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Pediatric telephone advice in the emergency department: results of a mock scenario
778 This paper describes the case characteristics of 20 pediatric patients who sustained CO poisoning while riding in the back of enclosed pickup trucks. All patients were treated with hyperbaric oxygen. Specific configurations of the vehicle exhaust systems included those with a previously known leak or a tail pipe that exited at the rear rather than at the side of the pickup truck. 15 patients had loss of consciousness (LOC), and 5 did not. The exposure time in the group with LOC ranged from 10 min to 150 min. Exposure time in the group without LOC ranged from 10 min to 60 min. Levels of carboxyhemoglobin did not differ significantly between the group with and the group without LOC. Nor did symptoms correlate with either COHb% level or history of LOC. One child died of cerebral edema, one had permanent neurological deficit, and 18 had no recognizable sequelae after treatment. This article is the first to report of the potential risk of carbon monoxide poisoning in children who travel as passengers in the back of enclosed pickup trucks. Proper referral may not occur due to failure to recognize the syndrome. Typical symptoms experienced by the children could easily be attributed to motion sickness,viral illness, a sleepy child, or other causes. The importance of long-term follow-up is stressed, as delayed neurological deterioration following significant CO exposure may also occur after a lucid interval of 2 days to 6 weeks. [Val L. Richey-Klein, MD] Editor’s Comment: Activities to enhance public awareness of this hazard need to be undertaken.
0 A RATIONAL SCREENING AND TREATMENT STRATEGY BASED ON THE ELECTROCARDIOGRAM ALONE FOR SUSPECTED CARDIAC CONTUSION. Illig KA, Swierzewski MJ. Feliciano DV, et al. AJ Surg. 1991;162:537-44. Two teaching institutions retrospectively reviewed charts of 133 patients admitted for blunt trauma where myocardial contusion (MC) was considered part of the admitting diagnosis. The patients were divided into three groups; the 1st group (n = 53) had normal admission EKG’s (chamber hypertrophy or no arrhythmias-except sinus arrhythmia or bradycardia in young healthy patients), and no cardiac problems on admission. The 2nd group (n = 67) had abnormal EKG’s (sinus tachycardia, non-specific ST segment of T wave changes, dysrhythmias, conduction defects, or evidence of anatomically specific ischemia), and no cardiac problems on their admission. The third group (n = 13) were those who had cardiac problems regardless of work-up. All the patients in group 3 had EKG changes while being evaluated in the ED. Five of these had normal CK-MB fractions, and 5 had normal echocardiograms. No patient with a normal EKG had any subsequent cardiac problems while being monitored. The authors suggest that using EKG as a screening tool in patients with a suspected diagnosis of cardiac contusion could eliminate unnecessary hospital admissions (providing they
The Journal of Emergency Medicine have no other injuries that require admission). Eliminating the use of CK-MB and ECMO as screening tests would result in substantial savings. Echocardiography would be used to evaluate patients as cardiac problems develop. [Joseph P. Brissette, MD] Editor’s Comment: These findings need to be tested prospectively, but this will be hampered by the lack of a “gold standard” diagnostic technique for cardiac contusion.
0 PENETRATING ZONE-II NECK INJURIES IN CHILDREN. Hall JR, Reyes HM, Meller JL. J Trauma. 1991;31:1614-17. A clinical, prospective trial was performed over a 4-year period in order to determine if observation is a reasonable alternative to surgical exploration in children with zone-II injuries of the neck. Twenty-four children between the ages of 1 and 15 years with zone-II injuries were seen at a level-I pediatric trauma center. Two children had glass wounds, 9 had stab wounds, and 13 had gunshot wounds. Criteria for mandatory exploration were established at the beginning of the 4-year period and were as follows: expanding or pulsatile hematoma, shock or active bleeding, subcutaneous air on x-ray film, bruit, thrill, crepitus, dysphagia, blood in oropharynx, the need for anesthesia to close the wound, and inability to follow or study the child because of other injuries. Children with neurologic deficits or equivocal physical examinations were studied with angiography, esophagography, esophagoscopy, or bronchoscopy. The remaining children were observed with hourly physical examinations for 12 hours and remained hospitalized for at least 36 hours. Six (25%) of the 24 underwent exploration, and 4 of these had positive findings. Five of the 24 (21%) underwent further studies. One patient had an occluded vertebral artery on angiogram, but it was not treated. Of the 24 children, 13 (54%) underwent observation only. There were no patients in this group who required operative intervention at a later date or who suffered any complications. The mean hospital stay was 8.6 days for patients who underwent exploration, and 6.8 days for patients who were observed (2.2 days excluding one patient with a spinal cord injury and one patient who was held because of child abuse). The authors of this trial believe that their data support nonoperative management of zone-II injuries when none of the previously listed criteria are met. Further diagnostic studies are only necessary when the physical examination is equivocal. [Eric H. Gilbert, MD] Editor’s Comment: Not every institution will be able to provide hourly physical examinations, and in these casesa more aggressiveapproach will be indicated.
q PEDIATRIC TELEPHONE ADVICE IN THE EMERGENCY DEPARTMENT: RESULTS OF A MOCK SCENARIO. Isaacman DJ, Verdile VP, Kohen, FP, Verdile LA. Pediatrics. 1992;89:35-9.
This study evaluated the appropriateness of pediatric telephone advice given by emergency departments (EDs). Sixty-one EDs were randomly selected, 30 of which were affiliated with pediatric residency training programs. A mock scenario was presented in the calls, simulating a 5week-old with signs and symptoms consistent with meningitis. Each call began with “Can I speak to a doctor,” and then proceeded with “My baby has been having a fever all day, and I can’t seem to get it down.” Additional information was then given only on request. The responses were evaluated by documenting the presence or absence of pertinent screening questions based on existing telephone advice protocols. Fifty three (87%) EDs gave medical advice by telephone. In 42 (79%) of these, the individual giving advice was a nurse. Thirty-eight (71.7%) EDs advised the patient to see a physician, and 32 (60.4%) suggested same day evaluation. Though the most frequently asked questions were age of patient and height of fever, 14 programs (26%) gave advice without asking either of these. EDs asking both of these questions were more likely to suggest evaluation by a physician. Few EDs asked questions regarding irritability, fluid intake, urine output, or breathing pattern. In several instances the caller was not advised to seek medical attention, despite documenting fever, irritability, and lethargy. The authors conclude that variability and inadequacies exist in pediatric telephone advice in the EDs studied, and that formal guidelines and telephone management protocols should be developed. [Steven A. Kohler, MD] Editor’s Comment: A system to deliver telephone advice should be viewed in the same way as an EMS base station. That is, protocols, medical direction, and quality assurance will be needed.
0 SEIZURES ASSOCIATED WITH MENINGITIS. Rosenberg NM, Meert K, Marino D, De Baker K. Pediatr Emerg Care. 1992;8(2):67-9. Children presenting to the emergency department with seizuresmay be as a result of a number of etiologies. Bacterial meningitis presenting as seizure is rare, yet if undiagnosed and untreated has a high morbidity and mortality. This study retrospectively reviewed 187 cases of documented bacterial meningitis in patients up to 5 years old. Twenty-five patients initially presented with seizure. Seven of this group of 25 had been treated with po antibiotics. In this group of 7, 4 children presented with seizure as their only symptom. The remaining 18 (of 25) untreated children had additional examination findings to suggest meningitis. In the total group of 187,45 had been taking oral antibiotics prior to diagnosis of meningitis. The authors concluded that it is unlikely for a bacterial meningitis to present with seizure as the only symptom in children. However, in children on antibiotics, who have a seizure, they recommend lumbar puncture since signs and symptoms of meningitis may be absent in this group. [Ahmed Stowers, MD]
0 CHILDHOOD INTUSSUSCEPTION: US-GUIDED HYDROSTATIC REDUCTION. Woo SK, Kim JS, et al. Radiology. 1992;182:77-80. Intussusception is a common pediatric emergency, with barium enema as the gold standard for diagnosis and therapeutic reduction. This study evaluated ultrasonography (US) both as a diagnostic screening tool and for guiding hydrostatic reduction with saline enema. One hundred sixteen children (average age of 10 months) with suspected intussusception underwent abdominal ultrasound. Diagnosis was made upon visualization of a doughnut or target shaped configuration of edematous bowel. Unless contraindicated by evidence of peritonitis, sepsis, or shock, hydrostatic reduction was attempted with the rectal placement of a foley catheter with balloon inflated. Failed reductions (n = 11) were sent to the operating room. Of 116, 75 had a correct diagnosis, with no casesshown to be positive on follow-up clinical observation. The diagnostic accuracy of US was 100% prior to hydroreduction. Total time for diagnosis and US-guided reduction was 15 minutes (average time for reduction was 10 minutes). Successrate with water enema was 85%, which was greater than that reported with air or barium enema. Caution is recommended in cases of edematous ileocecal valve, which can mimic intussusception. US proved superior to barium enema for initial diagnosis and in assisting with hydrostatic reduction. [Shawna J. Perry, MD] Editor’s Comment: US may be more accessibleand take lesstime to perform than traditional barium enema.
0 MULTIPLE-DOSE CHARCOAL AND WHOLEBOWEL IRRIGATION DO NOT INCREASE CLEARANCE OF ABSORBED SALICYLATE. Mayer AL, Sitar DS, Tenenbein M. Arch Intern Med. 1992;152:393-6. Is it effective to use whole-bowel irrigation (WBI) or oral multidose charcoal (MDC) to increase the clearance of already absorbed salicylate? In a controlled, randomized, three-limbed crossover protocol, 9 healthy volunteers ages 21 to 29 years were given 2880 mg of aspirin on an empty stomach. In the MDC limb of the study, 25-g dose of activated charcoal was given, starting 4 hours after the aspirin ingestion, and repeated every 2 hours for a total of 4 doses. The control limb consisted of the same sequence, but water was given instead of activated charcoal preparation to compensate for volume. In the third limb, WBI, a polyethylene glycol electrolyte solution was infused via nasogastric tube, also starting 4 hours after aspirin ingestion. Termination time occurred whenever rectal effluent was visibly the same as the infusate. Serial measurements of salicylate levels were made. Urine and kinetic parameters were calculated. Results of all three limbs did not show a statistically significant difference. The authors concluded that their data do not support either method (WBI or MDC) to potentiate excretion of
0 A RATIONAL SCREENING AND TREATMENT STRATEGY BASED ON THE ELECTROCARDIOGRAM ALONE FOR SUSPECTED CARDIAC CONTUSION. Illig KA, Swierzewski MJ. Feliciano DV, et al. AJ Surg. 1991;162:537-44. Two teaching institutions retrospectively reviewed charts of 133 patients admitted for blunt trauma where myocardial contusion (MC) was considered part of the admitting diagnosis. The patients were divided into three groups; the 1st group (n = 53) had normal admission EKG’s (chamber hypertrophy or no arrhythmias-except sinus arrhythmia or bradycardia in young healthy patients), and no cardiac problems on admission. The 2nd group (n = 67) had abnormal EKG’s (sinus tachycardia, non-specific ST segment of T wave changes, dysrhythmias, conduction defects, or evidence of anatomically specific ischemia), and no cardiac problems on their admission. The third group (n = 13) were those who had cardiac problems regardless of work-up. All the patients in group 3 had EKG changes while being evaluated in the ED. Five of these had normal CK-MB fractions, and 5 had normal echocardiograms. No patient with a normal EKG had any subsequent cardiac problems while being monitored. The authors suggest that using EKG as a screening tool in patients with a suspected diagnosis of cardiac contusion could eliminate unnecessary hospital admissions (providing they
The Journal of Emergency Medicine have no other injuries that require admission). Eliminating the use of CK-MB and ECMO as screening tests would result in substantial savings. Echocardiography would be used to evaluate patients as cardiac problems develop. [Joseph P. Brissette, MD] Editor’s Comment: These findings need to be tested prospectively, but this will be hampered by the lack of a “gold standard” diagnostic technique for cardiac contusion.
0 PENETRATING ZONE-II NECK INJURIES IN CHILDREN. Hall JR, Reyes HM, Meller JL. J Trauma. 1991;31:1614-17. A clinical, prospective trial was performed over a 4-year period in order to determine if observation is a reasonable alternative to surgical exploration in children with zone-II injuries of the neck. Twenty-four children between the ages of 1 and 15 years with zone-II injuries were seen at a level-I pediatric trauma center. Two children had glass wounds, 9 had stab wounds, and 13 had gunshot wounds. Criteria for mandatory exploration were established at the beginning of the 4-year period and were as follows: expanding or pulsatile hematoma, shock or active bleeding, subcutaneous air on x-ray film, bruit, thrill, crepitus, dysphagia, blood in oropharynx, the need for anesthesia to close the wound, and inability to follow or study the child because of other injuries. Children with neurologic deficits or equivocal physical examinations were studied with angiography, esophagography, esophagoscopy, or bronchoscopy. The remaining children were observed with hourly physical examinations for 12 hours and remained hospitalized for at least 36 hours. Six (25%) of the 24 underwent exploration, and 4 of these had positive findings. Five of the 24 (21%) underwent further studies. One patient had an occluded vertebral artery on angiogram, but it was not treated. Of the 24 children, 13 (54%) underwent observation only. There were no patients in this group who required operative intervention at a later date or who suffered any complications. The mean hospital stay was 8.6 days for patients who underwent exploration, and 6.8 days for patients who were observed (2.2 days excluding one patient with a spinal cord injury and one patient who was held because of child abuse). The authors of this trial believe that their data support nonoperative management of zone-II injuries when none of the previously listed criteria are met. Further diagnostic studies are only necessary when the physical examination is equivocal. [Eric H. Gilbert, MD] Editor’s Comment: Not every institution will be able to provide hourly physical examinations, and in these casesa more aggressiveapproach will be indicated.
q PEDIATRIC TELEPHONE ADVICE IN THE EMERGENCY DEPARTMENT: RESULTS OF A MOCK SCENARIO. Isaacman DJ, Verdile VP, Kohen, FP, Verdile LA. Pediatrics. 1992;89:35-9.
This study evaluated the appropriateness of pediatric telephone advice given by emergency departments (EDs). Sixty-one EDs were randomly selected, 30 of which were affiliated with pediatric residency training programs. A mock scenario was presented in the calls, simulating a 5week-old with signs and symptoms consistent with meningitis. Each call began with “Can I speak to a doctor,” and then proceeded with “My baby has been having a fever all day, and I can’t seem to get it down.” Additional information was then given only on request. The responses were evaluated by documenting the presence or absence of pertinent screening questions based on existing telephone advice protocols. Fifty three (87%) EDs gave medical advice by telephone. In 42 (79%) of these, the individual giving advice was a nurse. Thirty-eight (71.7%) EDs advised the patient to see a physician, and 32 (60.4%) suggested same day evaluation. Though the most frequently asked questions were age of patient and height of fever, 14 programs (26%) gave advice without asking either of these. EDs asking both of these questions were more likely to suggest evaluation by a physician. Few EDs asked questions regarding irritability, fluid intake, urine output, or breathing pattern. In several instances the caller was not advised to seek medical attention, despite documenting fever, irritability, and lethargy. The authors conclude that variability and inadequacies exist in pediatric telephone advice in the EDs studied, and that formal guidelines and telephone management protocols should be developed. [Steven A. Kohler, MD] Editor’s Comment: A system to deliver telephone advice should be viewed in the same way as an EMS base station. That is, protocols, medical direction, and quality assurance will be needed.
0 SEIZURES ASSOCIATED WITH MENINGITIS. Rosenberg NM, Meert K, Marino D, De Baker K. Pediatr Emerg Care. 1992;8(2):67-9. Children presenting to the emergency department with seizuresmay be as a result of a number of etiologies. Bacterial meningitis presenting as seizure is rare, yet if undiagnosed and untreated has a high morbidity and mortality. This study retrospectively reviewed 187 cases of documented bacterial meningitis in patients up to 5 years old. Twenty-five patients initially presented with seizure. Seven of this group of 25 had been treated with po antibiotics. In this group of 7, 4 children presented with seizure as their only symptom. The remaining 18 (of 25) untreated children had additional examination findings to suggest meningitis. In the total group of 187,45 had been taking oral antibiotics prior to diagnosis of meningitis. The authors concluded that it is unlikely for a bacterial meningitis to present with seizure as the only symptom in children. However, in children on antibiotics, who have a seizure, they recommend lumbar puncture since signs and symptoms of meningitis may be absent in this group. [Ahmed Stowers, MD]
0 CHILDHOOD INTUSSUSCEPTION: US-GUIDED HYDROSTATIC REDUCTION. Woo SK, Kim JS, et al. Radiology. 1992;182:77-80. Intussusception is a common pediatric emergency, with barium enema as the gold standard for diagnosis and therapeutic reduction. This study evaluated ultrasonography (US) both as a diagnostic screening tool and for guiding hydrostatic reduction with saline enema. One hundred sixteen children (average age of 10 months) with suspected intussusception underwent abdominal ultrasound. Diagnosis was made upon visualization of a doughnut or target shaped configuration of edematous bowel. Unless contraindicated by evidence of peritonitis, sepsis, or shock, hydrostatic reduction was attempted with the rectal placement of a foley catheter with balloon inflated. Failed reductions (n = 11) were sent to the operating room. Of 116, 75 had a correct diagnosis, with no casesshown to be positive on follow-up clinical observation. The diagnostic accuracy of US was 100% prior to hydroreduction. Total time for diagnosis and US-guided reduction was 15 minutes (average time for reduction was 10 minutes). Successrate with water enema was 85%, which was greater than that reported with air or barium enema. Caution is recommended in cases of edematous ileocecal valve, which can mimic intussusception. US proved superior to barium enema for initial diagnosis and in assisting with hydrostatic reduction. [Shawna J. Perry, MD] Editor’s Comment: US may be more accessibleand take lesstime to perform than traditional barium enema.
0 MULTIPLE-DOSE CHARCOAL AND WHOLEBOWEL IRRIGATION DO NOT INCREASE CLEARANCE OF ABSORBED SALICYLATE. Mayer AL, Sitar DS, Tenenbein M. Arch Intern Med. 1992;152:393-6. Is it effective to use whole-bowel irrigation (WBI) or oral multidose charcoal (MDC) to increase the clearance of already absorbed salicylate? In a controlled, randomized, three-limbed crossover protocol, 9 healthy volunteers ages 21 to 29 years were given 2880 mg of aspirin on an empty stomach. In the MDC limb of the study, 25-g dose of activated charcoal was given, starting 4 hours after the aspirin ingestion, and repeated every 2 hours for a total of 4 doses. The control limb consisted of the same sequence, but water was given instead of activated charcoal preparation to compensate for volume. In the third limb, WBI, a polyethylene glycol electrolyte solution was infused via nasogastric tube, also starting 4 hours after aspirin ingestion. Termination time occurred whenever rectal effluent was visibly the same as the infusate. Serial measurements of salicylate levels were made. Urine and kinetic parameters were calculated. Results of all three limbs did not show a statistically significant difference. The authors concluded that their data do not support either method (WBI or MDC) to potentiate excretion of