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Pediatric emergency care: An annotated bibliography of the recent literature
The Literature
of Emergency
Medicine
Pediatric Emergency Care: An Annotated Bibliography of the Recent Literature J.S. SURPURE,
MD, STEVEN M. BARRETT,
FRACTURES Efficacy of TAC topical anesthetic for repair of pediatric lacerations. Bonadio WA, Wagner V. Am J Dis Child 1988;142:203-205. Bonadio and Wagner prospectively evaluated 103 pediatric patients with minor skin lacerations who received TAC anesthesia for their wound repairs. The TAC solution was prepared by mixing 28 g of cocaine with 120 mL of 1:lOOOepinephrine and 60 mL of 2% tetracaine and then adding normal saline to bring the total solution volume to 240 mL. This solution contained 0.5% tetracaine, I:2000 epinephrine, and 11.8% cocaine. The authors correlated anesthetic efficacy with wound location and size. Furthermore, they assessed the elicited pain response on a suture-by-suture basis, that allowed finer discrimination of anesthetic efficacy. The authors documented TAC as an excellent anesthetic agent overall; approximately 95% of all sutures were placed without eliciting pain. Etiology and clinical course of missed spine fractures. Reid DC, Henderson R, Saboe L, et al. J Trauma 1987;27:980-986. What are the incidence and consequences of missed cervical spine fractures? Reid et al performed a prospective study of 253 patients with 274 spinal injuries to assess the incidence of delayed diagnosis and document the outcome of the identified cases. With the exception of high cervical injuries, the incidence of associated neurological injury was similar in the delayed and the nondelayed groups. In many circumstances, the neurological injury itself was overlooked, particularly if it was not severe. The associated factors leading to a missed diagnosis were intoxication, 2-level fractures, multiple injuries, and head injury or loss of consciousness. Most missed fractures occurred in the cervical spine and frequently at either Cl-3 or C6-7. The authors recommend that 1) if a spine fracture is identified, a second fracture must be sought, 2) routine cervical spine films should be obtained for all multitrauma patients, 3) routine roentgenograms are not complete unless the odontoid and C-7 can be identified and cleared of injury, 4) routine roentgenograms should be considered for all intoxicated patients with a history of a fall, and 5) no patient should have a manipulation of the cervical spine without prior radiography of the area. Selective management of pediatric pelvic fractures: A conservative approach. Musemeche CA, Fischer RP, Cotler HB, et al. J Pediatr Surg 1987;22:538-540. Most pelvic fractures in children (PFC) result from autopedestrian accidents and are commonly accompanied by injury to other organ systems and additional skeletal disruption. Musmeche From the University of Oklahoma Health Sciences Center, Oklahoma City. Address reprint requests to Dr Surpure: EMTC, Oklahoma Medical Center, PO Box 26307, Oklahoma City, OK 73126. 0 1990 by W.B. Saunders Company. 0735-6757/90/0602-0017$5.00 166
MD et al reviewed the records of 57 children (ages 2 to 14 years) with pelvic fractures. The types of PFC were similar to those in adults. The distribution of other major fractures were also similar and frequently involved the femur, tibia-fibula, clavicle, fibs, and skull. However, children suffered a higher incidence of head injury with pelvic fractures. Intra-abdominal and genitourinary injuries were less frequent in children with PFC than in adults. The type of pelvis fracture did not influence mortality. No cases of respiratory distress syndrome occurred in this series. Pelvic fracture hemorrhage is less common and children have a favorable result with a minimum of treatment. The mortality among children is entirely related to the severity of closed head injury. Blunt Cardiac Injury in Children. Tellez DW, Hardin WD, Takahashi M, et al. J Pediatr Surg 1987;22:1123-1128 Tellez et al prospectively evaluated 39 children with blunt trauma for the incidence and clinical significance of blunt cardiac injury (BCI). The authors used multiple diagnostic modalities (cardiac monitor, cardiac enzymes, creatinine kinase isoenzymes, serial 12lead electrocardiograms, two-dimensional M-mode echocardiograms and radionuclide angiography) to improve accuracy and permit a comparative evaluation of these modalities. The patients ranged in age from 2 to 16 years. Motor vehicle accidents were responsible for most admissions. Blunt trauma is capable of producing a broad spectrum of injuries in the heart. Cardiac contusions produce focal myocardial injury that is identifiable histopathologitally. Sequelae from contusions include ventricular aneurysms or rupture. and cardiac tamponade. Cardiac concussions are blunt injuries without histopathologic evidence of injury that may induce lethal dysrrhythmias. Electrocardiogram irregularities are the most sensitive indicators of BCI, but lack specificity. Based on this study, the authors cannot recommend a comprehensive diagnostic evaluation of the heart in all children sustaining multiple injuries from blunt trauma. Continuous cardiac monitoring should be initiated in the emergency department and maintained throughout the intensive care unit stay. In patients with significant dysrrhythmias and in those with obvious thoracic injuries, serial ECC and cardiac isoenzyme assays should be performed. Clearing the cervical spine: Initial radiologic evaluation. Ross SE, Schwab CW, David ET, et al. J Trauma 1987;27:1055-1060 Ross et al prospectively studied 214 patients over 13 years of age sustaining blunt high-energy transfer injuries. The initial radiographic neck examination included portable cross-table lateral cervical spine (LCV) with bilateral caudad arm traction or the threeview cervical spine series (LCV, open-mouth odontoid, and anterioposterior, supine films). The authors conclude that LCV alone cannot be safely used as a screening study for unstable cervical spine injury. The absence of unstable injury can be accurately predicted from a negative, technically adequate three-view cervical spine series. If these studies are inadequate, the addition of a limited
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computed tomography scan directed at the area in question can be used to “clear” the spine.
Air reduction of intussusception In infants and children. Tamanaha K, Wimbish K, Talwalkar YB, et al. Clin Lab Obs 1987;111:733-736.
The impact of computed tomography scanning on the child with renal trauma. Karp MP, Jewett TC, Kuhn JP, et al. J Pediatr Surg 1986;21:617-623.
How about a reduction of intussusception (ISN) by air ins&lation? Tamanaha et al from Japan discuss their experience with this technique in 207 patients. If air reduction was unsuccessful after two attempts, barium reduction was tried or surgery performed. Of 207 episodes of ISN, most 81%) were successfully treated with air reduction alone. No complications were noted and the procedure was well tolerated. Eighteen recurrences were also successfully reduced with air insufflation. Of the 40 children in whom the air reduction was unsuccessful, five could be reduced by barium immediately, and the other 35 underwent operations. The air insufflation reduction technique is raid, simple, safe, easily performed, and easily learned. The authors emphasize that the air technique is often successful even in the severely ill child and with obstruction by air fluid levels.
In the child with blunt abdominal trauma, selected renal injuries can be treated nonoperatively. Karp et al reviewed the records of 176 pediatric trauma patients with suspected renal injury to assess the impact of computed tomography (CT) on patient treatment. Of all patients admitted with hematuria, 66% had associated major injuries but no radiological evidence of renal trauma. No correlation existed between the severity of injury and amount of blood in the urine. All patients with renal injury had both hematuria and positive findings on abdominal examination. Cerebral injury was the most common associated lesion in the child with renal trauma. The authors conclude that patients with stable vital signs who present with hematuria, abdominal pain, and tenderness should be screened by CT scans.
GASTROINTESTINAL Appendicitis in children: Accuracy of the barium enema. Garcia C, Rosenfield NS, Markowitz RI, et al. Am J Dis Child 1987;141: 1309-1312. The use of barium enema (BE) to help make the preoperative diagnosis, especially in infants and young children, has been discussed previously. What is the accuracy of individual BE signs in the diagnosis of appendicitis? Are there any pitfalls? Dr Garcia analyzed a series of patients. The medical records of 563 children (8 months to 15 years) with a clinical suspicion of appendicitis were reviewed. In 19 of these children, because of the uncertainty of the diagnosis, a BE was requested before surgery. In 18 children, with surgically documented appendicitis, roentgenograms were reevaluated applying the preselected criteria. Fourteen of the 18 children studied had proven appendicitis supported at surgery, and 8 of the 14 children had a perforated appendix. There was one false positive. Positive BE findings may be rarely mimicked by other conditions. The authors conclude that BE is usually helpful in clinically equivocal cases of appendicitis. Surgical management of pancreatitis in childhood. Synn AY, Mulvihill SJ, Fonkalsrud EW. J Pediatr Surg 1987;22:628-632. Pancreatitis is an uncommon cause of abdominal pain in children; however, the frequency of complications and the mortality rate exceed those of adults. Synn et al discuss their experience with diagnosis and treatment. The medical records of 48 children with pancreatitis were reviewed. Most children (90%) had a typical presentation with epigastric pain, nausea and vomiting. Hyperamylasemia (serum amylase 150) occurred in the majority (34) of children. Radiological studies demonstrating a sentinel loop, colon cutoff sign and/or compression of the duodenal sweep were present in a few cases (19%). Etiology of the pancreatitis was idiopathic in 16 (33%) drug (steroids) induced in 12 (25%). Nine children developed pancreatitis after blunt trauma, seven had obstruction of the pancreaticobiliary drainage system. Two children developed pancreatitis in association with sepsis and two had recurrent hereditary pancreatitis. Thirty (majority) were managed with medical therapy alone, whereas operations were required for 18. The authors conclude that pancreatitis must be considered in the child with acute abdominal pain and a serum amylase level should be routinely obtained (amylase greater than three times normal is always significant). The amylase/creatinine clearance ratio (values of 5%) can be used as an additional diagnostic tool. Radiological signs of acute pancreatitis are inconsistent.
Comparison of preoperative sonography with intraoperative fmdings in congenital hyperetrophic pyloric stenosis. Keller H, Waldmann D, Greiner P. J Pediatr Surg 1987;22:950-952 How does sonography compare with actual intraoperative pyloric measurements? Keller et al from West Germany report an interesting study. A diagnosis of congenital hypertrophic pyloric stenosis (CHPS) was confirmed by ultrasound in 17 infants. The pyloric diameter was measured sonographically in an oblique section of upper abdomen. In every case the diagnosis of CHPS was confirmed intraoperatively. The authors reemphasize the diagnostic value of sonography in CHPS.
INFECTIOUS DISEASE Roentgenographic features of common pediatric viral respiratory tract infections. Wildin SR, Chonmaitree T, Swischuk LE. Am J Dis Child 1988;142:43-46. How reliable are chest radiograph (CXR) findings in differentiating the types of causal viral agents? Is there any correlation of specific CXR appearance with specific virus type? Wildin et al studied the CXR findings from 128 infants and children who were infected with respiratory syncytial virus (RSV), paraintluenza virus, influenza virus, and adenovirus. Based on presenting symptoms and signs recorded, a syndrome was assigned to each patient. Clinical and radiological data were examined for significant patterns. Chest radiographs were interpreted as abnormal in most (72%) patients. The common abnormality was parahilar peribronchial infiltrates (seen in 93% of abnormal CXRs), followed by hyperexpansion (79%). Respiratory synctial virus was more likely than influenza virus or adenovirus to cause hyperexpansion. Diffuse interstitial infiltrates and significant pleural fluid accumulations rarely occurred. Respiratory synctial virus infection was associated with more abnormal CXRs than any of the other viruses regardless of the clinical syndrome. The authors conclude that, in infants and children with viral infection of the lower respiratory tract, roentgenographic information can be a useful adjunct to a clinical viral diagnosis. Cerebrospinal fluid shunt infections in children. Meirovitch J, KitaiCohen Y, Keren G, et al. Pediatr Infect Dis J 1987;6:921-924. Shunt infection (SI) is one of the most common and serious complications of cerebrospinal fluid (CSF) shunt procedures. Is a medical approach superior to surgical? Meirovitch et al discuss their experiences with SI in children. Medical records of 95 children (age range 2 weeks to 17 years) with 214 shunt procedures were reviewed. About one third (37%) of the procedures were primary and the majority (63%) were performed because of SI. The mortality rate of the SI group was 9% (3 of 32). The most common shunting procedure was ventriculoperitoneal. The overall infection rate per shunt procedure was 21% and per patient was 33%. Children under
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three years of age had three times higher infection rate than older children. The authors conclude that the therapy for infected shunts with antibiotics alone or with antibiotics plus an operative shunt revision resulted in similar success rates. Short-course antibiotic therapy for urinary tract infections in children. Moffatt M, Embree J, Grimm P, et al. Am J Dis Child 1988;142:5761. Moffatt et al of Canada performed a methodological review of 14 published clinical trials of short course (less than 4 days) versus conventional (7 to 10 days) antibiotic therapy. Four reviewers independently assessed each study according to 35 criteria, 14 of which were considered critical for this type of study. The ratings were summed so that any study could receive a potential score of 140 for all criteria and 56 for the critical criteria. Only one study met more than 75% of all the criteria. The authors conclude that there is still insufficient evidence to recommend short course (single dose or 3 day) therapy for urinary tract infection children. Know when to treat with what in upper respiratory infection. Ginsburg C. Pediatr Infect Dis J 1987;6:843. Although viruses account for the majority of upper respiratory infections (URI), aerobic microorganisms are important etiologic agents in some infections. Their epidemiology and antimicrobial susceptibility patterns constantly change. These changes have implications for the clinician who must select antimicrobial agents for therapy. Dr Ginsburg discusses current trends of patients with acute otitis media, acute sinusitis, and cervical adenitis. Human bites in children. Baker MD, Moore SE. Am J Dis Child 1987;141:1285-1290. Baker et al report and discuss their experience with 322 children with human bites. The majority of patients (58%) were over 10 years of age and half of all bites occurred during the warm weather months. The upper extremities (42%), face and neck (32%) and trunk (22%) were most commonly bitten. The majority of wounds (75%) were superficial abrasions, 13% were punctures, and 11% were lacerations. None of the abrasions became infected unlike punctures and lacerations. Prophylactic use of penicillin was not effective in reducing infection rates in these children. Most patients (98%) were cared for on an outpatient basis and all admissions were for treatment of established infections. The authors conclude that prospective studies are needed to properly assess the effectiveness of prophylactic antibiotic use in the treatment of human bites. Antiviral agents for respiratory infections. Steele RW. Pediatr Infect Dis J 1988;7:457-460. Steele reviewed the spectrum of antiviral agents for respiratory infections. Amantadine is licensed for prophylaxis and treatment of influenza A. One hundred milligrams twice daily in adults reduced influenza attack rates by 78% to 98%. Equally effective was a dosage of 100 mg once daily in teenagers. The dosage in children is 5 to 8 mgikg/day divided every 12 hours maximum 200 mg/day). Rimantadine is an analogue of amantadine and will probably soon be licensed for general clinical use. Ribavirin is a broad spectrum virustatic agent with activity against RSV, influenza A and B, parainfluenza, and adenovirus. It is presently approved by the Food and Drug Administration in its aerosolized form for the therapy of RSV infections in hospitalized children who do not require assisted ventilation. Steele concludes that vitamin C (ascorbic acid) does not seem to be effective for prevention and treatment of the common cold. Fever response to acetaminophen in viral vs. bacterial infections. Weisse ME, Miller G, Brien JH. Pediatr Infect Dis J 1987;6: 10911694 Weisse et al studied the effect of acetaminophen
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terial versus viral infections in 100 children (ages 9 days to 17 years) with rectal or oral temperature of 102°F (389°C) or greater. Study patients were given 15 mg/kg (maximum 650 mg) acetaminophen, and their temperatures were rechecked 1 hour later. The authors found that the fever response to acetaminophen was a poor discriminator between bacterial and viral infections. Cost effectiveness in the choice of antibiotics for the initial treatment of otitis media in children: A decision analysis approach. Weiss JC, Melman ST. Pediatr Infect Dis J 1988;7:23-26. Weiss and Melman describe a decision analysis method that uses antibiotic cost, resistance rates, parental salaries, and physician charges in an attempt to help the practitioner decide if amoxicillin should or should not be used as the first choice antibiotic for otitis media. This analysis is designed for data relevant to one practice and may not be applicable in all settings. Simple clinical score and laboratory-based method to predict bacterial etiology of acute diarrhea in childhood. Fontana M, Zuin G, Paccagnini S, et al. Pediatr Infect Dis J 1987;6:1088-1091. Fontana et al discuss a two step predictive method to assess the probability of bacterial etiology in cases of diarrhea. A scoring system was developed by studying a series of 157 consecutive outpatients with acute diarrhea; the reproducibility of the method was tested in a second series of 180 cases. In every child a stool culture was performed for Salmonella, Shigeila, Campylobacter and Yersinia. For the development of the scoring system, four items were used: fever greater than 38.5”C; vomiting (at least three episodes); fecal mucus; and fecal blood. For each sign or symptom (considered either its presence or absence) the positive predictive value with regard to a bacterial etiology was determined. The authors recommend use of their two step predictive method to identify children with the highest probability of bacterial diarrhea and to reserve stool culture to a few selected cases. Bacterial meningitis presenting with normal cerebrospinal fluid. Polk DB, Steele RW. Pediatr Infect Dis J 1987;6:1040-1042. Polk and Steele discuss their experiences of children with bacterial meningitis and normal initial CSF determinations (other than culture and/or antigen detection assays). Patients were identified as having normal CSF if there were no more than 10 white blood cell&L with three or fewer polymorphonuclear leukocytes, glucose greater than 50% of serum concentration, and protein less than 45 mg/dL and a negative gram stain. Only 7 (2.7%) of 261 meningitis patients fulfilled these criteria. The physical examination also failed to show uniquely different findings from those for other patients with meningitis. Additional careful review of these cases did not show other indicators that might have distinguished bacterial meningitis. The authors conclude that the presence of meningeal signs of systemic toxicity were the only features that strongly suggested bacterial meningitis in patients with apparently normal CSF, therefore physicians must rely on clinical judgement for beginning antimicrobial therapy.
MISCELLANEOUS Fighting the fever phobia. McCarthy et al. J Pediatr 1987;110:26-30. Is there a correlation between a “toxic” appearing child with high fever and the serious illness? Does observational assessment done in a systematic manner add to the efficiency of the traditional history and physical examination in detecting serious illness in febrile children? McCarthy et al report and discuss their clinical experience. A physician performed the observation using the acute illness observation scales (AIOS) that included the following six items: quality of cry, reaction of crying to parent stimulation (comforting or holding), alert state variation, color, hydration, and response to social overtures. Subsequently, the history and physical examination were
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done by the physician and findings were scored as to whether they suggested the presence of a serious illness. The combined AIOS history and physical examination had a higher sensitivity and correlation for serious illness than did the traditional history and physical examination. The authors conclude that assessment of appearance in a febrile child, when performed in a careful, integrated fashion, improves the sensitivity of the history and physical examination in detecting serious illnesses.
before venipuncture. The degree of difficulty in cannulation was assessed on a scale of 1 (very easy) to 5 (failure). The mean scale for group 1 (NT0 application) was significantly lower than that for group II or group III. The amount of NT0 applied was estimated to be 0.4 or 0.8 mg nytroglycerine and no significant hemodynamic status change was noted. The authors conclude that local application of NT0 technique is simple and innocuous, and it is an efficient way of reducing failure in venous cannulation in infants.
Headache and acute illness In children. Kandt RS, Levine RM. J Child Neurol 1987;2:22-27.
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What is the relationship between headache (HA) and acute illness in children? Is fever a common cause of headache? What are the characteristics of these headaches? Doctors Kandt and Levine discuss their experience. Thirty-seven children (3 to 15 years) with HAS who were seen in the walk-in clinic were matched to 37 HA free controls. Pharyngitis was the most common diagnosis in both the groups. Neither meningeal signs nor alteration of consciousness suggestive of encephalitis was recorded for any patient. Headache location and intensity were not related to body temperature. A family history of migraine was most common in the HA group. The authors support the symptomatic use of an analgesic/antipyretic agent when HA is part of a child’s illness. They conclude that worsening HA may signal a worsening primary illness and HAS associated with acute illness may indicate migraines later.
Osteomyelitis secondary to trauma or infected contiguous soft tissue. Dubey L, Krasinski K, Hemanz-Schulman M. Pediatr Infect Dis J 1988;7:26-34.
Albeit not new-The intraosseous infusion. Spivey, WH, Pediatrics 1988;111:639-643 Intraosseous infusion (OSI) uses the rich vascular network of long bones to transport fluids and drugs from the medullary cavity to circulation. The distribution of fluid and drugs via OS1 appears similar to that of intravenous (IV) injection. Intraosseous infusion is also very similar to that of IV injection. Intraosseous infusion is also effective with closed chest cardiac massage. Insertion of a needle into the medullary cavity of a long bone is both rapid and simple. There are several commercially prepared intraosseous needles that have a shaft and provide a protective sheath. Several sites are available. Today the most commonly used sites are the distal femur, proximal and distal tibia. When using the proximal tibia, the halfway point between tibial tuberosity and medial aspect of the tibia is marked and 1 to 2 cm distal to this halfway point is the optimal site for needle insertion. After skin preparation, the needle is inserted perpendicular to the bone with the bevel pointing away from the joint space. A rotary motion is applied until there is a slight decrease in resistance, indicating that the center of the bone has been penetrated. Once needle placement has been confirmed, gravity may be used to infuse fluid. Although not optimal, OS1 may be used for volume resuscitation; however, it often requires a pressure infusion. Initially used for saline, glucose, and blood, OS1 has become useful for emergency administration of sodium bicarbonate, atropine, dopamine, epinephrine, diazepam, antibiotics, phenytoin, and succinylcholine. Cardiac arrest is the most common indication; others include shock, extensive bums and major trauma. The success rate of OS1 is about 88%. Complications do occur. Serious potential complications include osteomyelitis and damage to the epiphyseal plate. The author concludes that OS1 is a safe and rapid alternative for fluid and drug administration in infants and children. It is intended only for emergency resuscitation and stabilization in situations such as cardiac arrest, shock, and trauma. Nitroglycerine ointment as aid to venous cannulation in children. Vaksmann G, Rey C, Breviere GM, et al. J Pediatr 1987;111:89-91 Authors studied the effects of nitroglycerine ointment (NTO) on veins and ease of venous cannulation in children. One hundred ftity children were divided into 3 groups of 50. In group 1, NT0 was applied to the skin of the wrist or forearm; in group 2, a bland ointment was applied; in group 3, NT0 was applied elsewhere on the body. Ointments were applied in all groups 10 to 15 minutes
Dubey et al present their experience with nonhematogenous osteomyelitis (NHO) in 24 patients aged 8 months to 18 years. This retrospective review revealed that there are differences in the clinical presentation, infecting organisms and outcome in patients with NH0 as compared to patients with acute hematogenous osteomyelitis (AHO). Predisposing factors to NH0 include open fracture, deep decubiti, and foot puncture. Nonhematogenous osteomyelitis involved the tibia, foot bones, proximal femur, and ulna in this series of patients. Nonhematogenous osteomyelitis patients presented with drainage (64%), pain or tenderness (44%), and fever (32%) lasting for 1 to 180 days (median 10 days). In 24% of the patients, both white cell count and erythrocyte sedimentation rate were normal. Initial roentgenograms were nondiagnostic in 42% of patients with open fractures. Bone cultures generally grew Sraphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, or other gram-negative organisms. The authors recommend prompt operative bone culture as the best confirmatory test for diagnosis and the most reliable guide to appropriate antibiotic therapy in patients suspected of having NHO. While the optimum duration of therapy has not been defined, the authors suggest a minimum of 4 weeks of inhospital antibiotics after thorough debridement of the infected area. Radial head and neck fractures in children. Steinberg EL, Golomb D, Salama R, et al. J Pediatr Orthopaed 1988;8:35-40. Steinberg et al discuss their experience of 42 consecutive fractures of the neck of the radius (FNRs) in children. The age at the time of injury ranged from 5 to 14 years. The follow up ranged from 7 to 15 years, and more than half the patients were observed for more than 4 years. The results were assessed clinically and radiologically at 6 months and at review. Twenty-seven children (64%) had a good result, 5 (18%) had a fair result, and 13 (31%) had a poor result. Primary angulation was the most important factor affecting the results. Fractures treated by open reduction definitely had better quality of reduction than did those tested by closed reduction, especially when the displacement was severe. The authors conclude that more acute reduction is mandatory to improve the final outcome. Sudden acute hip pain-An emergency. Birch. J Pediatr Orthop 1987;7:334. Dr. Birch reports two patients with acute progression of a slipped capital femoral epiphysis (SCE). Both patients had radiographic diagnoses of a chronic slipped epiphysis with acute progression. Both patients were treated with in situ pinning, and recovered well. These two cases remind us that patients presenting in early stages of chronic SCE have the potential to displace the femoral epiphysis acutely. Ambulation with crutches is inadequate interim treatment, as definite orthopaedic intervention is essential. Acute hematogenous osteomyelitis in children. Lamont RL, Anderson PA, Dajani AS, et al. J Pediatr Orthop 1987;7:529-583. The prognosis and treatment of hematogenous acute osteomyelitis (HAO) continue to change as better antibiotic therapy becomes
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available. However, the role of surgical management has become less well defined. What are the indications for surgical therapy? How does surgical therapy plus antibiotics compare with antibiotics alone? Larnont et al discuss their experience with HA0 in children and offer guidelines for therapy. Staphylococcus aureus was the most common organism and cases of Haemophilus influenzae were associated with adjacent joint infection. Femur and tibia represented 60% of the total sites. The authors conclude that a satisfactory outcome can be obtained through the use of a vigorous antibiotic regimen without operative intervention in most HA0 cases in children.
Ultrasonography of hip joint effusions. Zieger MM, Door U, Schulz RD. Skeletal Radio1 1987;16:607-610. Ziegler et al discuss their experience with ultrasonography (USY) in patients with suspected hip joint effusions. Twenty apparently healthy patients were investigated as a control group to depict the normal anatomy of the joint spaces as seen by USY. One hundred twenty-three consecutive patients were examined prospectively. Ultrasonography positively demonstrated intra-articular effusions in 63 cases. The subgroup was mainly composed of 31 patients with transient synovitis and 15 with septic arthritis. In 26 patients, the joint effusion proved to be echo-free. The results of USY were compared with radiography, close clinical follow-up and intraoperative findings. Ultrasonography prospectively delineated a fluid collection in every case. The authors conclude that USY is reliable (ie, both sensitive and specific) and clearly superior to roentgenograms in the diagnosis of hip joint effusions.
RESPIRATORY Comparison of two methods of rapid theophylhne testing in clinical practice. Shaw KN, Fleisher RG, Schwartz JS. Chn Lab Obs 1987;112:131-134. Rapid availability of serum theophylline (ST) levels in the emergency department (ED) may facilitate the management of acute asthmatic attacks in children. Shaw et al compared the clinical accuracy of these rapid assays in an ED setting. Theophylline blood levels were obtained from 81 acutely wheezing children. Three ST levels in each sample were determined by the hospital clinical laboratories, high pressure liquid chromatography (HPLC), the Seralyzer dry reagent-strip immunoassay (uses serum and spectrophotometer for reading), and AccuLevel strip test (uses capillary blood and no instruments required). The authors conclude that Seralyzer assay is more precise and acceptable for hospital laboratories; however, it has the disadvantage of requiring a spectrophotometer and a trained technician. The loss of precision with the AccuLevel assay is offset by the ease of use with minimal training, no additional equipment, and can be done directly from a finger-stick sample. Pitfalls in the use of clinical asthma scoring. Baker MD. Am J Dis Child 1988;142:183-185. A number of clinical scoring systems have been devised to help assess the severity of the asthma episode. One such scoring system is the clinical asthma score (CAS) developed by Wood et al in 1972. The use of CAS has not been validated by adequate clinical trials. Does the CAS have prognostic value? Baker studied 210 asthma patients to evaluate the usefulness of the CAS in determining outcome in childhood asthmatics. The CAS is the summation of values assigned to five different clinical characteristics, that include cyanosis, inspiratory breath sounds, accessory muscle use, expiratory wheezing, and cerebral function. The author finds that the pretreatment CAS was not useful for the early identification of children requiring prolonged inpatient asthma care. Intravenous methylprednisolone efficacy in status asthmaticus of childhood. Younger RE, Gerber PS, Herrod HG, et al. Pediatrics 1987;80:225-229.
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Younger et al performed an interesting study to evaluate the role of steroids for status asthamaticus (SAS) in children. Forty-five nonsteroid dependent children (6 to 16 years) hospitalized with SAS were randomized to receive intravenous (IV) placebo or methylprednisolone (MPR) (1 m&kg. every 6 hours). All patients were refractory to three bronchodilator treatments comprised of epinephtine injection and/or isoetharine inhalation. The MPR treated group experienced a more rapid recovery from peripheral airway obstruction as measured by pulmonary function tests: Placebo-treated patients had a higher incidence of asthma relapse within 4 weeks of discharge (8 vs 2 patients). The authors conclude that the use of IV MPR in the treatment of pediatric SAS provides significant therapeutic advantages and supports the current recommendation for prompt institution in children requiring hospitalization. Therefore, the use of short term steroid therapy in the treatment of severe childhood asthma is appropriate. An approach to stridor in infants and children. Friedberg J. J Otolaryngol 1987;16:203-206. Stridor in infants and children (SIC) indicates some degree of air flow restriction. It is a clinical sign which is common to many disease entities compromising the upper airway. Friedberg discusses the diagnosis and offers guidelines for SIC management. Supraglottic, laryngeal, and cervical tracheal narrowing generally result in an inspiratory stridor, and more distal lesions produce expiratory stridor. The infant or child whose stridor heralds a life-threatening airway obstruction should have airway control accomplished as soon as possible. Endotracheal intubation or tracheotomy may be necessary, or bronchoscopy may be indicated early on to rule out structural lesions.
TOXICOLOGY Hallucinogenic mushrooms. Schwartz RH, Smith DE. Clin Pediatr 1988;27:70-72. Schwartz and Smith recently surveyed mushroom abuse patterns among a group of 174 adolescents enrolled in a drug abuse program in Washington, DC. Psilocybin mushroom ingestion was reported by 45 (26%) of the respondents. After an acute intoxication, psilocybin mushroom abusers complain of extreme exhaustion and profound mental depression. Treatment of the acute adverse effects is supportive and involves talking down of panic reactions. Gastric lavage should be considered if there is any doubt as to the identity of the mushroom ingested. Mushrooms sold illicitly for their mind-altering actions may not actually be psilocybin mushrooms, but may be the common mushroom purchased in a store and laced with phencyclinidine (PCP) or lysergic acid diethylamide (LSD). Organophosphate and carbamate poisoning in infants and children. Zwiener RJ, Ginsburg CM. Pediatrics 1988;81:121-126. Zwiener and Ginsburg conducted a retrospective study of 37 infants and children with organophosphate and carbamate poisoning. The age range of the patients was 1 month to 11 years. All poisoning occurred in the home, except for one child who ingested insecticide granules while in a feed store. The most common abnormal physical findings included miosis (73%) excessive salivation (70%), muscle weakness (68%) respiratory distress (S%), lethargy (54%), and tachycardia (49%). Fourteen patients (38%) required endotracheal intubation and mechanical ventilation because of respiratory insufficiency. Most patients were treated with atropine and ptahdoxime. One patient received 86 doses and another received 61 doses of atropine during a 24-hour period. Ten patients had chest roentgenogram findings consistent with atelectasis or pneumonitis. The authors recommend the following for care of infants and children with moderate to severe oranonphosphate and carbamate poisoning: supportive care; cordirrnation of diagnosis with serum and/or RBC cholinesterase activities; atropine in adequate doses; praladoxime
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for all patients with moderate to severe toxicity, but it should not be given to patients with carbamate toxicity. The effect of fluid volume on syrup of ipecac emesis time. Grande A, Ling LJ. Clin Toxic01 1987;25:473-481. Syrup of ipecac is widely recognized as safe and effective for the home induction of emesis. Large volumes of fluid have been recommended to aid rapid ipecac-induced emesis. Grande and Ling performed a prospective study to determine if copious fluid intake was essential for rapid induction of emesis. One hundred twenty-one children (1 to 15 years) were included in the study. These children were treated in the usual manner, except that parents were asked to measure the volume of fluid given and record the time of first emesis. Average time to first emesis ranged from 6 to 58 minutes (mean 20.6 minutes), and the amount of fluid consumed ranged from 0 to 28 ounces (mean 6.7 ounces). The authors conclude that there is no significant relationship between the amount of fluid given and the time until emesis with children who respond to ipecac. Therefore, the traditional recommendation of forcing fluid with ipecac syrup does not hasten emesis. Underdosing of acetaminophen by parents. Gribetz B, Cronley SA. Pediatrics 1987;80:630-633. Gribetz and Cronley discuss their experience with young children seen in the emergency department for perceived or measured fever.
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The parents of 96 children were asked about their treatment of the symptom with acetaminophen. Based upon parental information, acetaminophen dose was calculated for each child. Doses less than 10 mg/kg were considered inappropriately low and those greater than 15 m&g were considered inappropriately high. With all forms of acetaminophen, the majority of the parents (68%) administered a dose less than the recommended 10 to 15 mg/kg per dose). The authors conclude that underdosing of acetaminophen is the rule rather than the exception. Button battery ingestion: A case report and review of the literature. Kost KM, Shapiro RS. J Otolaryngol 1987;16:252-257. Button (disc) batteries (BB) are being used with increasing frequency in a variety of devices including hearing aids, watches, and calculators. Most batteries contain a heavy metal (such as mercury) and an alkaline electrolyte. Recent reports have emphasized that potential for severe morbidity and morality from ingestion of button batteries. Kost and Shapiro report a case of an ll-month-old boy who had prolonged esophageal impaction of BB. The authors suggest that ah patients suspected of a BB ingestion should undergo full roentgenogram evaluation from nasopharynx to the anus. Esophageal impaction mandates immediate endoscopic removal. Batteries which have passed beyond the esophagus can be treated conservatively.
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FRACTURES Efficacy of TAC topical anesthetic for repair of pediatric lacerations. Bonadio WA, Wagner V. Am J Dis Child 1988;142:203-205. Bonadio and Wagner prospectively evaluated 103 pediatric patients with minor skin lacerations who received TAC anesthesia for their wound repairs. The TAC solution was prepared by mixing 28 g of cocaine with 120 mL of 1:lOOOepinephrine and 60 mL of 2% tetracaine and then adding normal saline to bring the total solution volume to 240 mL. This solution contained 0.5% tetracaine, I:2000 epinephrine, and 11.8% cocaine. The authors correlated anesthetic efficacy with wound location and size. Furthermore, they assessed the elicited pain response on a suture-by-suture basis, that allowed finer discrimination of anesthetic efficacy. The authors documented TAC as an excellent anesthetic agent overall; approximately 95% of all sutures were placed without eliciting pain. Etiology and clinical course of missed spine fractures. Reid DC, Henderson R, Saboe L, et al. J Trauma 1987;27:980-986. What are the incidence and consequences of missed cervical spine fractures? Reid et al performed a prospective study of 253 patients with 274 spinal injuries to assess the incidence of delayed diagnosis and document the outcome of the identified cases. With the exception of high cervical injuries, the incidence of associated neurological injury was similar in the delayed and the nondelayed groups. In many circumstances, the neurological injury itself was overlooked, particularly if it was not severe. The associated factors leading to a missed diagnosis were intoxication, 2-level fractures, multiple injuries, and head injury or loss of consciousness. Most missed fractures occurred in the cervical spine and frequently at either Cl-3 or C6-7. The authors recommend that 1) if a spine fracture is identified, a second fracture must be sought, 2) routine cervical spine films should be obtained for all multitrauma patients, 3) routine roentgenograms are not complete unless the odontoid and C-7 can be identified and cleared of injury, 4) routine roentgenograms should be considered for all intoxicated patients with a history of a fall, and 5) no patient should have a manipulation of the cervical spine without prior radiography of the area. Selective management of pediatric pelvic fractures: A conservative approach. Musemeche CA, Fischer RP, Cotler HB, et al. J Pediatr Surg 1987;22:538-540. Most pelvic fractures in children (PFC) result from autopedestrian accidents and are commonly accompanied by injury to other organ systems and additional skeletal disruption. Musmeche From the University of Oklahoma Health Sciences Center, Oklahoma City. Address reprint requests to Dr Surpure: EMTC, Oklahoma Medical Center, PO Box 26307, Oklahoma City, OK 73126. 0 1990 by W.B. Saunders Company. 0735-6757/90/0602-0017$5.00 166
MD et al reviewed the records of 57 children (ages 2 to 14 years) with pelvic fractures. The types of PFC were similar to those in adults. The distribution of other major fractures were also similar and frequently involved the femur, tibia-fibula, clavicle, fibs, and skull. However, children suffered a higher incidence of head injury with pelvic fractures. Intra-abdominal and genitourinary injuries were less frequent in children with PFC than in adults. The type of pelvis fracture did not influence mortality. No cases of respiratory distress syndrome occurred in this series. Pelvic fracture hemorrhage is less common and children have a favorable result with a minimum of treatment. The mortality among children is entirely related to the severity of closed head injury. Blunt Cardiac Injury in Children. Tellez DW, Hardin WD, Takahashi M, et al. J Pediatr Surg 1987;22:1123-1128 Tellez et al prospectively evaluated 39 children with blunt trauma for the incidence and clinical significance of blunt cardiac injury (BCI). The authors used multiple diagnostic modalities (cardiac monitor, cardiac enzymes, creatinine kinase isoenzymes, serial 12lead electrocardiograms, two-dimensional M-mode echocardiograms and radionuclide angiography) to improve accuracy and permit a comparative evaluation of these modalities. The patients ranged in age from 2 to 16 years. Motor vehicle accidents were responsible for most admissions. Blunt trauma is capable of producing a broad spectrum of injuries in the heart. Cardiac contusions produce focal myocardial injury that is identifiable histopathologitally. Sequelae from contusions include ventricular aneurysms or rupture. and cardiac tamponade. Cardiac concussions are blunt injuries without histopathologic evidence of injury that may induce lethal dysrrhythmias. Electrocardiogram irregularities are the most sensitive indicators of BCI, but lack specificity. Based on this study, the authors cannot recommend a comprehensive diagnostic evaluation of the heart in all children sustaining multiple injuries from blunt trauma. Continuous cardiac monitoring should be initiated in the emergency department and maintained throughout the intensive care unit stay. In patients with significant dysrrhythmias and in those with obvious thoracic injuries, serial ECC and cardiac isoenzyme assays should be performed. Clearing the cervical spine: Initial radiologic evaluation. Ross SE, Schwab CW, David ET, et al. J Trauma 1987;27:1055-1060 Ross et al prospectively studied 214 patients over 13 years of age sustaining blunt high-energy transfer injuries. The initial radiographic neck examination included portable cross-table lateral cervical spine (LCV) with bilateral caudad arm traction or the threeview cervical spine series (LCV, open-mouth odontoid, and anterioposterior, supine films). The authors conclude that LCV alone cannot be safely used as a screening study for unstable cervical spine injury. The absence of unstable injury can be accurately predicted from a negative, technically adequate three-view cervical spine series. If these studies are inadequate, the addition of a limited
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computed tomography scan directed at the area in question can be used to “clear” the spine.
Air reduction of intussusception In infants and children. Tamanaha K, Wimbish K, Talwalkar YB, et al. Clin Lab Obs 1987;111:733-736.
The impact of computed tomography scanning on the child with renal trauma. Karp MP, Jewett TC, Kuhn JP, et al. J Pediatr Surg 1986;21:617-623.
How about a reduction of intussusception (ISN) by air ins&lation? Tamanaha et al from Japan discuss their experience with this technique in 207 patients. If air reduction was unsuccessful after two attempts, barium reduction was tried or surgery performed. Of 207 episodes of ISN, most 81%) were successfully treated with air reduction alone. No complications were noted and the procedure was well tolerated. Eighteen recurrences were also successfully reduced with air insufflation. Of the 40 children in whom the air reduction was unsuccessful, five could be reduced by barium immediately, and the other 35 underwent operations. The air insufflation reduction technique is raid, simple, safe, easily performed, and easily learned. The authors emphasize that the air technique is often successful even in the severely ill child and with obstruction by air fluid levels.
In the child with blunt abdominal trauma, selected renal injuries can be treated nonoperatively. Karp et al reviewed the records of 176 pediatric trauma patients with suspected renal injury to assess the impact of computed tomography (CT) on patient treatment. Of all patients admitted with hematuria, 66% had associated major injuries but no radiological evidence of renal trauma. No correlation existed between the severity of injury and amount of blood in the urine. All patients with renal injury had both hematuria and positive findings on abdominal examination. Cerebral injury was the most common associated lesion in the child with renal trauma. The authors conclude that patients with stable vital signs who present with hematuria, abdominal pain, and tenderness should be screened by CT scans.
GASTROINTESTINAL Appendicitis in children: Accuracy of the barium enema. Garcia C, Rosenfield NS, Markowitz RI, et al. Am J Dis Child 1987;141: 1309-1312. The use of barium enema (BE) to help make the preoperative diagnosis, especially in infants and young children, has been discussed previously. What is the accuracy of individual BE signs in the diagnosis of appendicitis? Are there any pitfalls? Dr Garcia analyzed a series of patients. The medical records of 563 children (8 months to 15 years) with a clinical suspicion of appendicitis were reviewed. In 19 of these children, because of the uncertainty of the diagnosis, a BE was requested before surgery. In 18 children, with surgically documented appendicitis, roentgenograms were reevaluated applying the preselected criteria. Fourteen of the 18 children studied had proven appendicitis supported at surgery, and 8 of the 14 children had a perforated appendix. There was one false positive. Positive BE findings may be rarely mimicked by other conditions. The authors conclude that BE is usually helpful in clinically equivocal cases of appendicitis. Surgical management of pancreatitis in childhood. Synn AY, Mulvihill SJ, Fonkalsrud EW. J Pediatr Surg 1987;22:628-632. Pancreatitis is an uncommon cause of abdominal pain in children; however, the frequency of complications and the mortality rate exceed those of adults. Synn et al discuss their experience with diagnosis and treatment. The medical records of 48 children with pancreatitis were reviewed. Most children (90%) had a typical presentation with epigastric pain, nausea and vomiting. Hyperamylasemia (serum amylase 150) occurred in the majority (34) of children. Radiological studies demonstrating a sentinel loop, colon cutoff sign and/or compression of the duodenal sweep were present in a few cases (19%). Etiology of the pancreatitis was idiopathic in 16 (33%) drug (steroids) induced in 12 (25%). Nine children developed pancreatitis after blunt trauma, seven had obstruction of the pancreaticobiliary drainage system. Two children developed pancreatitis in association with sepsis and two had recurrent hereditary pancreatitis. Thirty (majority) were managed with medical therapy alone, whereas operations were required for 18. The authors conclude that pancreatitis must be considered in the child with acute abdominal pain and a serum amylase level should be routinely obtained (amylase greater than three times normal is always significant). The amylase/creatinine clearance ratio (values of 5%) can be used as an additional diagnostic tool. Radiological signs of acute pancreatitis are inconsistent.
Comparison of preoperative sonography with intraoperative fmdings in congenital hyperetrophic pyloric stenosis. Keller H, Waldmann D, Greiner P. J Pediatr Surg 1987;22:950-952 How does sonography compare with actual intraoperative pyloric measurements? Keller et al from West Germany report an interesting study. A diagnosis of congenital hypertrophic pyloric stenosis (CHPS) was confirmed by ultrasound in 17 infants. The pyloric diameter was measured sonographically in an oblique section of upper abdomen. In every case the diagnosis of CHPS was confirmed intraoperatively. The authors reemphasize the diagnostic value of sonography in CHPS.
INFECTIOUS DISEASE Roentgenographic features of common pediatric viral respiratory tract infections. Wildin SR, Chonmaitree T, Swischuk LE. Am J Dis Child 1988;142:43-46. How reliable are chest radiograph (CXR) findings in differentiating the types of causal viral agents? Is there any correlation of specific CXR appearance with specific virus type? Wildin et al studied the CXR findings from 128 infants and children who were infected with respiratory syncytial virus (RSV), paraintluenza virus, influenza virus, and adenovirus. Based on presenting symptoms and signs recorded, a syndrome was assigned to each patient. Clinical and radiological data were examined for significant patterns. Chest radiographs were interpreted as abnormal in most (72%) patients. The common abnormality was parahilar peribronchial infiltrates (seen in 93% of abnormal CXRs), followed by hyperexpansion (79%). Respiratory synctial virus was more likely than influenza virus or adenovirus to cause hyperexpansion. Diffuse interstitial infiltrates and significant pleural fluid accumulations rarely occurred. Respiratory synctial virus infection was associated with more abnormal CXRs than any of the other viruses regardless of the clinical syndrome. The authors conclude that, in infants and children with viral infection of the lower respiratory tract, roentgenographic information can be a useful adjunct to a clinical viral diagnosis. Cerebrospinal fluid shunt infections in children. Meirovitch J, KitaiCohen Y, Keren G, et al. Pediatr Infect Dis J 1987;6:921-924. Shunt infection (SI) is one of the most common and serious complications of cerebrospinal fluid (CSF) shunt procedures. Is a medical approach superior to surgical? Meirovitch et al discuss their experiences with SI in children. Medical records of 95 children (age range 2 weeks to 17 years) with 214 shunt procedures were reviewed. About one third (37%) of the procedures were primary and the majority (63%) were performed because of SI. The mortality rate of the SI group was 9% (3 of 32). The most common shunting procedure was ventriculoperitoneal. The overall infection rate per shunt procedure was 21% and per patient was 33%. Children under
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three years of age had three times higher infection rate than older children. The authors conclude that the therapy for infected shunts with antibiotics alone or with antibiotics plus an operative shunt revision resulted in similar success rates. Short-course antibiotic therapy for urinary tract infections in children. Moffatt M, Embree J, Grimm P, et al. Am J Dis Child 1988;142:5761. Moffatt et al of Canada performed a methodological review of 14 published clinical trials of short course (less than 4 days) versus conventional (7 to 10 days) antibiotic therapy. Four reviewers independently assessed each study according to 35 criteria, 14 of which were considered critical for this type of study. The ratings were summed so that any study could receive a potential score of 140 for all criteria and 56 for the critical criteria. Only one study met more than 75% of all the criteria. The authors conclude that there is still insufficient evidence to recommend short course (single dose or 3 day) therapy for urinary tract infection children. Know when to treat with what in upper respiratory infection. Ginsburg C. Pediatr Infect Dis J 1987;6:843. Although viruses account for the majority of upper respiratory infections (URI), aerobic microorganisms are important etiologic agents in some infections. Their epidemiology and antimicrobial susceptibility patterns constantly change. These changes have implications for the clinician who must select antimicrobial agents for therapy. Dr Ginsburg discusses current trends of patients with acute otitis media, acute sinusitis, and cervical adenitis. Human bites in children. Baker MD, Moore SE. Am J Dis Child 1987;141:1285-1290. Baker et al report and discuss their experience with 322 children with human bites. The majority of patients (58%) were over 10 years of age and half of all bites occurred during the warm weather months. The upper extremities (42%), face and neck (32%) and trunk (22%) were most commonly bitten. The majority of wounds (75%) were superficial abrasions, 13% were punctures, and 11% were lacerations. None of the abrasions became infected unlike punctures and lacerations. Prophylactic use of penicillin was not effective in reducing infection rates in these children. Most patients (98%) were cared for on an outpatient basis and all admissions were for treatment of established infections. The authors conclude that prospective studies are needed to properly assess the effectiveness of prophylactic antibiotic use in the treatment of human bites. Antiviral agents for respiratory infections. Steele RW. Pediatr Infect Dis J 1988;7:457-460. Steele reviewed the spectrum of antiviral agents for respiratory infections. Amantadine is licensed for prophylaxis and treatment of influenza A. One hundred milligrams twice daily in adults reduced influenza attack rates by 78% to 98%. Equally effective was a dosage of 100 mg once daily in teenagers. The dosage in children is 5 to 8 mgikg/day divided every 12 hours maximum 200 mg/day). Rimantadine is an analogue of amantadine and will probably soon be licensed for general clinical use. Ribavirin is a broad spectrum virustatic agent with activity against RSV, influenza A and B, parainfluenza, and adenovirus. It is presently approved by the Food and Drug Administration in its aerosolized form for the therapy of RSV infections in hospitalized children who do not require assisted ventilation. Steele concludes that vitamin C (ascorbic acid) does not seem to be effective for prevention and treatment of the common cold. Fever response to acetaminophen in viral vs. bacterial infections. Weisse ME, Miller G, Brien JH. Pediatr Infect Dis J 1987;6: 10911694 Weisse et al studied the effect of acetaminophen
on fever in bac-
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terial versus viral infections in 100 children (ages 9 days to 17 years) with rectal or oral temperature of 102°F (389°C) or greater. Study patients were given 15 mg/kg (maximum 650 mg) acetaminophen, and their temperatures were rechecked 1 hour later. The authors found that the fever response to acetaminophen was a poor discriminator between bacterial and viral infections. Cost effectiveness in the choice of antibiotics for the initial treatment of otitis media in children: A decision analysis approach. Weiss JC, Melman ST. Pediatr Infect Dis J 1988;7:23-26. Weiss and Melman describe a decision analysis method that uses antibiotic cost, resistance rates, parental salaries, and physician charges in an attempt to help the practitioner decide if amoxicillin should or should not be used as the first choice antibiotic for otitis media. This analysis is designed for data relevant to one practice and may not be applicable in all settings. Simple clinical score and laboratory-based method to predict bacterial etiology of acute diarrhea in childhood. Fontana M, Zuin G, Paccagnini S, et al. Pediatr Infect Dis J 1987;6:1088-1091. Fontana et al discuss a two step predictive method to assess the probability of bacterial etiology in cases of diarrhea. A scoring system was developed by studying a series of 157 consecutive outpatients with acute diarrhea; the reproducibility of the method was tested in a second series of 180 cases. In every child a stool culture was performed for Salmonella, Shigeila, Campylobacter and Yersinia. For the development of the scoring system, four items were used: fever greater than 38.5”C; vomiting (at least three episodes); fecal mucus; and fecal blood. For each sign or symptom (considered either its presence or absence) the positive predictive value with regard to a bacterial etiology was determined. The authors recommend use of their two step predictive method to identify children with the highest probability of bacterial diarrhea and to reserve stool culture to a few selected cases. Bacterial meningitis presenting with normal cerebrospinal fluid. Polk DB, Steele RW. Pediatr Infect Dis J 1987;6:1040-1042. Polk and Steele discuss their experiences of children with bacterial meningitis and normal initial CSF determinations (other than culture and/or antigen detection assays). Patients were identified as having normal CSF if there were no more than 10 white blood cell&L with three or fewer polymorphonuclear leukocytes, glucose greater than 50% of serum concentration, and protein less than 45 mg/dL and a negative gram stain. Only 7 (2.7%) of 261 meningitis patients fulfilled these criteria. The physical examination also failed to show uniquely different findings from those for other patients with meningitis. Additional careful review of these cases did not show other indicators that might have distinguished bacterial meningitis. The authors conclude that the presence of meningeal signs of systemic toxicity were the only features that strongly suggested bacterial meningitis in patients with apparently normal CSF, therefore physicians must rely on clinical judgement for beginning antimicrobial therapy.
MISCELLANEOUS Fighting the fever phobia. McCarthy et al. J Pediatr 1987;110:26-30. Is there a correlation between a “toxic” appearing child with high fever and the serious illness? Does observational assessment done in a systematic manner add to the efficiency of the traditional history and physical examination in detecting serious illness in febrile children? McCarthy et al report and discuss their clinical experience. A physician performed the observation using the acute illness observation scales (AIOS) that included the following six items: quality of cry, reaction of crying to parent stimulation (comforting or holding), alert state variation, color, hydration, and response to social overtures. Subsequently, the history and physical examination were
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done by the physician and findings were scored as to whether they suggested the presence of a serious illness. The combined AIOS history and physical examination had a higher sensitivity and correlation for serious illness than did the traditional history and physical examination. The authors conclude that assessment of appearance in a febrile child, when performed in a careful, integrated fashion, improves the sensitivity of the history and physical examination in detecting serious illnesses.
before venipuncture. The degree of difficulty in cannulation was assessed on a scale of 1 (very easy) to 5 (failure). The mean scale for group 1 (NT0 application) was significantly lower than that for group II or group III. The amount of NT0 applied was estimated to be 0.4 or 0.8 mg nytroglycerine and no significant hemodynamic status change was noted. The authors conclude that local application of NT0 technique is simple and innocuous, and it is an efficient way of reducing failure in venous cannulation in infants.
Headache and acute illness In children. Kandt RS, Levine RM. J Child Neurol 1987;2:22-27.
ORTHOPEDICS
What is the relationship between headache (HA) and acute illness in children? Is fever a common cause of headache? What are the characteristics of these headaches? Doctors Kandt and Levine discuss their experience. Thirty-seven children (3 to 15 years) with HAS who were seen in the walk-in clinic were matched to 37 HA free controls. Pharyngitis was the most common diagnosis in both the groups. Neither meningeal signs nor alteration of consciousness suggestive of encephalitis was recorded for any patient. Headache location and intensity were not related to body temperature. A family history of migraine was most common in the HA group. The authors support the symptomatic use of an analgesic/antipyretic agent when HA is part of a child’s illness. They conclude that worsening HA may signal a worsening primary illness and HAS associated with acute illness may indicate migraines later.
Osteomyelitis secondary to trauma or infected contiguous soft tissue. Dubey L, Krasinski K, Hemanz-Schulman M. Pediatr Infect Dis J 1988;7:26-34.
Albeit not new-The intraosseous infusion. Spivey, WH, Pediatrics 1988;111:639-643 Intraosseous infusion (OSI) uses the rich vascular network of long bones to transport fluids and drugs from the medullary cavity to circulation. The distribution of fluid and drugs via OS1 appears similar to that of intravenous (IV) injection. Intraosseous infusion is also very similar to that of IV injection. Intraosseous infusion is also effective with closed chest cardiac massage. Insertion of a needle into the medullary cavity of a long bone is both rapid and simple. There are several commercially prepared intraosseous needles that have a shaft and provide a protective sheath. Several sites are available. Today the most commonly used sites are the distal femur, proximal and distal tibia. When using the proximal tibia, the halfway point between tibial tuberosity and medial aspect of the tibia is marked and 1 to 2 cm distal to this halfway point is the optimal site for needle insertion. After skin preparation, the needle is inserted perpendicular to the bone with the bevel pointing away from the joint space. A rotary motion is applied until there is a slight decrease in resistance, indicating that the center of the bone has been penetrated. Once needle placement has been confirmed, gravity may be used to infuse fluid. Although not optimal, OS1 may be used for volume resuscitation; however, it often requires a pressure infusion. Initially used for saline, glucose, and blood, OS1 has become useful for emergency administration of sodium bicarbonate, atropine, dopamine, epinephrine, diazepam, antibiotics, phenytoin, and succinylcholine. Cardiac arrest is the most common indication; others include shock, extensive bums and major trauma. The success rate of OS1 is about 88%. Complications do occur. Serious potential complications include osteomyelitis and damage to the epiphyseal plate. The author concludes that OS1 is a safe and rapid alternative for fluid and drug administration in infants and children. It is intended only for emergency resuscitation and stabilization in situations such as cardiac arrest, shock, and trauma. Nitroglycerine ointment as aid to venous cannulation in children. Vaksmann G, Rey C, Breviere GM, et al. J Pediatr 1987;111:89-91 Authors studied the effects of nitroglycerine ointment (NTO) on veins and ease of venous cannulation in children. One hundred ftity children were divided into 3 groups of 50. In group 1, NT0 was applied to the skin of the wrist or forearm; in group 2, a bland ointment was applied; in group 3, NT0 was applied elsewhere on the body. Ointments were applied in all groups 10 to 15 minutes
Dubey et al present their experience with nonhematogenous osteomyelitis (NHO) in 24 patients aged 8 months to 18 years. This retrospective review revealed that there are differences in the clinical presentation, infecting organisms and outcome in patients with NH0 as compared to patients with acute hematogenous osteomyelitis (AHO). Predisposing factors to NH0 include open fracture, deep decubiti, and foot puncture. Nonhematogenous osteomyelitis involved the tibia, foot bones, proximal femur, and ulna in this series of patients. Nonhematogenous osteomyelitis patients presented with drainage (64%), pain or tenderness (44%), and fever (32%) lasting for 1 to 180 days (median 10 days). In 24% of the patients, both white cell count and erythrocyte sedimentation rate were normal. Initial roentgenograms were nondiagnostic in 42% of patients with open fractures. Bone cultures generally grew Sraphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, or other gram-negative organisms. The authors recommend prompt operative bone culture as the best confirmatory test for diagnosis and the most reliable guide to appropriate antibiotic therapy in patients suspected of having NHO. While the optimum duration of therapy has not been defined, the authors suggest a minimum of 4 weeks of inhospital antibiotics after thorough debridement of the infected area. Radial head and neck fractures in children. Steinberg EL, Golomb D, Salama R, et al. J Pediatr Orthopaed 1988;8:35-40. Steinberg et al discuss their experience of 42 consecutive fractures of the neck of the radius (FNRs) in children. The age at the time of injury ranged from 5 to 14 years. The follow up ranged from 7 to 15 years, and more than half the patients were observed for more than 4 years. The results were assessed clinically and radiologically at 6 months and at review. Twenty-seven children (64%) had a good result, 5 (18%) had a fair result, and 13 (31%) had a poor result. Primary angulation was the most important factor affecting the results. Fractures treated by open reduction definitely had better quality of reduction than did those tested by closed reduction, especially when the displacement was severe. The authors conclude that more acute reduction is mandatory to improve the final outcome. Sudden acute hip pain-An emergency. Birch. J Pediatr Orthop 1987;7:334. Dr. Birch reports two patients with acute progression of a slipped capital femoral epiphysis (SCE). Both patients had radiographic diagnoses of a chronic slipped epiphysis with acute progression. Both patients were treated with in situ pinning, and recovered well. These two cases remind us that patients presenting in early stages of chronic SCE have the potential to displace the femoral epiphysis acutely. Ambulation with crutches is inadequate interim treatment, as definite orthopaedic intervention is essential. Acute hematogenous osteomyelitis in children. Lamont RL, Anderson PA, Dajani AS, et al. J Pediatr Orthop 1987;7:529-583. The prognosis and treatment of hematogenous acute osteomyelitis (HAO) continue to change as better antibiotic therapy becomes
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available. However, the role of surgical management has become less well defined. What are the indications for surgical therapy? How does surgical therapy plus antibiotics compare with antibiotics alone? Larnont et al discuss their experience with HA0 in children and offer guidelines for therapy. Staphylococcus aureus was the most common organism and cases of Haemophilus influenzae were associated with adjacent joint infection. Femur and tibia represented 60% of the total sites. The authors conclude that a satisfactory outcome can be obtained through the use of a vigorous antibiotic regimen without operative intervention in most HA0 cases in children.
Ultrasonography of hip joint effusions. Zieger MM, Door U, Schulz RD. Skeletal Radio1 1987;16:607-610. Ziegler et al discuss their experience with ultrasonography (USY) in patients with suspected hip joint effusions. Twenty apparently healthy patients were investigated as a control group to depict the normal anatomy of the joint spaces as seen by USY. One hundred twenty-three consecutive patients were examined prospectively. Ultrasonography positively demonstrated intra-articular effusions in 63 cases. The subgroup was mainly composed of 31 patients with transient synovitis and 15 with septic arthritis. In 26 patients, the joint effusion proved to be echo-free. The results of USY were compared with radiography, close clinical follow-up and intraoperative findings. Ultrasonography prospectively delineated a fluid collection in every case. The authors conclude that USY is reliable (ie, both sensitive and specific) and clearly superior to roentgenograms in the diagnosis of hip joint effusions.
RESPIRATORY Comparison of two methods of rapid theophylhne testing in clinical practice. Shaw KN, Fleisher RG, Schwartz JS. Chn Lab Obs 1987;112:131-134. Rapid availability of serum theophylline (ST) levels in the emergency department (ED) may facilitate the management of acute asthmatic attacks in children. Shaw et al compared the clinical accuracy of these rapid assays in an ED setting. Theophylline blood levels were obtained from 81 acutely wheezing children. Three ST levels in each sample were determined by the hospital clinical laboratories, high pressure liquid chromatography (HPLC), the Seralyzer dry reagent-strip immunoassay (uses serum and spectrophotometer for reading), and AccuLevel strip test (uses capillary blood and no instruments required). The authors conclude that Seralyzer assay is more precise and acceptable for hospital laboratories; however, it has the disadvantage of requiring a spectrophotometer and a trained technician. The loss of precision with the AccuLevel assay is offset by the ease of use with minimal training, no additional equipment, and can be done directly from a finger-stick sample. Pitfalls in the use of clinical asthma scoring. Baker MD. Am J Dis Child 1988;142:183-185. A number of clinical scoring systems have been devised to help assess the severity of the asthma episode. One such scoring system is the clinical asthma score (CAS) developed by Wood et al in 1972. The use of CAS has not been validated by adequate clinical trials. Does the CAS have prognostic value? Baker studied 210 asthma patients to evaluate the usefulness of the CAS in determining outcome in childhood asthmatics. The CAS is the summation of values assigned to five different clinical characteristics, that include cyanosis, inspiratory breath sounds, accessory muscle use, expiratory wheezing, and cerebral function. The author finds that the pretreatment CAS was not useful for the early identification of children requiring prolonged inpatient asthma care. Intravenous methylprednisolone efficacy in status asthmaticus of childhood. Younger RE, Gerber PS, Herrod HG, et al. Pediatrics 1987;80:225-229.
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Younger et al performed an interesting study to evaluate the role of steroids for status asthamaticus (SAS) in children. Forty-five nonsteroid dependent children (6 to 16 years) hospitalized with SAS were randomized to receive intravenous (IV) placebo or methylprednisolone (MPR) (1 m&kg. every 6 hours). All patients were refractory to three bronchodilator treatments comprised of epinephtine injection and/or isoetharine inhalation. The MPR treated group experienced a more rapid recovery from peripheral airway obstruction as measured by pulmonary function tests: Placebo-treated patients had a higher incidence of asthma relapse within 4 weeks of discharge (8 vs 2 patients). The authors conclude that the use of IV MPR in the treatment of pediatric SAS provides significant therapeutic advantages and supports the current recommendation for prompt institution in children requiring hospitalization. Therefore, the use of short term steroid therapy in the treatment of severe childhood asthma is appropriate. An approach to stridor in infants and children. Friedberg J. J Otolaryngol 1987;16:203-206. Stridor in infants and children (SIC) indicates some degree of air flow restriction. It is a clinical sign which is common to many disease entities compromising the upper airway. Friedberg discusses the diagnosis and offers guidelines for SIC management. Supraglottic, laryngeal, and cervical tracheal narrowing generally result in an inspiratory stridor, and more distal lesions produce expiratory stridor. The infant or child whose stridor heralds a life-threatening airway obstruction should have airway control accomplished as soon as possible. Endotracheal intubation or tracheotomy may be necessary, or bronchoscopy may be indicated early on to rule out structural lesions.
TOXICOLOGY Hallucinogenic mushrooms. Schwartz RH, Smith DE. Clin Pediatr 1988;27:70-72. Schwartz and Smith recently surveyed mushroom abuse patterns among a group of 174 adolescents enrolled in a drug abuse program in Washington, DC. Psilocybin mushroom ingestion was reported by 45 (26%) of the respondents. After an acute intoxication, psilocybin mushroom abusers complain of extreme exhaustion and profound mental depression. Treatment of the acute adverse effects is supportive and involves talking down of panic reactions. Gastric lavage should be considered if there is any doubt as to the identity of the mushroom ingested. Mushrooms sold illicitly for their mind-altering actions may not actually be psilocybin mushrooms, but may be the common mushroom purchased in a store and laced with phencyclinidine (PCP) or lysergic acid diethylamide (LSD). Organophosphate and carbamate poisoning in infants and children. Zwiener RJ, Ginsburg CM. Pediatrics 1988;81:121-126. Zwiener and Ginsburg conducted a retrospective study of 37 infants and children with organophosphate and carbamate poisoning. The age range of the patients was 1 month to 11 years. All poisoning occurred in the home, except for one child who ingested insecticide granules while in a feed store. The most common abnormal physical findings included miosis (73%) excessive salivation (70%), muscle weakness (68%) respiratory distress (S%), lethargy (54%), and tachycardia (49%). Fourteen patients (38%) required endotracheal intubation and mechanical ventilation because of respiratory insufficiency. Most patients were treated with atropine and ptahdoxime. One patient received 86 doses and another received 61 doses of atropine during a 24-hour period. Ten patients had chest roentgenogram findings consistent with atelectasis or pneumonitis. The authors recommend the following for care of infants and children with moderate to severe oranonphosphate and carbamate poisoning: supportive care; cordirrnation of diagnosis with serum and/or RBC cholinesterase activities; atropine in adequate doses; praladoxime
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BIBLIOGRAPHY
for all patients with moderate to severe toxicity, but it should not be given to patients with carbamate toxicity. The effect of fluid volume on syrup of ipecac emesis time. Grande A, Ling LJ. Clin Toxic01 1987;25:473-481. Syrup of ipecac is widely recognized as safe and effective for the home induction of emesis. Large volumes of fluid have been recommended to aid rapid ipecac-induced emesis. Grande and Ling performed a prospective study to determine if copious fluid intake was essential for rapid induction of emesis. One hundred twenty-one children (1 to 15 years) were included in the study. These children were treated in the usual manner, except that parents were asked to measure the volume of fluid given and record the time of first emesis. Average time to first emesis ranged from 6 to 58 minutes (mean 20.6 minutes), and the amount of fluid consumed ranged from 0 to 28 ounces (mean 6.7 ounces). The authors conclude that there is no significant relationship between the amount of fluid given and the time until emesis with children who respond to ipecac. Therefore, the traditional recommendation of forcing fluid with ipecac syrup does not hasten emesis. Underdosing of acetaminophen by parents. Gribetz B, Cronley SA. Pediatrics 1987;80:630-633. Gribetz and Cronley discuss their experience with young children seen in the emergency department for perceived or measured fever.
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The parents of 96 children were asked about their treatment of the symptom with acetaminophen. Based upon parental information, acetaminophen dose was calculated for each child. Doses less than 10 mg/kg were considered inappropriately low and those greater than 15 m&g were considered inappropriately high. With all forms of acetaminophen, the majority of the parents (68%) administered a dose less than the recommended 10 to 15 mg/kg per dose). The authors conclude that underdosing of acetaminophen is the rule rather than the exception. Button battery ingestion: A case report and review of the literature. Kost KM, Shapiro RS. J Otolaryngol 1987;16:252-257. Button (disc) batteries (BB) are being used with increasing frequency in a variety of devices including hearing aids, watches, and calculators. Most batteries contain a heavy metal (such as mercury) and an alkaline electrolyte. Recent reports have emphasized that potential for severe morbidity and morality from ingestion of button batteries. Kost and Shapiro report a case of an ll-month-old boy who had prolonged esophageal impaction of BB. The authors suggest that ah patients suspected of a BB ingestion should undergo full roentgenogram evaluation from nasopharynx to the anus. Esophageal impaction mandates immediate endoscopic removal. Batteries which have passed beyond the esophagus can be treated conservatively.