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Management of ventriculoperitoneal shunt complications in children
RESEARCH FORUM ABSTRACTS
Interventions: Clinical and autopsy records were reviewed for patient demographics, mechanism of injury, clinical diagnosis, and postmortem findings. Discrepancies between clinical diagnoses and autopsy reports were categorized as class 1 through ~r findings. Results: There were 76 deaths due to sudden infant death syndrome (SIDS; 41%), 67 due to accidental injury (36%), 23 due to natural causes (13%), and 18 related to suspected child abuse or neglect (10%). Major discrepancies between clinical and autopsy diagnoses (classes 1 and 2) were found m 19 patients (10%); the most common missed diagnoses were child abuse (seven) and pneumonia (four). Child abuse cases were more often mistaken for medical illness (ie, SIDS) than for accidental injury, indicating that autopsy is warranted whenever a child dies unexpectedly. Minor discrepancies (classes 3 and 4) were found during postmortem examination in 33 patients (18%). Conclusion: Routine autopsies in the pediatric population yield climcally relevant findings and are vital to ensure the quality of emergency medical care.
8 Procedure Skills Used to Stabilize and Transport Pediatric Patients PJansen, D van Stralen, R Perkin, R Vannix/Loma Linda University School of Medicine, California Study objective: Transporting critically ill pediatric patients to tertiary care centers may be complicated by deterioration of the patient's condition during transport. We studied what procedures were required in the resuscitation and stabilization of pediatric patients m the referral facility and during transport. Design: A one-year prospective study (December 1, 1990, to November 30, 1991) was done to evaluate all pediatric transports referred to our pediatric ICU. Information was gathered by members of the transport team that included a physician, nurse, and respiratory therapist. Setting: A 584-bed university hospital with a 25-bed pediatric ICU and an eight-bed stepdown pediatric ICU. Results: We transported 650 pediatric patients, of which 537 (83%) were less than 5 years of age, with a mean Pediamc Risk of Mortality score of 7.7 (0 to 44) and a mean Glasgow Coma Scale score of 11.6 (3 to 15). Referrals came from emergency departments (472), hospital wards (138), and ICUs (40). Seventy-eight (12%) of transports were from rural areas. Transports involved the use of fixed-wing or helicopter aircraft in 174 (26.8%) transports and covered distances of 0.7 to 300 miles (average 34 miles) No patients died during transport or during the first hour in the pediatric ICU. The type and frequency of mterventions are provided below. We defined transport as the time period of both ambulance transport and the first hour of pediatric ICU admission.
Interventions
Referri.gSite
Transport
Intubation 202 (17) 14* CPR 36 (1) 2 Intraosseous 41 (7) 2 Central line 11 (1) 31 Chesttube 9 (0) 3 Defibrillation/ cardioversTgn 4 (0) 2 Nasogastrictube 189 (54) 14 Foleycatheter 99 {12) 35 Numbersin parenthesesperformedbytransportteammembers. * All but oeeintubatJonwas electiveor nonemergent
TransportComplications Respiratory Accidental extubation Malpositioned ETI Cardiac Hypotension IV infiltrate Death Total complications
No. 8 3 2 5 4 2 O 15
Conclusion: Our study confirms that safe transports can be provided; however, transport personnel must be trained m pediatric advanced life support skills, the most important being intubation, CPR, and emergency vascular access. Other skills, such as chest tube placement and defibrillation, are rarely used, and therefore less emphasis should be placed on those training skills. Proper stabilization before transfer is important to prevent transport morbidity and mortality. ED personnel and transport team members should
MARCH 1@94
23:3
ANNALs OF EMERGENCY MEDICINE
complete a pediatric emergency skills training course. With adequate ED stabilization of the critically ill child by ED and transport personnel, only a small number of patients require emergency treatment during transport.
([]i Management of Ventricu]operitoneal Shunt Complications in 9D Scheifelbein, Children
JS Jones, LV White, JM Dougherty/Departments of Emergency Medicine; Akron General Medical Center and Butterworth Hospital, Grand Rapids, Michigan Study objective: Increasing numbers of hydrocephafic patients with a variety of shunt-related problems come to the attention of emergency physicians. This study was initiated to describe the major complicauons associated with ventriculopedtoneal (VP) cerebrospinal fluid shunts. Design: Retrospective analysis of medical records. Setting: Emergency departments of two university-affiliated teaching hospitals with a combined pediatric ED census of 89,000. Participants: One hundred ten consecutive ED patients less than 17 years old presenting with VP shunt complications (ICD codes 996.2,996.23, and 996.75). Interventions: Medical records were rewewed for patient demographics, specific descriptions of the shunt problem, chnical features, ED diagnosis and management, and final disposition. Results: Dunng the study period, 110 children made 162 visits to the ED for Vs shunt complications. Mean patient age was 3.5 + 4.4- years. TweIve major types of shunt devices were commonly seen. Major complications included VP shunt obstl~ction (38%), migration (15%), disconnection (14%), shunt infection (13%), and other complications (21%). The manifestations of shunt complications frequently were subtle and nonspecific. Nausea, vomiting, headache, lethargy, and feeding problems were commonly documented; however, the ED diagnosis was accurate m 92% of patients (149 of 162). Common misdiagnoses included gastroenteritis and meningitis. Ninety-three percent (150 of 162) of patient visits resulted in hospitalization, and 83% underwent surgery (shunt revision or replacement). Overall mortality was 2% (three of 162). Conclusion: Emergency physicians must be familiar with VP shunts to recognize critical complications associated with these devices.
1 N f ~ Tympanic Thermometry as an Aid in the Detection of Acute 11,1111JOtitis Media in Children DFBrennan,JL Falk, SG Rothrock, RB Kerr/Emergency Medicine Residency Program, Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida; Division of Emergency Medicine, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida Study objective: The reliabihty of infrared tympanic thennometry (ITT) in children and the effect of acute otius media (AOM) on ITT are unsettled. Accordingly, this study was undertaken to further explore the effect of AOM on ITT and the usefulness of ITT in the diagnosis of AOM. Design: Prospective, single-blind, observational study. Setting: Emergency department of an urban teaching hospital with annual census of 60,000. Participants: Five hundred fifteen consecutive children age 6 months to 6 years. Interventions: Nurses recorded oral or rectal reference (RetT) temperatures (IVAC TM)and bilateral ITT (First Temp TM)temperatures at admission and discharge. Emergency physicians were blinded to the ITT. AOM was diagnosed according to published clinical criteria. Results: Data are presented as mean _+SD and compared using appropriate t-tests with significance set at P < .05. This study had a >99% power to detect a 0.5~ difference for all groups compared. Among 515 patients, 107 had unilateral AOM and 78 had bilateral AOM. In pauents with unilateral AOM no difference was demonstrated between ITT of the infected ear (I = 37.9 • 1. I~
635
Interventions: Clinical and autopsy records were reviewed for patient demographics, mechanism of injury, clinical diagnosis, and postmortem findings. Discrepancies between clinical diagnoses and autopsy reports were categorized as class 1 through ~r findings. Results: There were 76 deaths due to sudden infant death syndrome (SIDS; 41%), 67 due to accidental injury (36%), 23 due to natural causes (13%), and 18 related to suspected child abuse or neglect (10%). Major discrepancies between clinical and autopsy diagnoses (classes 1 and 2) were found m 19 patients (10%); the most common missed diagnoses were child abuse (seven) and pneumonia (four). Child abuse cases were more often mistaken for medical illness (ie, SIDS) than for accidental injury, indicating that autopsy is warranted whenever a child dies unexpectedly. Minor discrepancies (classes 3 and 4) were found during postmortem examination in 33 patients (18%). Conclusion: Routine autopsies in the pediatric population yield climcally relevant findings and are vital to ensure the quality of emergency medical care.
8 Procedure Skills Used to Stabilize and Transport Pediatric Patients PJansen, D van Stralen, R Perkin, R Vannix/Loma Linda University School of Medicine, California Study objective: Transporting critically ill pediatric patients to tertiary care centers may be complicated by deterioration of the patient's condition during transport. We studied what procedures were required in the resuscitation and stabilization of pediatric patients m the referral facility and during transport. Design: A one-year prospective study (December 1, 1990, to November 30, 1991) was done to evaluate all pediatric transports referred to our pediatric ICU. Information was gathered by members of the transport team that included a physician, nurse, and respiratory therapist. Setting: A 584-bed university hospital with a 25-bed pediatric ICU and an eight-bed stepdown pediatric ICU. Results: We transported 650 pediatric patients, of which 537 (83%) were less than 5 years of age, with a mean Pediamc Risk of Mortality score of 7.7 (0 to 44) and a mean Glasgow Coma Scale score of 11.6 (3 to 15). Referrals came from emergency departments (472), hospital wards (138), and ICUs (40). Seventy-eight (12%) of transports were from rural areas. Transports involved the use of fixed-wing or helicopter aircraft in 174 (26.8%) transports and covered distances of 0.7 to 300 miles (average 34 miles) No patients died during transport or during the first hour in the pediatric ICU. The type and frequency of mterventions are provided below. We defined transport as the time period of both ambulance transport and the first hour of pediatric ICU admission.
Interventions
Referri.gSite
Transport
Intubation 202 (17) 14* CPR 36 (1) 2 Intraosseous 41 (7) 2 Central line 11 (1) 31 Chesttube 9 (0) 3 Defibrillation/ cardioversTgn 4 (0) 2 Nasogastrictube 189 (54) 14 Foleycatheter 99 {12) 35 Numbersin parenthesesperformedbytransportteammembers. * All but oeeintubatJonwas electiveor nonemergent
TransportComplications Respiratory Accidental extubation Malpositioned ETI Cardiac Hypotension IV infiltrate Death Total complications
No. 8 3 2 5 4 2 O 15
Conclusion: Our study confirms that safe transports can be provided; however, transport personnel must be trained m pediatric advanced life support skills, the most important being intubation, CPR, and emergency vascular access. Other skills, such as chest tube placement and defibrillation, are rarely used, and therefore less emphasis should be placed on those training skills. Proper stabilization before transfer is important to prevent transport morbidity and mortality. ED personnel and transport team members should
MARCH 1@94
23:3
ANNALs OF EMERGENCY MEDICINE
complete a pediatric emergency skills training course. With adequate ED stabilization of the critically ill child by ED and transport personnel, only a small number of patients require emergency treatment during transport.
([]i Management of Ventricu]operitoneal Shunt Complications in 9D Scheifelbein, Children
JS Jones, LV White, JM Dougherty/Departments of Emergency Medicine; Akron General Medical Center and Butterworth Hospital, Grand Rapids, Michigan Study objective: Increasing numbers of hydrocephafic patients with a variety of shunt-related problems come to the attention of emergency physicians. This study was initiated to describe the major complicauons associated with ventriculopedtoneal (VP) cerebrospinal fluid shunts. Design: Retrospective analysis of medical records. Setting: Emergency departments of two university-affiliated teaching hospitals with a combined pediatric ED census of 89,000. Participants: One hundred ten consecutive ED patients less than 17 years old presenting with VP shunt complications (ICD codes 996.2,996.23, and 996.75). Interventions: Medical records were rewewed for patient demographics, specific descriptions of the shunt problem, chnical features, ED diagnosis and management, and final disposition. Results: Dunng the study period, 110 children made 162 visits to the ED for Vs shunt complications. Mean patient age was 3.5 + 4.4- years. TweIve major types of shunt devices were commonly seen. Major complications included VP shunt obstl~ction (38%), migration (15%), disconnection (14%), shunt infection (13%), and other complications (21%). The manifestations of shunt complications frequently were subtle and nonspecific. Nausea, vomiting, headache, lethargy, and feeding problems were commonly documented; however, the ED diagnosis was accurate m 92% of patients (149 of 162). Common misdiagnoses included gastroenteritis and meningitis. Ninety-three percent (150 of 162) of patient visits resulted in hospitalization, and 83% underwent surgery (shunt revision or replacement). Overall mortality was 2% (three of 162). Conclusion: Emergency physicians must be familiar with VP shunts to recognize critical complications associated with these devices.
1 N f ~ Tympanic Thermometry as an Aid in the Detection of Acute 11,1111JOtitis Media in Children DFBrennan,JL Falk, SG Rothrock, RB Kerr/Emergency Medicine Residency Program, Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida; Division of Emergency Medicine, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida Study objective: The reliabihty of infrared tympanic thennometry (ITT) in children and the effect of acute otius media (AOM) on ITT are unsettled. Accordingly, this study was undertaken to further explore the effect of AOM on ITT and the usefulness of ITT in the diagnosis of AOM. Design: Prospective, single-blind, observational study. Setting: Emergency department of an urban teaching hospital with annual census of 60,000. Participants: Five hundred fifteen consecutive children age 6 months to 6 years. Interventions: Nurses recorded oral or rectal reference (RetT) temperatures (IVAC TM)and bilateral ITT (First Temp TM)temperatures at admission and discharge. Emergency physicians were blinded to the ITT. AOM was diagnosed according to published clinical criteria. Results: Data are presented as mean _+SD and compared using appropriate t-tests with significance set at P < .05. This study had a >99% power to detect a 0.5~ difference for all groups compared. Among 515 patients, 107 had unilateral AOM and 78 had bilateral AOM. In pauents with unilateral AOM no difference was demonstrated between ITT of the infected ear (I = 37.9 • 1. I~
635