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Safety practices and living conditions of low-income urban children
evaluated regarding their effectiveness (complete or partial versus inadequate anesthesia), use of additional injected anesthetics, parental acceptance, occurrence of side effects, and incidence of wound infection. Parameters w e r e evaluated using chi-square testing with P < .05 denoting significant difference. TAC was found to have no significant difference in effectiveness (87.9%) when compared with TA (80.4%), yet both were more effective than T (54.4%). Additional injected anesthesia was administered significantly more often after TA (10.9 % } and T (21%) compared with TAC (3.4%). Parents found the technique of topical anesthesia overwhelmingly satisfactory (90.7%). The incidence of immediate side effects Was low for all solutions (1.8%; 2.0%, and 1.8%) without significant differences. The incidence of wound infection did not show a significant difference; however, a definite trend of increased erythema was noted in wounds in which TAC was used. T A may be a preferable solution because it provides nearly equal efficacy with a 10w incidence of infection and adverse reactions, while avoiding the high cost and negative public perception associated with cocaine.
161 TAC Versus Cocaine Alone AA Ernst, LH Crabbe, DK Winsemius, R Bragdon, R Link/St Francis Hospital, Hartford, Connecticut; University of Connecticut, Farmington; South Louisiana Medical Center, Houma A mixture of tetracaine, adrenaline, and cocaine (TAC) has been used extensively in the repair of small lacerations, especially in children. Several studies have tried tetracaine alone or tetracaine and adrenaline for this purpose but have found inferior results. The purpose of our study was to determine if cocaine alone would provide anesthesia equal tO that of TAC, eliminating both the risk of tetracaine toxicity and the theoretical risk of side effects from the combination of cocaine and adrenaline and simplifying preparation. One hundred thirty-nine patients were enrolled in a randomized double-blind comparison study comparing TAC (69 patients) with cocaine alone (70 patients). Effectiveness was rated from 0 to 10 by the emergency department staff physician who applied the solution. Ranks of 0 to 3 were considered poor anesthesia; 4 to 7, fair anesthesia; and 8 to 10, good anesthesia. Using the Wilcoxon rank sum test, TAC was found to provide significantly better anesthesi a than cocaine alone (P = .005). The percentage of patients receiving good anesthesia in the TAC group was approximately 72%, which is equivalent to the efficacy found in other studies. Good anesthesia was obtained in 52% of the coCaine-alone group. No side effects were reported in either group. No increased rate of infection was found in either group. In summary, TAC was found to be a better topical anesthetic than cocaine alone. Neither was associatedwith significant complications.
162 Safety Practices and Living Conditions of LowIncome Urban C h i l d r e n LJ Santer, CB Stocking/Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Childrens Hospital, Cleveland, Ohio; Department of Medicine, Pritzker School of Medicine, Center for Clinical Medical Ethics, Chicago, Illinois Injuries remain the leading cause of mortality in children. Prior injury prevention efforts have targeted specific injury modes and primarily private patients, neglecting low-income urban children. In an a t t e m p t to assess the injury problem in this population, caregivers of indigent Children less than 6 years old enrolled in an Urban pediatric clinic were interviewed regarding l i v i n g conditions, transportation, household configuration, and previous injuries. Of the 133 adults approached, 89% agreed to be interviewed. The median age of patients and parents was 9 months and 25 years, respectively. Thirty-eight percent of homes were single-parent homes. The number of injuries or poisonings per household averaged .08 (range, 0 to 4), with 40% of households experiencing one or more incidents. Eleven percent of households had a poisoning episode. Eighteen percent of respondents were cognizant of ipecac, with ipecac available in only 8.5 % of homes. Medicine and poison storage were inadequatein 42% and 51% of homes, respectively. If a child ingested something the respondent believed might be poisonous, 51% would have gone to an emergency department before calling for advice. While the frequency of automobile use was low; unrestrained rides were common with 63% of children usually inappropriately restrained. Match or lighter storagewas inadequate in 78% of homes. Functional smoke detectors and fire extinguishers were present in 75 % and 27 % of homes, respectively. The storage of knives or scissors was inadequate in 68 % of homes,
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and firearms were present in 6%. Additionally, 89% of children 35 to 69 months old and 6% of those less than 3 years old sometimes bathed without adult supervision. These findings indicate the dramatic need for injury prevention programs focused on lowincome urban children. Specific concerr/s include exposure to hazardous transportation, chemicals, firearms, burns, and drowning. Lack of information and isolated caregivers may result in poor supervision and responses to life-threatening injuries.
163 Undiagnosed Abuse in Children Less Than 3 Years Old With Femoral Fractures • HJDalton, T Slovis, RE Heifer, J Comstock, S Scheurer/Wayne State University School of Medicine, Detroit, Michigan; Children's Hospital of Michigan; Departments of Radiology and Pediatrics/ Human Development, Michigan State University, Ypsilanti Retrospective evaluation of 138 children who presented consecutively to an emergency department in one of three major Michigan hospitals was completed. All hospital records and radiographs were reviewed. Initial data were evaluated by three pediatricians to classify the cases into one of four categories: accident (31), abuse (12), Underlying bone pathology (12), and uncertain etiology (83). These 83 uncertain cases were handled as follows: 36 were referred to Hospital Social Services, 29 of w h o m were subsequently reported to Protective Services. Abuse was confirmed in 20 of 29 (69%) of these eases. Thus, a total of 32 cases of femoral fracture were secondary to confirmed abuse. The remaining 16 of 36 cases were assessed by Hospital Social Services and abuse ruled out as the cause of the fracture. In the remaining 47 children from the uncertain group, no attempt was made to determine the etiology of the fracture. A total of 63 children left the hospital without an etiologic diagnosis of their femoral fracture. A review of the State registry revealed that seven of 63 (11%) undiagnosed cases were subsequently listed as victims of abuse. There was no fracture type characteristic for any specific etiology. The high incidence of abuse (32 of 138, 23%) as the etiology of femoral fracture and of subsequent abuse in "uncertain etiology" cases suggests that every young child with a femoral fracture whose cause is not absolutely certain should be admitted tO the hospital for an epidemiologi c evaluation by a muhidisciplinary team consisting of medical and social service personnel.
164 Outpatient Management of Febrile Infants 28 to 90 Days Old With Intramuscular Ceftriaxone MN Baskin, GR Fleisher, EJ O'Rourke/Division of Emergency Medicine and Infectious Diseases, Harvard Medical School, Children's Hospital, Boston, Massachusetts A bacterial focus is demonstrated in 3% to 8% of nontoxic febrile infants 1 to 3 months old despite a benign clinical examination. Traditional management includes admission and parenteral antibiotics pending bacterial culture results. We conducted a prospective study of intramuscular ceftriax0ne for the outpatient management of febrile infants 28 to 90 days old, with fever more than 38 C and no source on physical examination or screening laboratory tests. After blood, cerebral spinal fluid, and urine were obtained for culture, if peripheral white blood cells were less than 20,000, cerebral spinal fluid white blood cells were less than 10, and urine dipstick white blood cells were esterase negative, febrile infants received 50 mg/kg intramuscular ceftriaxone and were sent home. A second dose was administered 24 hours later, and febrile infants were followed-up by telephone at two and seven days. Over 20 months, 223 febrile infants were enrolled. Fourteen febrile infants (6.3 % ) had a bacterial focus identified (group 1}, and 209 did not (group 2). There were no significant differences in mean age (8.4 weeks )group 1], 7.4 weeks (group 2]), Yale observation scale (6.5 versus 6.6), WBC x 103 (11.2 versus 10.6), Or percent polymorphonuclear cells (32 versus 33). The two groups had significant differences in temperature (39.1 versus 38.8 C), and percent bands (9 versus 5) and approached a significant difference in total band count (924 versus 542; P = .06). Of 79 febrile infants with 6% or more bands, ten (13%) had bacterial foci eventually identified, whereas only three (2%) of 138 febrile infants with less than 6% bands ever had bacterial foci identified (P = .004). Of the 14 febrile infants with bacterial foci, four had bacteremia (one case each, Pneumococcus, group B Streptococcus, N meningitidis, and E cell). All febrile infants were afebrile with sterile blood cultures obtained when recalled and were well at follow-up. Nine febrile infants had bacterial gastroenteritis without bacteremia. Eight were followed at home, and one required hospitalization due to increasing bloody diarrhea without dehydration or toxicity. One febrile infant had
Annals of Emergency Medicine
18:4 April 1989
161 TAC Versus Cocaine Alone AA Ernst, LH Crabbe, DK Winsemius, R Bragdon, R Link/St Francis Hospital, Hartford, Connecticut; University of Connecticut, Farmington; South Louisiana Medical Center, Houma A mixture of tetracaine, adrenaline, and cocaine (TAC) has been used extensively in the repair of small lacerations, especially in children. Several studies have tried tetracaine alone or tetracaine and adrenaline for this purpose but have found inferior results. The purpose of our study was to determine if cocaine alone would provide anesthesia equal tO that of TAC, eliminating both the risk of tetracaine toxicity and the theoretical risk of side effects from the combination of cocaine and adrenaline and simplifying preparation. One hundred thirty-nine patients were enrolled in a randomized double-blind comparison study comparing TAC (69 patients) with cocaine alone (70 patients). Effectiveness was rated from 0 to 10 by the emergency department staff physician who applied the solution. Ranks of 0 to 3 were considered poor anesthesia; 4 to 7, fair anesthesia; and 8 to 10, good anesthesia. Using the Wilcoxon rank sum test, TAC was found to provide significantly better anesthesi a than cocaine alone (P = .005). The percentage of patients receiving good anesthesia in the TAC group was approximately 72%, which is equivalent to the efficacy found in other studies. Good anesthesia was obtained in 52% of the coCaine-alone group. No side effects were reported in either group. No increased rate of infection was found in either group. In summary, TAC was found to be a better topical anesthetic than cocaine alone. Neither was associatedwith significant complications.
162 Safety Practices and Living Conditions of LowIncome Urban C h i l d r e n LJ Santer, CB Stocking/Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Childrens Hospital, Cleveland, Ohio; Department of Medicine, Pritzker School of Medicine, Center for Clinical Medical Ethics, Chicago, Illinois Injuries remain the leading cause of mortality in children. Prior injury prevention efforts have targeted specific injury modes and primarily private patients, neglecting low-income urban children. In an a t t e m p t to assess the injury problem in this population, caregivers of indigent Children less than 6 years old enrolled in an Urban pediatric clinic were interviewed regarding l i v i n g conditions, transportation, household configuration, and previous injuries. Of the 133 adults approached, 89% agreed to be interviewed. The median age of patients and parents was 9 months and 25 years, respectively. Thirty-eight percent of homes were single-parent homes. The number of injuries or poisonings per household averaged .08 (range, 0 to 4), with 40% of households experiencing one or more incidents. Eleven percent of households had a poisoning episode. Eighteen percent of respondents were cognizant of ipecac, with ipecac available in only 8.5 % of homes. Medicine and poison storage were inadequatein 42% and 51% of homes, respectively. If a child ingested something the respondent believed might be poisonous, 51% would have gone to an emergency department before calling for advice. While the frequency of automobile use was low; unrestrained rides were common with 63% of children usually inappropriately restrained. Match or lighter storagewas inadequate in 78% of homes. Functional smoke detectors and fire extinguishers were present in 75 % and 27 % of homes, respectively. The storage of knives or scissors was inadequate in 68 % of homes,
190/470
and firearms were present in 6%. Additionally, 89% of children 35 to 69 months old and 6% of those less than 3 years old sometimes bathed without adult supervision. These findings indicate the dramatic need for injury prevention programs focused on lowincome urban children. Specific concerr/s include exposure to hazardous transportation, chemicals, firearms, burns, and drowning. Lack of information and isolated caregivers may result in poor supervision and responses to life-threatening injuries.
163 Undiagnosed Abuse in Children Less Than 3 Years Old With Femoral Fractures • HJDalton, T Slovis, RE Heifer, J Comstock, S Scheurer/Wayne State University School of Medicine, Detroit, Michigan; Children's Hospital of Michigan; Departments of Radiology and Pediatrics/ Human Development, Michigan State University, Ypsilanti Retrospective evaluation of 138 children who presented consecutively to an emergency department in one of three major Michigan hospitals was completed. All hospital records and radiographs were reviewed. Initial data were evaluated by three pediatricians to classify the cases into one of four categories: accident (31), abuse (12), Underlying bone pathology (12), and uncertain etiology (83). These 83 uncertain cases were handled as follows: 36 were referred to Hospital Social Services, 29 of w h o m were subsequently reported to Protective Services. Abuse was confirmed in 20 of 29 (69%) of these eases. Thus, a total of 32 cases of femoral fracture were secondary to confirmed abuse. The remaining 16 of 36 cases were assessed by Hospital Social Services and abuse ruled out as the cause of the fracture. In the remaining 47 children from the uncertain group, no attempt was made to determine the etiology of the fracture. A total of 63 children left the hospital without an etiologic diagnosis of their femoral fracture. A review of the State registry revealed that seven of 63 (11%) undiagnosed cases were subsequently listed as victims of abuse. There was no fracture type characteristic for any specific etiology. The high incidence of abuse (32 of 138, 23%) as the etiology of femoral fracture and of subsequent abuse in "uncertain etiology" cases suggests that every young child with a femoral fracture whose cause is not absolutely certain should be admitted tO the hospital for an epidemiologi c evaluation by a muhidisciplinary team consisting of medical and social service personnel.
164 Outpatient Management of Febrile Infants 28 to 90 Days Old With Intramuscular Ceftriaxone MN Baskin, GR Fleisher, EJ O'Rourke/Division of Emergency Medicine and Infectious Diseases, Harvard Medical School, Children's Hospital, Boston, Massachusetts A bacterial focus is demonstrated in 3% to 8% of nontoxic febrile infants 1 to 3 months old despite a benign clinical examination. Traditional management includes admission and parenteral antibiotics pending bacterial culture results. We conducted a prospective study of intramuscular ceftriax0ne for the outpatient management of febrile infants 28 to 90 days old, with fever more than 38 C and no source on physical examination or screening laboratory tests. After blood, cerebral spinal fluid, and urine were obtained for culture, if peripheral white blood cells were less than 20,000, cerebral spinal fluid white blood cells were less than 10, and urine dipstick white blood cells were esterase negative, febrile infants received 50 mg/kg intramuscular ceftriaxone and were sent home. A second dose was administered 24 hours later, and febrile infants were followed-up by telephone at two and seven days. Over 20 months, 223 febrile infants were enrolled. Fourteen febrile infants (6.3 % ) had a bacterial focus identified (group 1}, and 209 did not (group 2). There were no significant differences in mean age (8.4 weeks )group 1], 7.4 weeks (group 2]), Yale observation scale (6.5 versus 6.6), WBC x 103 (11.2 versus 10.6), Or percent polymorphonuclear cells (32 versus 33). The two groups had significant differences in temperature (39.1 versus 38.8 C), and percent bands (9 versus 5) and approached a significant difference in total band count (924 versus 542; P = .06). Of 79 febrile infants with 6% or more bands, ten (13%) had bacterial foci eventually identified, whereas only three (2%) of 138 febrile infants with less than 6% bands ever had bacterial foci identified (P = .004). Of the 14 febrile infants with bacterial foci, four had bacteremia (one case each, Pneumococcus, group B Streptococcus, N meningitidis, and E cell). All febrile infants were afebrile with sterile blood cultures obtained when recalled and were well at follow-up. Nine febrile infants had bacterial gastroenteritis without bacteremia. Eight were followed at home, and one required hospitalization due to increasing bloody diarrhea without dehydration or toxicity. One febrile infant had
Annals of Emergency Medicine
18:4 April 1989