater in the study group (-4.4 deg C for the study group and -3.7 deg C for controls; p=0.05). At 6 hours this difference was even more pronounced (-4.8 deg C for the study group versus -1.3 deg C for controls; p=0.02). Conclusion: Although the combination of ibuprofen and acetaminophen was no more effective than ibuprofen alone at 2 hours, it may offer a more prolonged antipyretic effect.
S54 Annals of Emergency Medicine
193
Attitudes and Practices of Emergency Medicine Residents Regarding Family Presence During Pediatric Procedural and Resuscitation Scenarios
Barata IA, LaMantia J, Riccardi D, Mayerhoff RM, Litroff A, D’Abbracci P, Livote E, Ward MF, Sama A, North Shore University Hospital, Manhasset, NY
Objective: Determine attitudes and practices of emergency medicine (EM) residents regarding family presence (FP) during hypothetical pediatric procedural and resuscitation scenarios. Methods: This was a prospective, anonymous survey of residents in ACGME accredited residency programs. Surveys were mailed in September 2004 for completion by residents. Descriptive statistics were employed. Results: Responses were received from 61 programs with the following geographic distribution: 38% Northeast, 37% Midwest, 18% South and 5% West Coast. A total of 521 surveys were completed by EM residents: 193 EM-1, 170 EM2, 133 EM-3, 16 EM-4, 8 other or missing; 129 residents completed an internship year other than EM: 52 IM, 18 General Surgery, 13 Family Practice, 5 Pediatrics, 41 other; 169 (32%) residents see pediatric patients primarily at a children’s hospital. EM residents reported that FP during selected procedures would interfere with their ability to perform the interventions: 25% conscious sedation, 45% spinal tap, 48% intubation, 50% resuscitation. In addition, only a small percentage of residents would always allow FP during certain procedures: 31% conscious sedation, 19% spinal tap, 11% resuscitation, 10% intubation. EM-1 residents that have completed a prior internship year or residency were as likely as EM-1 residents without prior experience to report that FP would interfere with their performance, especially in the case scenarios of intubation (59% vs.49%; p value 0.2505) and resuscitation (51% vs. 40%; p value 0.1827). When comparing the practices of emergency medicine residents regarding FP during pediatric resuscitation at children’s hospitals ED vs. a general ED it seems that a greater number of families would be allowed to be present during resuscitation at children’s hospitals: 17% vs. 9% (p value 0.0108) (7 yr old major resuscitation), 23% vs.15% (p value 0.0375) (2 month old major resuscitation with death); however, overall it is still a small percentage. Many residents felt that FP benefits parents. Conclusions: A high percentage of EM residents report FP as an interfering factor with performance of certain procedures especially intubation and resuscitation. Residents with prior internship or residency were as likely to report FP as an interfering factor in those situations. It seems that a greater number of families would be allowed to be present during resuscitation at children’s hospital ED vs. a general ED. However, overall it is still a small percentage. Complexity of the procedures performed appears to be a significant factor in decreasing residents’ acceptance of FP. However, EM residents expressed that FP benefits parents.
194
Potential Adverse Events in Children Treated in the Emergency Department
Vega RM, Mayerhoff RM, Livote E, Argota E, Ward MF, Sama A, North Shore University Hospital, Manhasset, NY; Institute for Medical Research at North Shore-Long Island Jewish, Manhasset, NY
Objective: To determine the rate of PAEs in pediatric emergency department patients over the course of a six-week period. Methods: A retrospective review of medical records of all pediatric patients admitted through the emergency department (ED) during an approximately six-week period in June and July of 2003. Variables to be studied included documentation of patient’s weight, use of milligram per kilogram (mg/kg) dosing, type of medication ordered including intravenous fluids. Study setting was a suburban Level I Trauma Center with an annual census of approximately 60,000 total and 15,000 pediatric patients. Inclusion criteria: All patients \18 years old seen in the ED and for whom at least one weight-based medication was ordered. Exclusion criteria: Patients greater than or equal to 18 years old or patients for whom no weight-based medications were ordered. Statistical analysis: A power analysis determined that the sample size needed to show a difference of 0.1 (0.23 to 0.33) was 1973. A total of 1132 medical records were reviewed with a total of 809 medications or fluids orders prescribed. Medications were categorized as to whether they required weight based dosing or not, and classified into the following categories: antibiotics, narcotics, none-narcotic analgesics, sedatives, steroids and other. Patients ages were divided into the following groups: infants, pre-school, school age, and teenage. Results: The total number of patients for whom weight-based medications were ordered was 440. The rate of PAEs within this group were as follows: overall 36.4%; by age group: infants 12.2%, pre-school 21.2%, school age 33.8%, teenage 80%. The potential adverse event rate by drug category were as follows: antibiotics 31.3%, narcotics 38.5%, non-narcotic analgesics 32.5%, sedatives 10%, and steroids 21.3%.
Volume 46, no. 3 : September 2005