Accuracy of clinical variables in the identification of radiographically proven constipation in children

STUDY OBJECTIVE

To determine whether clinical variables accurately identify children with radiographically proven constipation.

METHODS

Prospective, cross sectional case series of children 2-12 years of age with abdominal pain (AP) requiring radiographic evaluation. Constipation was defined radiographically as the presence of fecal material throughout the colon. The presence of other pathology was noted. The pediatric emergency department (ED) physicians recorded a comprehensive history and physical examination and a provisional diagnosis was made. Radiographs were initially interpreted by the pediatric ED attending physicians; the official interpretation was later provided by a single board certified pediatric radiologist who was blinded to the ED interpretation. A discriminant analysis was performed to identify variables that could best discriminate between patients with, and without, radiographically proven constipation.

RESULTS

In total 251 patients were enrolled over a 12 month period. Four variables were noted to be more common in constipated patients: a history of normal or hard stools, absence of rebound tenderness, presence of tenderness in the left lower quadrant and stool in the rectal vault on exam. Stool present on rectal exam was the best discriminator between patients with and without constipation. The discriminant analysis model had a sensitivity of 77%, specificity of 35% and a negative predictive value of 55%.

CONCLUSION

No clinical variable, either as a single variable or in a model, accurately identified patients with abdominal pain and radiographically proven constipation.

The need for a second dose of ceftriaxone in febrile infants age 4-8 weeks

OBJECTIVE

To determine if a second intramuscular injection of ceftriaxone was necessary in febrile infants who meet low-risk criteria for outpatient therapy.

SETTING

Children's Hospital Emergency Department.

PATIENTS

Febrile infants 4-8 weeks of age.

METHODS

Outpatient treatment criteria included non-toxic appearance, no identifiable source for infection on physical examination, CSF WBC > or = 10/mm3, peripheral WBC < or = 15,000/mm3, normal UA, and normal chest radiograph study, if obtained. Additional requirements included a reliable caretaker and re-evaluation in 24 hours. Infants who met these criteria received intramuscular ceftriaxone 50 mg/kg with instructions to follow-up in 24 hours. At the follow-up visit, infants with no identifiable source for infection and negative cultures received a second dose of intramuscular ceftriaxone and were discharged. Cultures were read at 48 hours and at the conclusion of the study. Medical records were reviewed to identify delayed complications.

RESULTS

172 infants were enrolled. The mean age was 45 days. All CBC, UA, CSF analyses were normal. Chest radiographs were obtained in 56 (30%) infants; all were normal. One (.05%) patient was admitted at the follow-up visit. The mean time to follow-up was 25 hours. Two positive cultures were identified at the re-evaluation visit; one blood culture grew Salmonella and a urine culture grew E. coli. The CSF cultures were all negative at follow-up and remained negative.

CONCLUSION

Febrile infants 4-8 weeks of age who meet outpatient therapy criteria and have negative cultures and no identifiable source for infection at 24 hours may not require the second dose of intramuscular ceftriaxone.

Advance directives in a pediatric emergency department

Parents of children with terminal illnesses are not always present when a life-threatening event occurs. For many of these children, an advance directive specifying alternate code orders has been written by the parent or legal guardian (hereafter the use of parent is to be interpreted as parent/legal guardian) and the patient's attending physician. Implementing a pediatric advanced directive presents significant problems for emergency personnel if the parent is not present to identify the existence of the directive and interpret the contents in the context of the current medical crisis.

Latex allergy: a patient and health care system emergency

Latex allergy, an IgE-mediated reaction to proteins retained in finished natural rubber latex products, has become one of the most pervasive problems in medicine. Latex allergy has resulted in death, progressive asthma, severe food allergy from cross-reactivity, and disability of health care professionals with the accompanied loss of self-esteem and income from their inability to work in their chosen profession. This article reviews the risks of latex allergy and proposes strategies for prevention and management of the problem.

Impact of violence and the emergency department response to victims and perpetrator. Issues and protocols

Research on the current epidemic of violence and its victims is limited. In the past decade, considerable attention has been focused in the area of domestic violence. Comprehensive emergency department (ED) domestic violence protocols have been developed and evaluated that address identification, treatment, safety issues, legal reporting statutes, and medical and psychosocial interventions. This article focuses on victims, perpetrators, and the occurrence of violence in the ED and describes issues and strategies for identification, intervention, and documentation.

False-positive preliminary radiograph interpretations in a pediatric emergency department: clinical and economic impact

A prospective, case control study at a university-affiliated, academic pediatric emergency department was undertaken to determine the clinical impact and cost of false-positive preliminary radiograph interpretations and to compare the cost of false-positive interpretations with the estimated cost of a 24-hour on-site pediatric radiologist. Data were collected on all patients undergoing radiography of the chest, abdomen, lateral (soft tissue) neck, cervical spine, or extremities during a 5-month period. A total of 1,471 radiograph examinations was performed, and 200 (14%) misinterpretations (false-positive and false-negative) by the pediatric emergency medicine physicians were identified. As reported previously, 20 (10%) of the false-negative interpretations were noted to be clinically significant, in the current analysis, 103 (7%) false-positive radiograph interpretations were identified. False-positive interpretations were noted more frequently (14%) for soft tissue lateral neck radiographs than for any other radiograph type. Of the 103 total false-positive radiographs, nine (0.6%) resulted in an increased patient cost totaling $764.75. These data show that false-positive radiograph interpretations have limited economic and clinical impact.

Chest radiography in the initial episode of bronchospasm in children: can clinical variables predict pathologic findings?

STUDY OBJECTIVE

To determine whether historical or clinical variables can accurately discriminate among children, experiencing a first episode of bronchospasm, with chest radiography findings that are normal, consistent with reactive airway disease (RAD), or pathologic.

METHODS

We assembled a prospective case series of patients in our tertiary, academic, pediatric emergency department. All patients aged newborn to 18 years presenting to the ED with their initial episode of wheezing were enrolled.

RESULTS

Six hundred thirty-three patients presented to the ED during the study period. Pathologic radiographic findings were identified in 39 (6.2%). Radiographs revealing normal findings and evidence of RAD were noted in 25.4% and 68%, respectively. No single variable accurately predicted all pathologic radiographs. Discriminant function analysis identified nine variables, which we combined into a model. The model failed to accurately discriminate among patients with radiographs revealing evidence of a pathologic condition, normal chest findings, and RAD.

CONCLUSION

No clinical variables, isolated or combined into a model, accurately identify patients with pathologic radiography findings. Continued use of chest radiography as a diagnostic intervention in the initial episode of childhood bronchospasm is recommended.

Clinical impact of radiograph misinterpretation in a pediatric ED and the effect of physician training level

Radiograph interpretation in the pediatric emergency department (ED) is commonly performed by pediatric emergency medicine (PEM) attendings or physicians-in-training. This study examines the effect of physician training level on radiograph interpretation and the clinical impact of false-negative radiograph interpretations. Data were collected on 1,471 radiographs of the chest, abdomen, extremity, lateral neck, and cervical spine interpreted by PEM attendings, one PEM fellow, one physician assistant, and emergency medicine, pediatric and family practice residents. Two hundred radiographs (14%) were misinterpreted, including 141 chest (16%), 24 extremity (8%), 20 abdomen (12%), 14 lateral neck (18%), and 1 cervical spine radiograph (2%). Physicians-in-training misinterpreted 16% of their radiographs versus 11% for PEM attendings (P = .01). Twenty (1.4%) radiographs had clinically significant (false-negative) misinterpretations, including 1.7% of physician-in-training and 0.8% of attending interpretations (P = 0.15). No morbidity resulted from the delay in correct interpretation. Radiograph misinterpretation by ED physicians occurs but is unlikely to result in significant morbidity.

The role of abdominal x-rays in the diagnosis and management of intussusception

The management of intussusception requires early diagnosis and reduction with either barium enema or surgical intervention. Supine and erect abdominal radiographs are often obtained prior to ordering a barium enema. In many pediatric centers, the critical, initial interpretation of these radiographs is made by nonradiologists and, in most instances, by pediatric emergency physicians. We determined the sensitivity and specificity of abdominal radiographs in diagnosing intussusception when interpreted by these physicians. Six full-time pediatric emergency physicians evaluated 126 radiographs from 42 patients with intussusception, 42 in whom the disease was clinically suspected but ruled out, and 42 in whom the final radiology report was "normal." These were presented to pediatric emergency physicians in a blinded, randomized sequence without any additional clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% (range, 71-93%), and the mean specificity was 58% (range, 48-69%). This compares favorably to the sensitivity of signs and symptoms, and we conclude that plain and upright abdominal films are a useful adjunct for the clinician evaluating patients for suspected intussusception.

Upper airway dysfunction--an unusual presentation of Guillain-Barré syndrome

We report the case of a 9-year-old boy who presented to the emergency department with dysphagia, respiratory distress, hoarseness, and generalized weakness. While in the ED, his respiratory status deteriorated, and he required intubation. At that time, he was found to have normal upper airway anatomy. He was admitted to the pediatric ICU and, within 24 hours, developed areflexia and muscle weakness; he was diagnosed with Guillain-Barré syndrome. Atypical presentations of Guillain-Barré syndrome are discussed, and the necessity of considering this diagnosis when evaluating patients with evidence of cranial nerve dysfunction or upper airway distress is emphasized.

The effect of oral midazolam on anxiety of preschool children during laceration repair

Preschool age children often experience marked anxiety and physical pain during laceration repair. Locally infiltrated anesthetics or topical tetracaine, adrenaline, and cocaine (TAC) usually control the physical pain but have little or no effect on anxiety. Midazolam is a short-acting benzodiazepine with anxiolytic, hypnotic, and antegrade amnestic effects. In a double-blind, randomized clinical trial, we evaluated the efficacy of midazolam in alleviating anxiety during laceration repair in children less than 6 years old. On admission to the emergency department, anxiety level was determined on a scale of 1 to 4 based on a predetermined behavior criteria. Patients with high anxiety level (3 or 4) received a single oral dose of either midazolam (0.2 mg/kg) or placebo. The anxiolytic effect of midazolam was considered adequate if the anxiety level decreased two or more points (from 4 to less than or equal to 2 or from 3 to 1) during laceration repair. In the midazolam group (30), 70% of the children had a two-point or more decrease in anxiety level compared with 12% in the placebo group (25) (P less than .0001). No respiratory depression or other complications were noted in the midazolam group. We conclude that a single oral dose of midazolam (0.2 mg/kg) is a safe and effective treatment for alleviating anxiety in children less than 6 years old during laceration repair in the ED.

HMOs and pediatric emergency care

In 1984, recipients of Aid to Families of Dependent Children in Milwaukee County, Wisconsin, were assigned to health maintenance organizations (HMOs). Difficulties in delivering quality pediatric emergency care were associated with this HMO assignment process. Three pediatric emergency cases are presented to illustrate these difficulties. Suggestions for maintaining high quality pediatric emergency care for health maintenance organization patients who are recipients of Aid to Families of Dependent Children are presented.

Intraosseous infusion of phenytoin

In the critically ill child, administration of fluids and medications via the intraosseous route often proves life-saving. The authors describe the case of a child with status epilepticus in whom phenytoin was administered via the intraosseous route, and seizure resolution and therapeutic serum levels were achieved. Intraosseous drug administration should be reserved for the rare critically ill child in whom vascular access proves impossible.