Category: Pediatrics

Send Children With Negative CTs Home

We should all love PECARN.  I love PECARN (Pediatric Emergency Care Applied Research Network) – and not just because I helped set it up as a research assistant peon before medical school.  I love it because it takes multicenter enrollment cohorts to conduct adequately powered research in a population that is rarely affected by serious morbidity and mortality.

Of 13,543 children with GCS 14 or 15 and a normal CT scan, none needed neurosurgical intervention in their follow-up period.  A small handful of these patients had a repeat CT or MRI for some reason, and between 10-25% of the hospitalized patients and 2-10% of the discharged patients had an abnormal result on repeat imaging.  None led to any intervention…which then, of course, begs the question whether it was appropriate to perform a test that did not result in meaningful change in management.  But, there’s not enough patients in this group to draw conclusions as to whether repeat scans should or should not be performed.

My only caveat – when you take an over-utilized test in which nearly all patients are certainly fine and will continue to be fine, you actually dilute its external validity to the patient population that really matters.  However, even in a higher-risk patient population in which CTs are used far more conservatively, the clinically relevant answer is still going to be same – the only reasonable practice is still going to be to discharge these patients home.

“Do children with blunt head trauma and normal cranial tomography scan results require hospitalization for neurologic observation?”
www.ncbi.nlm.nih.gov/pubmed/21683474

Surfactant for Hydrocarbon Aspiration

I’ve seen surfactant administered for alveolar collapse following near-drowning, but this is a case report regarding surfactant use in severe pneumonitis after low viscosity/low volatility lamp oil.  Less than 1mL of similar aspirated hydrocarbons may result in significant lung injury.  In their specific case they administered 80 mL/m2 of surfactant intratracheally as rescue therapy when their patient continued to become hypoxemic despite recruitment maneuvers on mechanical ventilation.

Definitely something to keep in mind depending on the pathophysiology of the lung injury.

“Early administration of intratracheal surfactant (Calfactant) after hydrocarbon aspiration.”
http://www.ncbi.nlm.nih.gov/pubmed/21624880

Kids Are Too Fat For The Broselow Tape Now

Now that increasing numbers of children are overweight and obese (up to 36% of 10 to 17 year olds now), 53% of this pediatric sample from West Virginia fell out of the Broselow tape estimate based on height.  Of these, 77.1% of the incorrect weights were greater than that predicted by the Broselow.

It is West Virginia – not the healthiest state in the U.S. – but any hospital that serves a predominantly disadvantaged population may have similar results, and should realize that they may be under dosing their medications.  The authors suggest only a couple alternative strategies, but I think we’re probably just best off using clinical judgement as to whether the tape is accurate in each individual clinical situation.

“Is the Broselow tape a reliable indicator for use in all pediatric trauma patients?”
http://www.ncbi.nlm.nih.gov/pubmed/21629149

Pediatric Sexual History Should Not Be Neglected

I am torn regarding whether 82% represents appropriate performance on history taking in pediatric adolescent (ages 14 – 19) lower abdominal pain/dysuria/vaginal complaint, or whether that remaining 18% represents potentially uncaptured pathology.  Considering that 76% of patients asked regarding sexual history reported sexual activity, and 83% of their subgroup completing anonymous questionnaires reported sexual activity, I think >90% enquiry regarding sexual activity would be a better target.

So, we’re doing a pretty good job – but it could be better.

“Sexual history documentation in adolescent emergency department patients.”
http://www.ncbi.nlm.nih.gov/pubmed/21646260

Public Insurance Places Children At Risk

Determining proper payment for healthcare services is a fascinating problem of substantial complexity, and, with the “Affordable Care Act” and various past and future movements towards public insurance, there is a great deal of uncertainty regarding physician payment – both in the amount (public vs. private insurance) or whether (uncompensated care in hospitals, emergency departments).

This is a very interesting study out of NEJM that is applicable to the 70 to 80% of emergency departments we send home with instructions to “follow-up with X”.  They nicely demonstrate that, in Chicago, at least, “follow-up with X” is nearly trivially easy with private insurance, and much more difficult if funded by one of their Medicaid providers for children.  Excepting child psychiatry – which is in shortage – when calling a specialist for follow-up claiming to have private insurance, their research assistants could schedule an appointment well over 90% of the time.  Alternatively, when stating they had public insurance for their child, ability to follow-up ranged from 20 to 57%, depending on the specialty.

Not only that, public insurance patients waited a mean of 42 days for their appointment versus 22 days for private insurance, when they looked at clinics that would even accept that insurance option.

And, the clinical scenarios they presented for follow-up were not just routine new patient appointments – they were pediatric patients with legitimate uncontrolled morbid disease with the potential to significantly worsen and impact their overall health.

I don’t have a solution to a complex social, financial, and political problem with complex social, financial, and political obstacles – but the more good articles like this are published, the more likely smart folks will start working on solutions.

“Auditing access to specialty care for children with public insurance.”
http://www.ncbi.nlm.nih.gov/pubmed/21675891

Do Not Use Etomidate/Fentanyl For Orthopedic Reduction In Children

Sometimes, when I read a study, I think to myself – great study!  If only they had sufficient enrollment to have power and validity!  When I read this study, I thought, Heavens to Betsy – I am so glad they only subjected 12 patients to etomidate/fentanyl for sedation.

This is comparing ketamine/midazolam to etomidate/fentanyl for procedural sedation and the authors hoped that, perhaps, the shorter duration of action of etomidate would make it a viable alternative.  But, it isn’t.  Objective measures of procedural distress favored ketamine, parents favored ketamine, and the practitioners favored ketamine.  Sedation time and recovery time favored etomidate – but at what cost?  18% of the ketamine group had an adverse event (vomiting, emergency reaction), while 50% of the etomidate group did (hypoxemia, etc.)

Propofol/fentanyl may be considered, but not etomidate/fentanyl.

“Ketamine/midazolam versus etomidate/fentanyl procedural sedation for pediatric orthopedic reductions.”
http://www.ncbi.nlm.nih.gov/pubmed/20502386

Significant Populations Have No Timely Access to Stroke, Pediatric Trauma Care

These are a couple studies from a family of publications that use population data, GIS mapping tools, and travel times by air and ground to estimate what percentage of the population has access to a certain healthcare resource.  In these two papers, the resources in question are Primary Stroke Centers and Pediatric Trauma Centers.  They estimate that 71% of the pediatric population is within 60 minutes of a pediatric trauma center by ground or air – which is appropriate, because trauma systems are set up to use aeromedical transport.  However – and, depending on what direction the TPA pendulum swings – only 55.4% of the population has access to a stroke center within 60 minutes – by ground, which is typical.  They say this could be increased to 79% within 60 minutes if aeromedical resources were involved, but I think we should wait to establish a greater treatment effect for acute stroke treatment before we go nuts with air travel.

I like maps; I worked with one of the authors (Dr. Branas) on previous iterations of descriptive articles similar to these.  The problem with these articles is the statistic they describe – timeliness of care – may or may not have significant effects on patient outcomes.  And, in theory, the solutions – moving trauma center designations, establishing new stroke centers, increasing aeromedical use, etc., have significant costs and unintended consequences.

http://www.ncbi.nlm.nih.gov/pubmed/20937948
http://www.ncbi.nlm.nih.gov/pubmed/19487606

Fluid Boluses Increase Mortality In Children

…or, at least, that’s the gist of the New England Journal Article making rounds in the news.

And, while a close reading of the article doesn’t offer great support for harm, it certainly supports saying that albumin, saline, or nothing were equivalent.

The absolute difference in survival was 3% – and, looking at the demographic breakdown, there were 2-3% differences or trends in favor of the control group regarding dehydration, acidemia, base-deficit, and bacteremia.  Enough that it lets me cling in denial to standard practice and teaching here in the U.S., in addition to whatever you want to say about external validity of a study in resource-poor settings in Africa.

It is an odd and unexpected finding, so say the least.  The authors attribute at least part of the unusual discovery to the high percentage of malaria cases they treated, and that fluid resuscitation in malaria is controversial – but regardless, this is going to be a frequently discussed study on the Pediatric Critical Care side of things for some time.  I also expect follow-up confirmatory studies to be a tough sell to U.S. IRBs.

http://www.nejm.org/doi/full/10.1056/NEJMoa1101549

Comparison of Adult Head CT Rules in Pediatrics

Interesting – if limited in prospective use – retrospective comparison of the New Orleans, Canadian, and NEXUS II instruments for risk stratifying adults suffering minor head trauma.  Busy, urban children’s ED went through 8 years of data to find over 6000 patients with minor head trauma.

Unfortunately, they only looked at the 2,101 that received a head CT, so we lose a huge chunk of our population to “clinical judgement” that could have profoundly affected the specificity of the rules and perhaps had small effects on their sensitivity.

Full of interesting tidbits – 25% of their study population was under 2 years old, but 41% of their injuries were detected in the under 2 population.  Sensitivity and specificity essentially rose and fell with the percentage of the cohort scanned – the New Orleans rule would have scanned 89% of their cohort…that had an incidence of 4.4% of intracranial injury.  That made the sensitivity 96%, but the specificity 11% – and I hate to think what the specificity would have been if the other 4000 patients had been included.  The Canadian Rule scanned the least, missed the most at 65% sensitivity, but achieved a 36% specificity.

But the real question is – what’s the point?  The PECARN criteria get you up to ~96% sensitivity with a specificity of 53-58%.  Kids aren’t small adults – especially infants, and especially in trauma.  Don’t apply adult criteria in kids.

http://www.ncbi.nlm.nih.gov/pubmed/21465153

Intracranial Extension of Sinusitis in Children

Interesting descriptive study of a decade’s worth of children transferred/admitted to Texas Children’s in Houston with intra-orbital or intra-cranial extension of their sinusitis.  It’s really just a summary of the clinical and hospital courses of 118 patients identified through retrospective chart review.

Interesting tidbits:
– Of these patients, 40% had been prescribed outpatient courses of antibiotics prior to the time of diagnosis of intra-cranial or intra-orbital extension.
– All patients with intra-orbital involvement presented with eye swelling.
– Intra-cranial extension had substantially (and significantly) more headache and vomiting, and only 67% received antibiotics prior to transfer.
– Identical numbers in each group – 16% – of patients were afebrile upon presentation.
– 33% of patients with intracranial extension of sinusitis did not complain of a URI-like syndrome at presentation.
– Frontal sinus involvement was associated with 84% of their intra-cranial extension.
– All organisms recovered were sensitive to clindamycin or vancomycin plus cefotaxime except for a single pseudomonal infection.
– There were no deaths, and four patients had persistent neurologic or visual sequelae.

Short summary – orbital cellulitis was a little more straightforward in diagnosis than intracranial extension of sinusitis, and a significant minority of both groups would definitely diagnostic challenges.  CT imaging, anathema as it may be, is the diagnostic modality of choice.

http://www.ncbi.nlm.nih.gov/pubmed/20970813