Pediatric Emergency Care 2015

Treatment


1. Pediatr Emerg Care. 2015 Sep 24. [Epub ahead of print]

A Randomized Controlled Trial of Positioning for Lumbar Puncture in Young
Infants.

Hanson AL(1), Schunk JE, Corneli HM, Soprano JV.

Author information: 
(1)From the *Division of Pediatric Emergency Medicine, Department of Pediatrics, 
University of Louisville School of Medicine, Louisville, KY; and †Division of
Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School
of Medicine, Salt Lake City, UT.

OBJECTIVE: The lateral and sitting positions are those most widely used to
perform lumbar puncture (LP) in infants. This study sought to compare LP success
rates by position. Secondary outcomes were successful on the first attempt and
rates of procedural complications.
METHODS: Infants aged 1 to 90 days undergoing LP in our pediatric emergency
department between June 1, 2012 and October 31, 2013 were randomized to 1
position or the other. Successful LP was defined as collection of cerebrospinal
fluid with a red blood cell count of less than 10,000 cells/mm on either of the
first 2 attempts. Electronic medical records were reviewed for patient
information, cerebrospinal fluid results, and procedural complications. Providers
completed a questionnaire detailing their previous LP experience and technique.
Primary results were analyzed using the intention-to-treat principle.
RESULTS: We enrolled 168 infants. Of 167 with data eligible for analysis, 82
(49%) were randomized to the lateral position. There was no statistically
significant difference in LP success rate between the lateral (77%, 63/82) and
sitting (72%, 61/85) positions (difference, 5.1%; 95% confidence interval,
-8.2%-18.3%). There were no significant differences in success on the first LP
attempt or the rates of procedural complications.
CONCLUSIONS: Among infants 1 to 90 days of age, this study found no difference in
LP success between the lateral and sitting positions.

PMID: 26417957  [PubMed - as supplied by publisher]


2. Pediatr Emerg Care. 2015 Sep;31(9):611-5. doi: 10.1097/PEC.0000000000000544.

A Prospective Pilot Study of the Use of Telemedicine During Pediatric Transport: 
A High-Quality, Low-Cost Alternative to Conventional Telemedicine Systems.

Patel S(1), Hertzog JH, Penfil S, Slamon N.

Author information: 
(1)From the Department of Anesthesia and Critical Care Medicine, Nemours/Alfred
I. duPont Hospital for Children, Wilmington, DE.

OBJECTIVE: Few trials address the use of telemedicine during pediatric transport.
We believe that video conferencing has equivalent quality, connectivity, and ease
of operation, can be done economically, and will improve evaluation.
METHODS: Prospective randomized pilot study was used to examine video versus
cellular communication between the medical command officer (MCO) and pediatric
transport team (TT) for children with moderate to severe illness undergoing
interhospital transport. Twenty-five patients were randomized to cellular
communication, and 25 patients were randomized to video. The MCO completed a
Likert scale to evaluate connection, quality, and ease of operation. Call
durations were recorded. A Likert scale to evaluate the communication mode on
patient care was completed.
RESULTS: Connection and audio quality were equivalent and there were no dropped
calls. Average call duration in the phone group was 186 versus 139 seconds in the
video group (P = 0.055). The MCO survey results were the following: 100% found
video intuitive, 92% felt that disposition based on phone report was difficult,
80% felt that video provided better understanding of patient condition, 70% felt
that video assisted disposition, and 80% believe that video should be used for
transport. The iPad system offers a significant savings when compared with
conventional telemedicine.
CONCLUSIONS: Video conferencing seems as easy to complete as phone with
equivalent quality and connectivity. Duration of video was equivalent to phone
conferencing. Surveyed MCOs believed that video conferencing improved assessment
and disposition. The iPad-based conferencing provided significant savings when
compared with conventional cart-based or robotic units. Further evaluation of
video conferencing during interhospital transport is warranted.

PMID: 26335229  [PubMed - in process]


3. Pediatr Emerg Care. 2015 Nov;31(11):779-86. doi: 10.1097/PEC.0000000000000199.

Three-Dimensional Computed Tomography Skull Reconstructions as an Aid to Child
Abuse Evaluations.

Parisi MT(1), Wiester RT, Done SL, Sugar NF, Feldman KW.

Author information: 
(1)From the Departments of *Radiology, and †Pediatrics, ‡Seattle Children's;
§University of Washington School of Medicine; and ∥Harborview Hospital,
University of Washington School of Medicine, Seattle, WA.

OBJECTIVES: Skull fractures can be difficult to recognize on radiographs and
axial computed tomography (CT) bone windows. Missed findings may delay abuse
diagnosis. The role of three-dimensional (3-D) reconstructions in child abuse
evaluations was retrospectively evaluated.
METHODS: Twelve exemplary cases between August 2006 and July 2009 are described. 
All, except 2 medical-legal cases, were clinical abuse consultations. With the
use of a 1-to-3 scale, ease and accuracy of interpretation of findings between
plain films, bone windows, and 3-D CT images were independently assessed by 2
radiologists.
RESULTS: In 7 cases, skull fractures were missed on initial review of skull films
and/or bone windows. Three children sustained additional abusive injury before
3-D CT reconstructions demonstrated subtle skull fractures, though imaged, were
missed on initial readings. Three children with initially unrecognized fractures
had timely 3-D reconstructions confirming fractures, allowing protective
intervention before additional injury. An unrecognized ping-pong fracture was
discovered on 3-D reconstructions with an inflicted subdural hemorrhage, defining
the injury as an impact. Two 3-Ds demonstrated communication of biparietal
fractures along the sagittal suture. This changed interpretation to single,
rather than 2 separate, concerning impacts. Three potential skull fractures were
found to represent large sutural bones. In all cases, ease and accuracy of
interpretation scores were highest for 3-D CT.
CONCLUSIONS: Without increasing patient radiation exposure, 3-D CT
reconstructions may reveal previously unrecognized skull fractures, potentially
allowing abuse diagnosis before additional injury. They may clarify normal skull
variants and affirm accidental injury causes. We now routinely include 3-D
reconstructions on cranial CTs for children younger than 3 years.

PMID: 25198766  [PubMed - in process]


4. Pediatr Emerg Care. 2015 Feb;31(2):122-6. doi: 10.1097/PEC.0000000000000352.

The efficacy of isotonic and hypotonic intravenous maintenance fluid for
pediatric patients: a meta-analysis of randomized controlled trials.

Yang G(1), Jiang W, Wang X, Liu W.

Author information: 
(1)From the Department of Pediatric Surgery, *West China Hospital of Sichuan
University, †Center of Children Medicine, Sichuan Academy of Medical Sciences and
Sichuan Provincial People's Hospital, Chengdu, People's Republic of China.

AIM: This study aimed to analyze the effect of isotonic versus hypotonic solution
as intravenous maintenance fluid on level of plasma sodium in hospitalized
children.
METHODS: A fully recursive literature search in May 2013 was conducted in PubMed
and EMBASE to identify potentially relevant randomized controlled trials. Jadad
score and allocation concealment were adopted to evaluate the methodological
quality of each trial. RevMan5.2 was used for statistical analysis.
RESULTS: Eight randomized controlled trials with 752 patients were included.
Combined analysis showed a significant lower risk of hyponatremia with isotonic
solution (odds ratio, 0.36; 95% confidence interval, 0.26-0.51). The isotonic
intravenous maintenance did not increase the possibility of hypernatremia (odds
ratio, 0.86; 95% confidence interval, 0.36-2.06).
CONCLUSIONS: The meta-analysis revealed that there was potential risk of
hyponatremia for routine infusion of hypotonic maintenance fluid. The use of
isotonic solution was warranted in hospitalized pediatric patients.

PMID: 25654679  [PubMed - in process]

Diagnostic

None

Review

None

Clinical Prediction Rules

None