PAS2006

Randomized Control Trial of Cast Versus Removable Brace in Children with Low Risk Ankle Fractures

Kathy Boutis, Andy Willan, Paul Babyn, Unni Narayanan, Benjamin Alman, Suzanne Schuh. Emergency Medicine, The Hospital for Sick Children, Toronto, ON, Canada.

BACKGROUND: Isolated distal fibular fractures in children are very low-risk for future complications. Standard therapy with casting carries risks, inconveniences, and use of subspecialty health care resources. A strategy that is more convenient while offering comparable comfort and protection is preferable.

OBJECTIVE: In children between the ages of 5 and 18 years with low risk ankle fractures, to determine if a removable ankle brace is at least as effective as casting with respect to recovery of performance of daily activities as measured by the Activities Scale for Kids (ASK) at 4 weeks post injury. Secondary objectives included determining differences in range of motion, pain scores, return to baseline activities, and patient preferences at 4 weeks.

DESIGN/METHODS: A non-inferiority randomized controlled, single assessor blinded, and single centre trial in a tertiary care pediatric emergency department (ED). Sample size of 111 patients with low risk fractures was based on testing the null hypothesis (H0) that the brace is 5% less effective at the 5% level and having an 80% probability of rejecting H0 if brace and cast are equally effective. H0 was tested by a t-test for a non-zero difference. For the other outcomes, proportions and means were compared with the Fisher Exact and Students t-test, respectively.

RESULTS: 679 ankle injuries presented to the ED from July 2003-September 2005. Of the 111 randomized patients, 104 were included in the final analysis, 54 brace and 50 cast. Follow up of the primary outcome was completed in 99% of patients. The mean ASK at 4 weeks was 91.3% in the brace group compared with 85.3% in the cast group, a mean difference of 6.0%, with the lower bound of a one-sided 95% confidence interval = 1.13%, p<0.0001. There were no differences in follow up of range of motion or pain scores at 4 weeks (p>0.05). However, 80.8% of the children in the brace group returned to normal activities by 4 weeks compared with 59.5% in the cast group (p=0.038). 54.0% of the children who received the cast would have preferred the brace versus 5.7% of children who received the brace would have preferred the cast (p<0.0001).

CONCLUSIONS: The removable ankle brace is no worse than the cast with respect to recovery of physical function and is superior with respect to returning to normal activities and patient preference.

Secretory Phospholipase A2: A Biomarker for Serious Bacterial Infection in Children Presenting with Fever to a Pediatric Emergency Department

Karim M. Mansour, Frans A. Kuypers, Sandra K. Larkin, Tammy N. Wang, Annabeth Miller, Claudia R. Morris. Emergency Department, Childrens Hospital Research Center Oakland, Oakland, CA; Childrens Hospital Oakland Research Institute, Oakland, CA.

BACKGROUND: Although the overall incidence of serious bacterial infection (SBI) is reducing with the advent of new vaccines, untreated bacterial infections are still a significant cause of morbidity and mortality. Since the biomarkers that are widely used to predict SBI, white blood cell count, absolute neutrophil count and c-reactive protein, have relatively low sensitivities, specificities and predictive values, the need to identify other more useful measures remain. Secretory phospholipase A2 (sPLA2) is a pro-inflammatory mediator that has been shown to be elevated during infection and may serve as a useful marker for SBI among febrile children.

OBJECTIVE: To examine the relationship between sPLA2 and bacterial infection in febrile children presenting to the emergency department.

DESIGN/METHODS: All children who presented to the emergency department with a temperature >38.5C were considered for enrollment into the study. Enrolled patients had a complete blood count, blood culture, urinalysis and urine culture obtained, as well as serum collected for sPLA2 analysis. An Enzyme Immunometric Assay (EIA) for sPLA2 type IIa (Cayman, Ann Arbor, MI) was used to determine sPLA2 concentrations. The patients were then divided into groups based on their final diagnosis and compared.

RESULTS: In the 76 patients studied, 60 (79%) had a presumed viral infection, 12 (16%) had a urinary tract infection, 2 (3%) had pneumococcal bacteremia, 1 had Kawasaki disease and 1 had acute lymphoblastic leukemia. A comparison of all patients is shown in the table below.

CONCLUSIONS: Among febrile children presenting without a source of infection, serum concentrations of sPLA2 differ significantly between those who are presumed to have a viral infection to those with known bacterial infection.

A Randomized Trial Comparing Triage Oxycodone vs. Codeine in Reducing Pain in Children with Suspected Forearm Fractures

Rachel L. Smith, Brent Griffith, Yan Yan, Robert M. Kennedy, Jan D. Luhmann. Pediatrics, Washington University School of Medicine, St.Louis, MO; Surgery, Washington University School of Medicine, St. Louis, MO; Washington University School of Medicine, St. Louis, MO.

BACKGROUND: Emergency (ED) triage analgesia administration provides timely management of fracture pain; however, the most effective agent has not been determined.

OBJECTIVE: To compare the efficacy of pain reduction and adverse effects (AE) of triage oxycodone (O) vs. codeine (C) to children with suspected forearm fractures.

DESIGN/METHODS: Children 4-18 years were randomized to receive O (0.2mg/kg, max 15 mg) or C (2mg/kg, max 120 mg) if an isolated forearm fracture was suspected by the ED triage nurse. All other ED staff were blinded to assignment. The primary outcome measure was a 5-point (0 = no pain, 4 = severe) visual analog scale (VAS) completed by subjects to assess pain at baseline (B) then at 30 min intervals until ED discharge or procedural sedation for fractures requiring reduction. Ten AE were assessed at B and the above intervals. Identification of the most painful part of the visit was assessed by subjects at discharge. Efficacy and AE of O vs.C were compared using generalized estimate equation modeling, which accounts for repeated measurements within subjects.

RESULTS: 107 subjects (mean age = 10.4 y, 55% AA, 56% M) were randomized to O (51 subjects) or C (56). Groups were similar in age, race, gender, presence or type of fracture, AE, pain between groups at B, and in number of interval surveys completed in O (4.4 + 2.0) vs. C (4.2 + 1.7). After adjusting for pre-defined covariates, O (mean = 1.6 + 0.13) reported a pain score lower than C (2.1 0.13; 95% CI: 0.09-0.72). The effect of O vs. C did not vary over time. Minor AE occurred in both groups but itching occurred less in O (OR: 0.37; 95% CI: 0.14-0.99). Two subjects in C developed urticaria. The most painful part of the visit was radiography (O = 41%, C = 38%) followed by extremity examination (O = 16%, C = 13%) then casting (O = 8%, C = 13%).

CONCLUSIONS: Triage-administered O provided greater pain reduction compared to C in children with suspected forearm fractures. Although minor AE occurred in both groups, itching occurred more in C. Identification of radiography as the most painful part of fracture evaluation underscores the need for early/triage administration of analgesia for suspected fractures.

Do Children with Acute Bronchiolitis Need Chest Radiographs?

Suzanne Schuh, Amina Lalani, Paul Dick, David Manson, Paul Babyn, Derek Stephens, Matthew Mokanski, Svetlana Khaikin, Upton Allen. Emergency Medicine; Paediatric Medicine; Diagnostic Imaging; Population Health Sciences; Infectious Diseases; Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.

BACKGROUND: Radiographs are recommended and often done in bronchiolitis. However, chest radiography suffers from many disadvantages and its main benefit lies in rare identification of diagnoses inconsistent with bronchiolitis. Therefore, radiography may rarely yield new useful information.

OBJECTIVE: To determine what proportion of infants with typical clinical presentation of bronchiolitis have radiographs inconsistent with bronchiolitis (primary); to determine diagnostic accuracy of radiographs read by the ED, to compare proportions of children scheduled for antibiotic therapy pre- versus post-radiograph, and rates of antibiotic therapy in children with radiographs accurately versus inaccurately interpreted.

DESIGN/METHODS: Prospective ED cohort study of 311 infants 2-23 months of age with typical and atypical clinical presentation of bronchiolitis and radiographs with either airway disease only (simple bronchiolitis), airway and airspace disease (complex bronchiolitis) and inconsistent diagnoses as per single radiologist. For a 95% confidence interval and assumed proportion of typical bronchiolitis with inconsistent radiographs 3% 2%, and =0.05, and =0.2, the number of patients with typical bronchiolitis is 260. 95% confidence intervals were calculated around the target proportions and McNemar and Fishers Exact tests used to compare proportions.

RESULTS: The rates of inconsistent radiographs were 2/265 (0.75%) cases of typical bronchiolitis (95% CI 0;1.8%) and 2/46 atypical cases [95% CI 0;10.2%] [P=0.002]. The ED misclassified 93 (28%) radiographs, with a false positive rate of complex bronchiolitis of 23.8%. Of 50 radiographs influential in subsequent antibiotic therapy (added post-radiograph in 47), 29 or 58% were inaccurately classified by ED, as compared to 65 inaccurate interpretations in 261 (24.8%) non-influential radiographs (P<0.0001). Thirty-eight of 93 infants with inaccurate radiographs (40.9%) received antibiotics versus 26/218 (11.9%) infants with accurate interpretations (P<0.0001).

CONCLUSIONS: Radiographs in typical bronchiolitis are almost always consistent with bronchiolitis, often misinterpreted and frequently result in unnecessary antibiotic therapy.

Does Ondansetron Reduce Vomiting Associated with Intravenous Ketamine Procedural Sedation? A Double Blind, Randomized, Placebo Controlled Trial

Tom Langston, Joe Wathen, Mark Roback, Lalit Bajaj. Childrens Hospital of Austin, Austin, TX; Pediatrics/Emergency Medicine, The Childrens Hospital/UCDHSC, Denver, CO.

BACKGROUND: Vomiting is a frequent adverse event associated with ketamine procedural sedation and analgesia (PSA). Ondansetron has been widely used in a variety of settings to reduce vomiting in children.

OBJECTIVE: To investigate whether the addition of ondansetron would reduce the incidence of vomiting associated with intravenous (IV) ketamine PSA.

DESIGN/METHODS: A double blind, randomized, placebo controlled trial was performed in a childrens hospital emergency department (ED). A convenience sample of patients undergoing PSA with IV ketamine were randomized to receive either ketamine (1 mg/kg) alone or ketamine plus ondansetron (0.15 mg/kg, max 4mg). All patients received glycopyrolate. Patients were contacted by phone to assess if any emesis had occurred within 24 hours after discharge from the ED. Primary outcome measures were vomiting in the ED and vomiting post discharge.

RESULTS: 223 patients (mean age 7.7 years, 58% male) were enrolled from 1/03 to 8/05. 109 patients (49%) were randomized to the placebo arm and 114 (51%) to the ondansetron arm. There were no differences between groups in age, gender, or preprocedural fasting time. Acute vomiting was more common in placebo group vs the ondansetron group: 13/109 (11.9%) vs 6/114 (5.3%). Follow-up data was obtained for 193/223 patients (86.5%). Total vomiting (acute + vomited at home but not in the ED) was more common in the placebo group vs the ondansetron group: 19/109 (17.4%) vs 10/114 (8.8%). Relative risk reduction = 49.7% (95% CI = -3.3%, 75.5%), Absolute risk reduction = 8.7% (95% CI = -0.2%, 17.5%). The number needed to treat to prevent one patient from vomiting = 12.

CONCLUSIONS: Ondansetron reduces the incidence of vomiting associated with IV ketamine procedural sedation. Ondansetron may be considered as an anti-emetic for children undergoing PSA with IV ketamine.

L.M.X.4 vs. LET for Topical Anesthesia in the Repair of Facial Lacerations in the Pediatric Emergency Department

Jill Jasper, A. Chantal Caviness. Dept. of Pediatrics-Emergency Medicine, Baylor College of Medicine, Houston, TX.

BACKGROUND: Local anesthesia in the pediatric emergency department (PED) is a necessity in the treatment of lacerations. Injection of anesthesia is the most common route used to anesthetize lacerations but can cause pain and anxiety for children. For these reasons, many PED personal are pretreating lacerations with topical anesthesia.

OBJECTIVE: To compare the anesthetic efficacy of L.M.X.4 and LET (lidocaine, epinephrine, tetracaine) solution for facial laceration repair and to determine the need for supplemental injected anesthesia.

DESIGN/METHODS: We performed a double-blind, randomized, clinical trial including patients 5-18 years old who presented to an urban tertiary hospital PED for laceration repair. Eligible patients had uncomplicated facial lacerations less than 5 cm in length. All subjects were consented and randomized to L.M.X.4 or LET. The wound edge was assessed for adequate anesthesia using the visual analog scale (VAS).If the VAS score was 20 mm, the laceration was repaired. If the VAS score was >20 mm, the laceration was infiltrated with 1% lidocaine with epinephrine. The primary endpoint was the VAS score before suturing and before lidocaine infiltration, if needed. The need for supplemental lidocaine was a secondary outcome.

RESULTS: Thirty-four patients were enrolled with 17 randomized to L.M.X.4 and 17 to LET. One subject was excluded from the LET group after randomization. Fifty-one percent of participants were between the ages of 5 and 8 years, and 49% were between the ages of 9 and 18. The mean VAS score was 17 mm (95% CI 7.7, 26.3) in the LET group and 25.4 mm (95% CI 9.1, 41.7) in the L.M.X.4 group (p=0.39). Given an unexpectedly high variability of VAS scores in the younger age group, adequate power to detect a difference between LET and L.M.X.4 was achieved only for the 9- to-18-year age group. In this age group, the mean VAS score was 9.6 mm (95% CI 5.3, 14.0) for those in the LET group and 7.4 mm (95% CI 5.2, 9.5) for those in the L.M.X.4 group. Three (18.8%) in the LET group and 4 (23.5%) in the L.M.X group required supplemental lidocaine (P=0.74).

CONCLUSIONS: L.M.X.4 provides similar anesthesia to LET for facial laceration repair of 9- to- 18-year-old patients in the pediatric ED. This implies that either medication can be used to pretreat lacerations with similar reduction in the requirement for supplemental injectable lidocaine.

Risk Factors for Extremely Long Length-Of-Stay Among Pediatric Emergency Patients

Kyle A. Nelson, Sarah E. Boslaugh, Dee Hodge III. Pediatric Emergency Medicine, Washington Univ Schl of Med, St. Louis, MO; Pediatrics/Biostatistics, Washington Univ Schl of Med, St. Louis, MO.

BACKGROUND: Emergency unit (EU) length-of-stay (LOS) is often cited as a measure of efficiency and flow. Long LOS has implications for patient care, staffing, and patient satisfaction. As part of our continuous quality improvement process, we track LOS as an indicator in our pediatric EU. We noticed an increasing number of visits with LOS>10 hours, considerably longer than our mean LOS of 2.8 hours.

OBJECTIVE: We sought to characterize visits with LOS>10 hours and identify risk factors for this extremely long LOS.

DESIGN/METHODS: We identified 81 case visits with LOS>10 hours from 1/1/2001 to 6/30/2003. In a retrospective case-control study, we compared these cases to 405 age-matched control visits with LOS<10 hours. Statistical techniques used included Chi analyses, independent t-tests, and binary logistic regression to determine both unadjusted and adjusted odds ratios.

RESULTS: The groups were similar in age, gender, month of visit, mode of arrival, and supervising physicians. Cases were more likely to arrive during nightshifts, have laboratory tests, radiological studies (radiographs, CT scans, ultrasounds, or fluoroscopic studies), procedures, sedations, subspecialty consultations, chief complaints of abdominal pain, diagnoses of appendicitis, and require hospitalization. After adjustment for other variables, risk factors for LOS>10 hours were: younger age (OR=0.9; 95% CI 0.83-0.98), nightshift arrival (OR=5.2; 95% CI 1.9-14.4), laboratory test (OR=23.8; 95% CI 7.2-79.0), CT scan (OR=23.1; 95% CI 7.3-73.1), medical procedure (OR=7.4; 95% CI 2.4-23.1), and subspecialty consultation [if 1 consult (OR=5.2; 95% CI 1.9-14.6); if >1 consult (OR=12.8; 95% CI 3.1-52.8)]. Although cases had a larger proportion of White patients than controls (57% vs. 31%), race was not a risk factor after adjustment for other variables. These data suggest that LOS>10 hours is associated with medical needs of patients, but is not independently associated with race.

CONCLUSIONS: Risk factors for LOS>10 hours in our pediatric EU were younger age, nightshift arrival, use of laboratory tests or CT scans, completion of procedures, and subspecialty consultations. We must improve methods to promptly identify patients with these risk factors and improve procedures to more efficiently provide the necessary evaluation and care.

Multi-Center Validation and Refinement of a Clinical Decision Rule for Identifying Children with CSF Pleocytosis at Low Risk of Bacterial Meningitis

L. Nigrovic, N. Kuppermann, C. Macias, C. Cannavino, D. Moro-Sutherland, R. Schremmer, S. Schwab, D. Agrawal, K. Mansour, J. Bennett, Y. Katsogridakis, M. Mohseni, B. Bulloch, D. Steele, R. Kaplan, M. Herman, S. Bandyopadyay, P. Dayan, U. Troung, V. Wang, B. Bonsu, J. Chapman, R. Malley. Pediatric Emergency Medicine Collaborative Research Committee, AAP.

BACKGROUND: Children with cerebrospinal fluid (CSF) pleocytosis are routinely hospitalized and treated with parenteral antibiotics, although few have bacterial meningitis (BM). Our previously developed Bacterial Meningitis Score (BMS) identifies patients at low risk of BM if they fulfill all of the following criteria: negative CSF Gram stain, CSF absolute neutrophil count (ANC) < 1000 cells/mm3, CSF protein < 80 mg/dL, peripheral blood ANC < 10,000 cells/mm3, and absence of seizure.

OBJECTIVE: To validate and further refine the BMS in the era of widespread pneumococcal conjugate (PCV7) vaccination.

DESIGN/METHODS: We retrospectively identified a cohort of all children with CSF pleocytosis (CSF white blood cells 10 cells/mm3) and no antibiotic pretreatment age 1 month18 years who presented to the emergency departments of 20 U.S. centers between 2001 and 2004. BM was defined as a positive CSF culture and/or a CSF pleocytosis with a positive blood culture. We evaluated the performance of the BMS for predicting patients at very low risk of BM and performed recursive partitioning to refine the decision rule.

RESULTS: Among 3312 patients with CSF pleocytosis, 120 [3.6%; 95% confidence interval (CI): 3.0-4.3%] had BM. Of the 1714 patients categorized as low risk by the BMS, 2 had BM [Negative Predictive Value (NPV) 99.9%; 95% CI: 99.6-100%]. Eighty-three percent of the low risk patients were hospitalized. Using recursive partitioning analysis, we identified the following low risk predictors: CSF protein < 80 mg/dL, negative CSF Gram Stain, and peripheral ANC < 10,000 cells/mm.3 Of 1786 patients predicted to be at low risk by the recursive model, 3 had BM (NPV 99.8%: 95% CI: 99.5-100%).

CONCLUSIONS: This large study validates the BMS decision rule in the era of PCV7 vaccination. The BMS accurately identified patients at low risk of BM, with a misclassification rate of 0.1%. Recursive partitioning analysis simplified the model without improving performance. Future studies should evaluate use of the BMS to guide clinical decision making in patients with CSF pleocytosis.

Validation of a Clinical Decision Instrument in Identifying Children with Intra-Abdominal Injuries

James F. Holmes, Amy Mao, Smita Awasthi, David H. Wisner, Nathan Kuppermann. Emergency Medicine, UC Davis School of Medicine, Sacramento, CA; Surgery, UC Davis School of Medicine, Sacramento, CA.

BACKGROUND: Identification of children with intra-abdoiminal injuries (IAI) can be difficult.

OBJECTIVE: To validate the performance of a previously derived clinical decision instrument to detect children with IAIs.

DESIGN/METHODS: We conducted a prospective observational study of children with blunt torso trauma who were evaluated for IAI with abdominal computed tomography (CT) or laparotomy at a level 1 trauma center. The emergency department (ED) physician providing care documented history and physical examination findings onto a standardized data form prior to knowledge of the presence or absence of IAI. The clinical decision instrument used included the following six high-risk components: low age-adjusted systolic blood pressure, abdominal tenderness, femur fracture, elevated liver enzymes (serum aspartate aminotransferase concentration > 200 U/L or serum alanine aminotransferase concentration > 125 U/L), urinalysis > 5 RBCs/hpf, and an initial hematocrit < 30%.

RESULTS: 934 children with blunt trauma with a mean age of 9.7 5.7 years were enrolled. 775 (83%) patients had the necessary variables in the decision instrument documented and make up the study population. Ninety-four (94%, 95% CI 87, 98%) of the 100 patients with an IAI were identified by the clinical decision instrument. Of the 6 patients not identified by the decision instrument only one underwent laparotomy for their IAI. This patient had a serosal tear and a mesenteric hematoma which did not require therapy. 258 (33%, 95% CI 30, 37%) patients had none of the six high risk variables in the decision instrument, and 252 (98%, 95% CI 95, 99%) did not have an IAI.

CONCLUSIONS: A clinical decision decision instrument consisting of six variables easily obtainable in the ED, identifies most children with IAI including all children who require specific intervention for their IAI. Application of the clincia decision instrument would have significantly reduced the number of abdominal CT scans performed. Further refinement of this rule, however, is indicated.

Prospective Validation of the Pediatric Appendicitis Score (PAS)

M. Bhatt, D. McGillivray, G. Dougherty. Pediatrics, Montreal Childrens Hospital, Montreal, QC, Canada.

BACKGROUND: Appendicitis can be a difficult diagnosis in children. Clinical scores attempt to improve diagnostic accuracy but most are not unique to pediatrics and have not been consistently validated. The PAS showed excellent performance in the derivation study, but was administered by surgeons in a referred population and has not been externally validated.

OBJECTIVE: To validate the PAS in a non-referred population by non-surgeons.

DESIGN/METHODS: A convenience sample of children, 4-18 yrs old, presenting to a pediatric ER with 72 hours of abdominal pain and in whom a diagnosis of appendicitis was considered was prospectively evaluated. Children who were non-verbal, had previous appendectomy, or chronic abdominal pathology were excluded. PAS components (RLQ and hop tenderness, anorexia, pyrexia, emesis, pain migration, leukocytosis, neutrophilia) were collected on a standardized form by the treating physician who was blind to the scoring system. Interobserver assessment was completed when possible. Appendicitis was defined as appendectomy with positive histology. At 1 month, discharged patients were contacted to verify final outcome. Sensitivity, specificity and NPV of the score were calculated. PAS overall performance was assessed by the receiver operating characteristic (ROC) curve.

RESULTS: 246 children (mean 11.8yrs) were enrolled from Nov 2003-Jul 2005. 84 (34%) had pathology proven appendicitis. Mean PAS in children with and without appendicitis was 7.3 (SD 1.2) and 3.3 (SD 1.5) respectively (p<0.0001). There was no difference in mean age, duration of symptoms or sex between groups. If a PAS of <5 was used to discharge patients without further investigation, 2 (2.4%) patients with appendicitis would have been discharged. At this cutpoint, the scores sensitivity was 97.6%, specificity 52.1% and NPV 97.7%. If a PAS of >7 determined need for appendectomy, 8 (4.9%) children would have undergone a negative appendectomy. At this cutpoint, the scores sensitivity was 54% and specificity 95%. The area under the ROC curve was 0.90. PAS interobserver scores were determined in 14.6% of patients. 94% of scores correlated within 2 points, with 2 patients having a change in management based on our cutpoint.

CONCLUSIONS: The PAS is a useful tool in the evaluation of children with possible appendicitis. Scores <5 help rule out appendicitis while scores >7 help predict appendicitis. Patients with PAS 5-7 may need further radiological evaluation.

Evaluating Appendicitis Scoring Systems Using a Prospective Pediatric Cohort

Carisa Schneider, Anupam Kharbanda, Richard Bachur. Medicine, Childrens Hospital, Boston, MA; Emergency Medicine, Morgan Stanley Childrens Hospital, NY, NY; Emergency Medicine, Childrens Hospital, Boston, MA.

BACKGROUND: Pediatric appendicitis (AP) is diagnostically challenging. Previous literature proposes scoring systems to risk stratify patients being investigated for AP. Alvarado (Ann Emer Med, 1986) and Samuel (J Ped Surg, 2002) are the two most cited AP scoring systems.

OBJECTIVE: To compare the performance of Alvarado (ALV) and Samuels (SAM) appendicitis scoring systems in a prospectively-identified pediatric cohort.

DESIGN/METHODS: As part of a larger study to develop a prediction rule for pediatric AP, a prospective cohort was studied for 20 consecutive months at a large, urban pediatric hospital. Patients requiring surgical consultation for potential AP were enrolled. Study forms were completed by pediatric emergency medicine attendings during the ED visit prior to imaging or surgery. Final diagnosis was determined by pathology or follow-up phone call. Both ALV and SAM utilized a point system (see Table 1) for scoring. Surgery was recommended for point values of 7 (ALV) and 6 (SAM) with published sensitivities of .81(ALV) and 1(SAM).

RESULTS: 588 patients were studied. Median age 11.9y (IQR 8.5,14.9y). 34% had AP. Based on point values of 7(ALV) and 6(SAM), the sensitivity and negative predictive value (NPV) for each score system was 72% [95% CI 66,78] and 85%[81,89] for ALV and 82% [77,87] and 88% [84,91] for SAM. When only patients <10y were analyzed, the sensitivity and NPV for each score system was 73% [62,84] and 89% [83,94] for ALV and 77% [66,87] and 88%[82,94] for SAM. ROC analysis of all scores yielded an area under the curve of 0.82 (ALV) and 0.81 (SAM).

CONCLUSIONS: Neither scoring system adequately predicted appendicitis. These scores should not be applied in clinical practice, and certainly not to determine the need for surgery. Future scoring systems would benefit from the addition of laboratory and radiologic advances to accurately diagnose appendicitis.

Prevalence of Serious Bacterial Infection in Infants 60 Days Old with an Apparent Life Threatening Event (ALTE)

Noel S. Zuckerbraun, Arezoo Zomorrodi, Raymond D. Pitetti. Pediatrics, Ped Emerg Med, U of Pitt, Childrens Hosp of Pittsburgh, Pittsburgh, PA.

BACKGROUND: Infants with an ALTE often undergo extensive evaluation to determine the etiology, including an evaluation for infection.

OBJECTIVE: To describe the prevalence of serious bacterial infections (SBI) in infants 60 days old with an ALTE.

DESIGN/METHODS: We retrospectively reviewed microbiologic testing in a prospectively enrolled cohort of patients 60 days old with an ALTE, who were well-appearing, afebrile and admitted to a tertiary care childrens hospital from 1/02-7/05. Patients were followed throughout their hospitalization and for 6 months following discharge. Results of testing (blood, urine, cerebrospinal fluid (CSF), respiratory and stool studies) and chest x-rays (CXR) were recorded. SBI was defined as a positive blood, urine or CSF culture for bacteria, pertussis PCR or CXR read by a radiologist as pneumonia. Demographic and clinical characteristics were compared among those who did and did not undergo microbiologic testing, those who did and did not undergo a full sepsis evaluation (FSE; blood, urine and CSF) and those who did and did not have SBI.

RESULTS: 296 patients with an ALTE were enrolled. Of the182 patients who were 60 days old, 112 (61.5%) had microbiologic tests and 52 (28.6%) had a FSE. 5 patients (2.7%) had a SBI which included 3 blood cultures (E. coli, E. faecalis, Group B Streptococcus), 1 urine culture (E. coli) and 1 pertussis PCR. No patient had a positive CSF culture. 3 patients had a positive viral test (1 parainfluenza, 1 RSV and 1 ROTA). 160 patients (87.9%) had a CXR; the 4 with pneumonia had a known source (2 bacteremia, 2 positive viral tests). Patients who had microbiologic tests were significantly more likely to have had a history of a prodrome, change in mental status or limpness and were significantly less likely to have had a prior or family history of an ALTE. Patients who had a FSE were younger (23.4 vs 29.2 days, p=0.05), were significantly more likely to have had a change in tone or limpness and were significantly less likely to have choked. Only a history of prematurity was associated with a SBI (6.7 vs 0.8%, p=0.04).

CONCLUSIONS: SBI occurred in 2.7% of well appearing, afebrile infants 60 days old with an ALTE. Only prematurity was associated with having SBI. For patients with ALTE 60 days old and those with a history of prematurity, evaluation for a SBI is indicated.

Ultrasound Measurement of the Inferior Vena Cava Diameter in the Assessment of Children with Dehydration

Lei Chen, Yunie Kim, Karen Santucci. Pediatrics, Yale University School of Medicine, New Haven, CT; Yale University School of Medicine, New Haven, CT.

BACKGROUND: Dehydration is a common condition in children. Various physical exam findings and laboratory results are used by clinicians to evaluate the degree of dehydration in children. Accurate assessment of intravascular volume status, however, is fraught with difficulties. Bedside ultrasound measurement of the inferior vena cava (IVC) diameter may offer a more objective and noninvasive measure of intravascular volume in children.

OBJECTIVE: To compare the IVC diameter of dehydrated children with controls and to compare the IVC diameter before and after intravenous hydration in the subjects.

DESIGN/METHODS: A prospective case-control study was carried out in an urban pediatric emergency department. Children between birth and 16 years of age were eligible as subjects if they presented with clinical evidence of dehydration and were treated with intravenous (IV) fluids. Bedside ultrasound measurements of the IVC and aorta (Ao) were taken before, and immediately after, IV fluids were administered. An age, gender, and weight-matched control without dehydration was enrolled for each subject. The IVC/Ao ratios of subjects and controls were compared using the Wilcoxon signed rank test, as were the ratios pre- and post- IV hydration for each subject.

RESULTS: During the study period 25 pairs of subjects and matched controls were enrolled. The mean (SD) age of the subjects was 8 years (+/-5.6). Mean (SD) IVC/Ao ratio for subjects was 0.74 (+/- 0.13), compared with 1.01(+/- 0.11) for the controls (p<0.001). After hydration the mean (SD) IVC/Ao ratio in the subjects was 1.10 (+/-0.18). This difference between pre- and post- hydration ratios was also significant (p<0.001).

CONCLUSIONS: The IVC/Ao ratio was smaller in children with dehydration as compared to controls, as measured by bedside ultrasound. In addition, increases in the ratios were measured after IV hydration. Bedside ultrasound measurement of the IVC is an objective method in evaluating children with dehydration.

Accuracy and Speed of Different Resuscitative Aids in Pediatric Mock Codes

K. Franco, R. van Amerongen, J. C. Foltin, I. Datta, K. Sadow, M. Waseem, M. G. Tunik. Pediatric Emergency Medicine, NYUSOM, NY, NY; Emergency Medicine, NY Methodist Hospital, Brooklyn, NY; Emergency Medicine, Mt. Sinai SOM, NY, NY; Emergency Medicine, Lincoln Hospital Center, Bronx, NY.

BACKGROUND: The Broselow Tape (BT) aids in determining weights, medication doses and equipment sizes. It is more accurate than MDs or RNs child weight estimates. No studies comparing BT to other resuscitation aids (RA) exist. Pilot data revealed significant improvement in medical errors in groups using the BT versus other RA.

OBJECTIVE: To determine if resident use of the BT during mock codes results in more accurate weight estimation, fewer medication dose and equipment size errors and took less time than other RA.

DESIGN/METHODS: A multi-center, prospective randomized study was performed. 3rd year pediatric (Peds) and emergency medicine (EM) residents participated in a pediatric mock code. Randomly assigned differences included: resuscitative aid (BT, Harriet Lane (HL), Crash Card (CC) and Survival Card (SC); manikin size (child, infant). All were instructed on how to use the assigned aid. 8 questions were asked regarding medication doses and equipment sizes. Responses and times were recorded. Resident performance was kept confidential.

RESULTS: 38 Peds 30 EM residents participated. 17 (25%) residents were assigned BT, 16 (24%) HL, 19 (28%) CC and 16 (24%) SC. 29 residents were assigned the infant manikin; 39 the child manikin. Differences were identified through bivariate comparisons and confirmed by multiple linear regression. SC use resulted in less accurate weight estimate (4.5 kg higher) and less accurate defibrillation dose estimate (12 joules higher) than BT, p<.05. BT use resulted in faster atropine dose estimate (6-10 sec) than all other RA, p<.05. SC use resulted in longer time to blade size (18 sec) and epinephrine dose (22 sec) estimates than BT, p<.05. Peds residents were slower (1.6 sec) than EM in weight estimate, p<.05.

CONCLUSIONS: The BT is better at producing accurate weight and defibrillation dose estimates, and faster at estimating blade size and epinephrine dose than SC. BT use produced faster atropine dose estimates than all other RA. As accuracy and speed are important in pediatric resuscitations, the BT should be used more often to eliminate the need for calculations and allow physicians to focus on the decision-making aspects of resuscitations.

Presence of a Family Member Does Not Affect Success of Lumbar Puncture in a Pediatric Emergency Department

Lise E. Nigrovic, Mark I. Neuman. Division of Emergency Medicine, Childrens Hospital Boston.

BACKGROUND: The presence of a family member during pediatric invasive procedures such as lumbar puncture (LP) has been shown to reduce patient stress and anxiety. However, family presence might be expected to affect clinicians stress and anxiety, with uncertain consequences for procedural success.

OBJECTIVE: To determine the effect of family member presence on the number of LP attempts and the incidence of bloody or unsuccessful LPs in children.

DESIGN/METHODS: We performed a prospective cohort study of consecutive children undergoing a LP in a single pediatric emergency department between July 2003 and January 2005. Presence of a family member, defined as a relative or guardian, during the procedure was recorded. A bloody LP was defined as cerebrospinal fluid (CSF) red blood cells (RBC) 10,000 cells/mm.3 An LP was considered unsuccessful when attempts at the procedure yielded no CSF for cell counts.

RESULTS: Of the 1474 eligible LPs, 1459 (99%) were included in the analysis. A family member was present for 1178 (81%) of all procedures studied. Neither the mean number of LP attempts (1.6 present vs. 1.7 absent; p =0.16) nor the incidence of bloody or unsuccessful LPs (25% present vs. 23% absent; p=0.58) differed by family member presence. After adjusting for patient age, patient race, time of day, and physician prior experience with LPs, the success rate of LP did not differ based on presence of a family member (adjusted odds ratio 0.8; 95% confidence interval 0.6-1.2).

CONCLUSIONS: Neither the number of attempts nor the incidence of traumatic or unobtainable LPs differed based on family member presence. The benefits of having a family member present at time of procedure are therefore not counterbalanced by adverse effects on procedural success.

Does Length-Based Resuscitation Tape Accurately Place Patients into Appropriate Color-Coded Zones?

Andrew Hashikawa, Jim Homme, Brian Gardner, Young Juhn, Brian Moore. Pediatric Medicine, Mayo Clinic, Rochester, MN; Emergency Medicine, Mayo Clinic, Rochester, MN; Pediatric Pharmacy, Mayo Clinic, Rochester, MN.

BACKGROUND: Visual weight estimation is unreliable. Length-based resuscitation tape (LBT) was developed from data collected between 1963 and 1975. Accuracy of LBT in an era of increasing obesity trends is unclear. Little is known about the relationship of LBT based color zones used for drug dosing and actual weight determined color zones.

OBJECTIVE: To determine the relationship between LBT based color-coded zones and actual weight based color-coded zones.

DESIGN/METHODS: Data were retrospectively abstracted from 839 patients in Rochester, MN at birth, 4-6 and 10-12 years of age. Children with height exceeding LBT or with incomplete data were excluded. Actual height was plotted on Broselow-Luten tape to determine estimated weight and corresponding color zone. Patients actual weight based color zone was obtained by plotting measured weight on LBT. Degree of discrepancy between LBT based color zones and actual weight based color zones were assessed.

RESULTS: Total of 544, 520 and 143 subjects were analyzed at birth, 4-6 and 10-12 years of age respectively. Among infants, all LBT based color zones were the same as actual weight based color zones. In children age 4-6 years, 70% (n=361) of LBT estimated color zones were the same as actual weight based color zones; LBT underestimated color zones for 19% (n=99) of subjects by one color zone below actual weight based color zone; 0.5% (n=3) were underestimated by two color zones; 0.6% (n=3) exceeded weight limit on LBT; 10.3% (n=54) were overestimated by one color zone. In adolescents 10-12 years, 40.5% (n=58) of LBT estimated color zones were the same as actual weight based color zones; LBT underestimated color zones for 3.5% (n=5) of subjects by one color zone; 44.1% (n=63) exceeded weight limit on LBT; 11.1% (n=16) were overestimated by one color zone; 0.6% (n=1) were overestimated by two color zones.

CONCLUSIONS: LBT reasonably estimates color zones when compared to actual weight based color zones. However, LBT tends to underestimate color zones among younger obese children and adolescents. Potential implications of the rising trend of overweight children on resuscitation practice and drug administration must be considered. Further studies are needed to elucidate the biological nature of LBT dosing.

Parental Assessment of Their Childs Pain Using the Color Analogue Scale

Thomas E. McConahay, Blake Bulloch, Matt Bryson. Pediatric Emergency Medicine, Phoenix Childrens Hospital, Phoenix, AZ.

OBJECTIVE: To determine whether parental assessment of childrens pain, as measured by the Color Analogue Scale (CAS), correlates with childrens perception of pain when evaluated in an acute setting.

DESIGN/METHODS: Prospective study, using convenience sampling, of children presenting to a pediatric ED between the ages of 5 and 16 years with a complaint of pain. After obtaining informed consent the child was asked to quantify their pain using the CAS, a previously validated pain scale. They were then asked to describe the severity of their pain by circling none, mild, moderate, or severe. The parents, who were blinded to their childs answers and scores, were then asked to score their childs pain with the same CAS and to describe the severity of the pain. After the initial pain assessments, there was a pain intervention. After 30 minutes, the child and parent were asked to repeat the measurements on the CAS, and to mark the severity of the pain at that time. Both children and parents were blinded to all previous CAS scores and descriptions. The comparisons between child and parent pain assessments were analyzed using Pearson Correlation Coefficients. A significant correlation is 0.45 or greater and a strong correlation is considered greater than 0.7.

RESULTS: A total of 171 children were enrolled with a mean age of 10.1 years (SD 3.2). Males accounted for 94 (55.0%), 89 (53.6%) were Hispanic, 63 (38.0%) Caucasian, and 8 (4.8%) African-American. Trauma was the etiology of the pain in 80 (47.6%) and non-traumatic conditions such as abdominal pain and headache accounted for 88 (52.4%). At initial presentation to the ED (time 0), the correlation between child and parent CAS pain scores was 0.545 (P<0.001). After initial intervention (Time 30), the correlation was 0.785 (P<0.001). The agreement between the child and parent description of the severity of pain was also analyzed. At time 0, the correlation was 0.480 (P<0.001). At time 30, the correlation was 0.744 (P<0.001).

CONCLUSIONS: This study reveals that parental assessment of their childs pain has moderate correlation in the emergency setting. Interestingly, there is an improvement in the correlation between child and parent assessment over time.

Clinical Decision Rule To Predict Perforated Appendicitis in Children

Anupam B. Kharbanda, Richard G. Bachur. Pediatrics, Morgan Stanley Childrens Hospital of New York, New York, NY; Pediatrics, Childrens Hospital Boston, Boston, MA.

BACKGROUND: Appendicitis is the most common acute surgical process in children. Appendiceal perforation (AP) has been reported in up to 50% of cases of pediatric appendicitis. AP is often requires different medical and surgical management than non-perforated appendicitis (AA).

OBJECTIVE: To identify clinical factors distinguishing AA from AP and to create a rule to predict AP

DESIGN/METHODS: Prospective cohort collected over 20 months at an urban, tertiary care hospital. Children between 3-18 years with suspected appendicitis were enrolled. Pediatric emergency medicine physicians completed standardized surveys for subjects prior to radiologic studies or operative care. Diagnosis was determined by pathology and/or follow-up phone call. Presence of perforation was obtained from the attending surgeons operative note. Univariate analysis identified predictors for AA and AP. Recursive partitioning was utilized to create a rule to predict which patients had AP.

RESULTS: Of 739 enrolled, 219 had AA (30%) and 46 (6%) had AP. The mean age of children with AP was 11.0 yrs (SD +/- 4.3) and for those with AA 12.5 (+/- 3.6). Table one summarizes clinical variables that differed significantly between patients with AA, AP and other diagnoses. Recursive partitioning created a rule that utilized WBC > 12.25103/L, duration of pain > 24 hours and pain with percussion to identify AP. Rule identified 29/46 AP patients; sensitivity of 63% [95% CI 47-76], specificity of 91% [88-93], PPV of 32% [22-42] and PPV of 79% [69-87] for AA + AP.

CONCLUSIONS: A clinical rule can help to identify which children with suspected appendicitis should be more aggressively managed with early surgical consultation and antibiotic administration.

Clinical Variables Associated with Pertussis Infection in Infants

Hazel Guinto-Ocampo, Magdy W. Attia. Division of Emergency Medicine, A.I. duPont Hospital for Children, Wilmington, DE.

BACKGROUND: The incidence of reported cases of pertussis is increasing, despite high rates of vaccination among infants and children. The burden of disease, rates of complications, and death, are highest among infants. The limited availability of a timely, reliable confirmatory test for pertussis hinders early identification of infected infants.

OBJECTIVE: Our objective is to investigate the association of symptoms, physical examination findings, and laboratory data with a positive pertussis test among infants.

DESIGN/METHODS: Demographic, clinical, and laboratory data were collected from the medical records of all infants less than 12 months of age who underwent confirmatory testing (culture, direct fluorescent assay, and polymerase chain reaction) for B. pertussis and parapertussis from January 1, 2001 to July 31, 2005. The association of 20 variables with a positive pertussis test was analyzed using univariate analysis, and when appropriate, using receiver operating characteristics .

RESULTS: We reviewed the medical records of 96 infants who were tested for pertussis. The mean age was 89 days, and the most common chief complaints were cough and difficulty breathing. 13 (14%) had a positive, and 83 (87%) had a negative test . Bronchiolitis and upper respiratory infection were the most common discharge diagnoses among infants with a negative test. The two groups were similar with respect to gender, presence of fever, hypoxia and heart rate. Infants who were younger (54 vs 95 days, p<.03), less tachypneic (39 vs 47 breaths/min, p< .05), have higher white blood cell counts { (WBC) 21K vs 16K, p<.04}, higher percentage of lymphocytes (73 vs 56, p <.00), and higher absolute lymphocyte counts {(ALC) 15,400 vs 9600, p<.01} were more likely to have a positive test. ROC for ALC demonstrated an area under the curve of 0.8; 95%CI 0.7 - 0.9. An ALC cutoff point of 10,700 was determined to maximize sensitivity (70%) and specificity (70%). The negative predictive value of this cutoff point was 90%, odds ratio 5.3, 95%CI 1.5-18.6 and a likelihood ratio 2.3, 95% CI 1.2-3.9.

CONCLUSIONS: Among infants who underwent confirmatory testing for pertussis, those who are younger (less than 60 days), have higher WBCs, higher percentage of lymphocytes, and higher ALCs, are more likely to have a positive test. A cutoff point for ALC, which may be valuable in identifying infants who are likely to have pertussis, was determined.

Sedation and Analgesia Practices for Incarcerated Inguinal Hernias in Children

Khalid M. Al-Ansari, Savithiri Ratnapalan, Chris Sulowiski. Pediatric Emergency, The Hospital for Sick Children, Toronto, ON, Canada; Pediatric Emergency, The Hosital for Sick Children, Toronto, ON, Canada; Medicine, University of Toronto, Toronto, ON, Canada.

BACKGROUND: Incarcerated inguinal hernia is the most common reason for children with inguinal hernia to present to the emergency department. The majority of them are successfully reduced, with a small percentage needing surgical intervention

OBJECTIVE: The objective of this study was to analyse the use of medications for sedation and or analgesia for incarcerated inguinal hernia reductions in the emergency department.

DESIGN/METHODS: Retrospective chart review study of all patients presented to the Hospital for Sick Children emergency department with incarcerated inguinal hernias, from April 1st 2001 to March 31st 2004

RESULTS: There were 99 cases of incarcerated inguinal hernias presenting to the emergency department over a 3-year period. Eighty two percent of these children had been term babies, ranging from under one month to 11 years of age predominantly males (87%). Seventy five percent present before 18 months of age with 9% presenting before 1 month of age, 25% 1- 6 months of age and 22% at 6- 12 months of age. Of these, 44 % of children obtained medications for sedation and/or analgesia; 75% obtained moderate sedation and or analgesia. The children who received medications for hernia reduction did not differ significantly form those that did not receive any medication with respect to average age of presentation; history of premature birth or gender, the only statistically different factor was the time between presentation and reduction (3.9 hours vs. 1.6 hours). The surgical fellows performed the most number of successful reductions in both groups ( 63%) whereas the emergency fellow or staff performed more reductions in the no medication group (27% vs. 11% p 0.05).

CONCLUSIONS: More than half the children presenting with inguinal hernias do not receive any medication for pain and or sedation. The only factors that seem to be associated with medication use are the length of time from presentation to reduction, which may indicate the number of attempts at reduction. Standardized guidelines medication use in incarcerated hernia reduction educational intervention for emergency physicians in hernia reduction techniques should be developed.

Fever Phobia in the Pediatric Emergency Department

Marc Auerbach, Michael Traister, Michael Mojica. NYU-Bellevue Department of Pediatrics, New York University, New York, NY.

BACKGROUND: Fever is a common reason for a caregiver to bring their child to the Emergency Department (ED). Prior outpatient studies document that caregivers have a poor understanding and a high degree of worry about fever. This is the first study to explore caregiver understanding and concern about fever in the ED.

OBJECTIVE: To compare the understanding and level of concern about fever between caregivers presenting to a Pediatric ED and to a private practice.

DESIGN/METHODS: A questionnnaire adapted from Schmitts original fever phobia survey was completed by a convenience sample of caregivers of children less than six years old in the Pediatric ED and a private practice. Likert scales (1-5) assessed worry related to fever. Diagrams of thermometers and multiple-choice questions were used to assess knowledge. Data was collected in English and Spanish between 10/1/04 and 1/31/05. The ED serves a medicaid insured population of low socioeconomic status (SES). The private practice population is of high SES.

RESULTS: ED caregivers (EDC) and private practice caregivers (PPC) possesed a similar knowledge of fever. Knowledge was poor compared to prior published studies. 40% of all caregivers defined fever as T<100. 90% reported that fever causes seizure, death, or brain damage. 38% reported concern for these sequelae at T<102. Only 50% reported viral infection as the most common cause of fever. Less than 50% recalled a physician educating them about fever. EDC reported a higher level of worry about fever and failure of antipyretics than PPC (table). 72% of 215 EDC were Latinos and 89% of 231 PPC were non-Latino white. Age of child, reason for visit, and number of other children were similar in both groups.

CONCLUSIONS: EDC compared to PPC possess a higher level of worry related to fever. This can not be explained by variations in knowledge. This higher level of concern could relate to socioeconomic, cultural, and language barriers as well as lack of a medical home. ED educational interventions may decrease ED utilization for benign febrile illness.

Local Anesthetic Techniques for Closed Forearm Fracture Reduction in Children: Variations in Practice Among Academic Pediatric Emergency Departments

Erika Constantine, Dale W. Steele, Craig P. Eberson, Siraj Amanullah, James G. Linakis. Brown Medical School, Department of Pediatrics and Emergency Medicine, Hasbro Childrens Hospital, Providence, RI; Brown Medical School, Department of Pediatric Orthopedics, Hasbro Childrens Hospital, Providence, RI.

BACKGROUND: There is much variation in the analgesic techniques used for management of forearm fractures in the emergency department (ED). While local anesthetic techniques have been well described and commonly used in adults, it is unclear how often these techniques are used in children.

OBJECTIVE: To characterize the use of local anesthesia for reduction of pediatric closed forearm fractures among teaching hospitals in Canada and the United States (US).

DESIGN/METHODS: We designed an online survey targeted at physicians practicing in hospitals with pediatric emergency medicine (PEM) fellowships in Canada and the US. An initial email invitation and 4 reminders were sent to the PEM fellowship director and orthopedic department head at each hospital.

RESULTS: 63 orthopedic surgeons and 70 PEM physicians were invited to participate in the survey, and 86 responses (65%) were received. Of these, two responses were eliminated because one physician inconsistently answered the survey twice. There was no difference (p=0.78) in response rates between PEM physicians (64%) and orthopedic surgeons (62%). All respondents routinely use sedation for forearm fracture reduction. Local anesthesia for forearm fracture reduction is used by 77% of respondents (54% rarely, 29% sometimes and 17% frequently). Hematoma blocks were used by 92% of respondents that use local anesthesia. 20% of respondents use Bier blocks and 2% use cubital blocks. Among respondents who never use local anesthesia, all believe that sufficient analgesia is obtained from conscious sedation alone, and 33% believe that local anesthesia is ineffective.

CONCLUSIONS: Among those surveyed, although systemic medications for sedation and analgesia are used almost universally for forearm fracture reduction, local anesthetic techniques are used only occasionally. The use of local anesthesia may reduce the depth of sedation required and decrease pain after discharge. Future studies should evaluate these potential benefits of local anesthestic techniques in children, particularly when used in conjunction with parenteral sedation and analgesia.

Predictors of Cerebrospinal Fluid Pleocytosis in Febrile Infants 0-90 Days of Age

William P. Meehan, Richard G. Bachur. Division of Emergency Medicine, Childrens Hospital Boston, Boston, MA.

BACKGROUND: Febrile infants 0-90 days of age often undergo lumbar puncture (LP) as part of their fever evaluation. The ability to predict pleocytosis in the cerebrospinal fluid (CSF) might affect the decision of caretakers to perform LP.

OBJECTIVE: To identify factors associated with CSF pleocytosis in febrile infants 0-90 days of age.

DESIGN/METHODS: Emergency department records of febrile (T>37.9C) infants 0-90 days of age who presented to a large, urban, pediatric medical center over a period of 46 consecutive months were reviewed. Patients with a traumatic LP (>10,000 RBCs per mm of CSF) were excluded. The CSF white blood cell count (WBC) was corrected for the number of red blood cells using a ratio of 500:1. Pleocytosis was defined as having a corrected CSF WBC of >24/mm in patients aged 0 and 28 days and >9/mm in patients aged 29-90 days. Recursive partitioning analysis of age, temperature, gender, peripheral WBC, absolute neutrophil count, and clinical appearance was used to identify potential predictors.

RESULTS: 2,839 febrile infants were studied. Non-traumatic CSF was obtained on 2032 (72%). 54.9% were male. The mean age and temperature were 1.6 months (SD 0.76) and 38.6C (SD 0.52) respectively. 200 (9.8%, 95%CI 8.6-11.2%) patients had pleocytosis. 7 (0.3%, 95%CI 0.2-0.7%) had bacterial meningitis. Recursive partitioning analysis determined that the best predictor of CSF pleocytosis was season. Patients presenting in summer months (JuneSeptember) had a higher prevalence of pleocytosis (125/637, 19.6%) than those presenting in non-summer months (75/1395, 5.4%) [p< 0.001, LR 2.2]. For those presenting in non-summer months, the prevalence of CSF pleocytosis increased from 5.4% to 12.2% if T > 38.4C and peripheral WBC >13.6 (LR 2.4). Only 2.2% of patients with pleocytosis were described as ill appearing, including 2 out of the 7 with bacterial meningitis.

CONCLUSIONS: Although bacterial meningitis is rare, 1 in 10 febrile infants have CSF pleocytosis. During the summer months the prevalence increases to 1 in 5. Therefore, the evaluation of febrile infants must include LP if empiric antibiotics are considered. Age, temperature, gender, peripheral WBC, absolute neutrophil count, and clinical appearance are not useful in predicting the likelihood of CSF pleocytosis.

Impact of the Pneumococcal Conjugate Vaccine in the Management of Highly Febrile Children 6-24 Months in an Emergency Department

Santiago Mintegi, Javier Benito, Eider Astobiza, Maria Gonzalez, Mikel Santiago. Pediatric Emergency Department, Hospital Cruces, Barakaldo, Bizkaia, Basque Country, Spain.

OBJECTIVE: To evaluate the impact of the introduction of the heptavalent pneumococcal conjugate vaccine (PCV-7) in the management of the children 6 to 24 months of age with high fever without source (FWS) in a Paediatric Emergency Department (PED).

DESIGN/METHODS: Patients and method: Retrospective study of 770 patients 6 to 24 months of age attended in a PED between October-04 and April-05 with FWS 39C without alteration in the dipstick.

RESULTS: Of these 770 children, 215 (27.9%) were PCV-7 fully vaccinated (group A) and 555 (72.0%) were PCV-7 incompletely or no vaccinated (group B) Both groups didnt show differences related with temperature registered at home or ED. WBC and blood culture were practised to 163 patients (21.1%), chest radiograph to 117 (15.1%), lumbar puncture (LP) to 15 (1.9%). Thirty-three (4.3%) received a dose of IM ceftriaxone, 20 (2.6%) were admitted in the Observation Unit and 5 (0.6) were admitted into the Hospital. One blood culture was positive and 2 other children had a consolidation in the chest radiograph (all of group B). In the patients not fully PCV-7 vaccinated, whole blood count (WBC) and blood culture were practised more frequently (group B=26,6% versus group A= 7%; p<0.000001; O.R. 4,85 (limits: 2.70-8,83)) and ceftriaxone was also more frequently administered (group B = 5,3% versus group A= 1.3%; p=0.02; OR=4.04 (limits =1.16-16.77)). Three children of group A (1.4%) were admitted in the Observation Unit or in floor versus 22 of group B (4%, p=0.11)

CONCLUSIONS: Inclusion of PCV-7 vaccinal status in the management of highly febrile children 6 to 24 months reduces significativelly WBC and blood cultures practised in the ED and the administration of ceftriaxone.

A National Survey of Triage Practices in Pediatric Emergency Departments

Tonya M. Thompson, Kendall Stanford, Rhonda M. Dick, James Graham. Pediatrics, University of Arkansas College of Medicine, Little Rock, AR.

BACKGROUND: A triage system is used in most pediatric emergency departments to perform a rapid physiological assessment of each patient and to determine the order in which patients are seen.

OBJECTIVE: The purpose of this study was to examine and document current triage practices used in pediatric emergency departments in the United States.

DESIGN/METHODS: A mailed survey was sent in August, 2005 to the medical director of the 99 pediatric emergency departments listed on the National Association of Childrens Hospitals and Related Institutions (NACHRI) website using addresses downloaded from the organization website. A second mailing was sent to nonresponders in October, 2005. The study protocol was reviewed and approved by the UAMS IRB.

RESULTS: 51 surveys were returned. The mean annual emergency department (ED) patient volume was 44,731. There is significant variation in the assessment of physiological measurements at triage; for example, 100% reported that all patients have pulse rate and respiratory rate assessed at triage, but only 88% take temperature on all patients, 61% take blood pressure on all patients, 29% assess pulse oximetry on all patients, and 14% perform a Glasgow Coma Scale on all patients. The methods used to measure temperature are variable; 98% use rectal for 0-2 month olds, 61% use rectal for 12-24 month olds, and 29% use rectal for 2-3 year olds. The use of tympanic thermometry varies by age: none use for 0-2 month olds, 16% for 2-12 month olds, 25% for 12-24 month olds, and 27% for 2-3 year olds. Most (84%) use an electronic method of assessing blood pressure routinely. The method used to assess pain is variable: for 0-2 years 43% use a Wong faces scale and 51% use a behavioral scale. At 2-4 years, 82% use the Wong faces scale, but in older 10-18 year old patients, 75% use a numerical scale. Medical directors reported having standing orders at triage for: antipyretic for fever (94%), urinalysis for abdominal pain (51%), pregnancy test for adolescent female with abdominal pain (43%), and pain medication for extremity trauma (53%).

CONCLUSIONS: Despite the important decisions made based on triage assessment in a pediatric emergency department, there is wide variability in the parameters assessed and the methodology used. Additional research should focus on the validity and reliability of each assessment to determine the best practices.

End Tidal Carbon Dioxide as an Objective, Noninvasive Measurement of Acute Asthma Exacerbations

Melissa L. Langhan, Mark R. Zonfrillo, Alia Bazzy-Asaad, James Dziura, David M. Spiro. Department of Pediatrics, Section of Emergency Medicine, Yale-New Haven Childrens Hospital, New Haven, CT; Department of Pediatrics, Yale-New Haven Childrens Hospital, New Haven, CT; Department of Pediatrics, Section of Pulmonary Medicine, Yale-New Haven Childrens Hospital, New Haven, CT; General Clinical Research Center, Yale-New Haven Hospital, New Haven, CT.

BACKGROUND: Clinical signs are used to classify an asthma exacerbation as mild, moderate, or severe; however these are subjective and imperfectly related to asthma severity. Capnography is a noninvasive, objective monitoring modality that closely approximates levels of arterial carbon dioxide. Several studies have noted the potential utility of capnography in asthma. However, none have compared quantitative end-tidal carbon dioxide (ETCO2) in children during acute asthma exacerbations with healthy controls.

OBJECTIVE: 1) To determine if quantitative ETCO2 correlates with clinical signs and symptoms in asthmatics during exacerbations compared with controls. 2) To determine if the capnograph can reliably and accurately output values among pediatric patients in the emergency department.

DESIGN/METHODS: In this ongoing study, we enrolled a sample of children from 1 to 21 years of age presenting to an urban pediatric ED with a known diagnosis of asthma during an acute asthma exacerbation (wheezing, cough, increased work of breathing). Patients in the same age group without respiratory or acid/base disturbances were enrolled as controls. Prior to medical intervention, vital signs, ETCO2, and clinical signs were recorded.

RESULTS: We enrolled 38 asthmatics and 59 controls from 1 19 years old [mean age 9.7 vs 10 years respectively, (p=0.8)]. ETCO2 was successfully obtained in 99% of enrollees. There was a statistically significant difference between asthmatics and controls for mean respiratory rate [27 bpm vs 20 bpm (p<.001)], mean heart rate [117 bpm vs 92 bpm (p=.004)] and mean oxygen saturation [97% vs 99% (p<.001)]. Mean ETCO2 differed between asthmatics and controls [33 mmHg vs 38 mmHg (p=.001)]. This difference was statistically significant after adjusting for respiratory rate (p<.001).

CONCLUSIONS: Capnography can be successfully utilized in the pediatric ED. ETCO2 is significantly lower in children with acute asthma compared with controls.

End Tidal Carbon Dioxide as an Objective, Noninvasive Measurement of Acute Asthma Exacerbations

CONCLUSIONS: Capnography can be successfully utilized in the pediatric ED. ETCO2 is significantly lower in children with acute asthma compared with controls.

End Tidal Carbon Dioxide Changes with Bronchodilator Therapy During Acute Asthma Exacerbations in Children

Melissa L. Langhan, Mark R. Zonfrillo, Alia Bazzy-Asaad, James Dziura, David M. Spiro. Department of Pediatrics, Section of Emergency Medicine; Department of Pediatrics; Department of Pediatrics, Section of Pulmonary Medicine, Yale-New Haven Childrens Hospital; General Clinical Research Center, Yale-New Haven Hospital, New Haven, CT.

BACKGROUND: Clinical scoring systems, such as the Pulmonary Score (PS), are used to classify asthma exacerbations; however they are subjective and imperfectly related to asthma severity. End-tidal carbon dioxide (ETCO2) is a noninvasive, objective marker of respiratory status. No previous studies have evaluated the effects of nebulized bronchodilator therapy on ETCO2.

OBJECTIVE: 1) To determine if quantitative ETCO2 changes with bronchodilator therapy in children during asthma exacerbations. 2) To determine if ETCO2 correlates with the PS.

DESIGN/METHODS: In this ongoing study, we enrolled children presenting to a pediatric ED with a known diagnosis of asthma during an acute asthma exacerbation (wheeze, cough, increased work of breathing). On arrival and after all asthma related treatments, vital signs, ETCO2, and the PS were recorded.

RESULTS: 33 subjects were enrolled (mean age 9.7 years, range 1 19 years) who received a minimum of one nebulized treatment. The mean ETCO2 on arrival was not significantly associated with the number of treatments [34.4, 33.1, and 28.9 mmHg for 1, 2, and 3 treatments (p=.07)], whereas prior to disposition there was a significant association between ETCO2 and number of treatments [34.7, 31.3, and 29.8 mmHg for 1, 2, and 3 treatments (p=.02 for trend)]. The ETCO2 was significantly higher in discharged patients (n=25) versus those admitted (n=8) both on arrival [33.9 vs 28.5 mmHg (p=.04)] and prior to disposition [33.9 vs 27.3 mmHg (p=.002)]. Adjustment for respiratory rate did not appreciably change these aforementioned results. PS was also significantly associated with disposition status (p=.008). There was no significant correlation between the changes in ETCO2 and PS from arrival to disposition.

CONCLUSIONS: ETCO2 at disposition decreases with the number of bronchodilator treatments given for acute asthma exacerbations over time. ETCO2 on arrival and at disposition is lower in patients admitted to the hospital compared to those discharged home. ETCO2 may be an objective method to assess therapeutic response and disposition of patients with acute asthma exacerbations.

A Randomized Controlled Trial Comparing a Breath Activated Nebulizer to Standard Intermittent and One-Hour Continuous Albuterol in the Treatment of Emergency Room Pediatric Asthma

Katie Sabato, Priscilla Ward, William Hawk, Jeanette Asselin. Respiratory Care, Emergency Medicine and Neonatal/Pediatric Research, Childrens Hospital and Research Center at Oakland, Oakland, CA.

BACKGROUND: Bronchodilator treatments for asthma can be provided by a various number of aerosol generating devices and methods. To date, there are few trials comparing the efficacy, effectiveness and safety of undiluted and continuous diluted administration of albuterol in the treatment of pediatric asthma.

OBJECTIVE: We conducted a randomized study comparing the efficacy of a one-time treatment with the AeroEclipse breath actuated nebulizer (BASVN), to our standard therapy (single treatment small volume nebulizer (SSVN) or a one-hour continuous treatment (CONT)) for asthmatics presenting to the emergency room ER.

DESIGN/METHODS: Eligible patients were: admitted to the ER, between 0 months to 18 years of age, presenting with wheezing or status asthmaticus. Patients were assessed using a clinical asthma score (CAS) and peak flows when possible. Patients were stratified by CAS score (CAS 4 and > 4) and weight (< 20 kg and 20kg). Patients were randomized to receive their first treatment in the ER via the BASVN or standard therapy. Patients were evaluated at baseline and 10 minutes after treatment. Primary endpoints included change in CAS, need for additional bronchodilator treatments, time in the ER, ability to breath activate and incidence of side effects.

RESULTS: 151 patients were enrolled between 10/14/04 and 11/11/05. 2 patients were dropped due to consent issues. 84 patients randomized to the BAN and 65 randomized to standard therapy. Average age was 5.5 years. There were no differences in demographics between the groups. Initial CAS scores were 5.3 and 5.2 for the BAN and Standard groups respectively. The BAN group showed significant improvement in CAS (38% vs 24%, p<0.003), the number of patient requiring admission (31 vs 37, p= 0.03), and decrease in respiratory rate (-3.9 vs 0.5, p=0.002). There were no differences in side effects.

CONCLUSIONS: The Monaghan AeroEclipse appears to be a safe and effective nebulizer for the administration of bronchodilator aerosols and may be more effective than continuous aerosols in the initial treatment of Emergency Room pediatric asthma.

Adherence and Morbidity Following Emergency Department Care for Inner-City Children with Asthma

Sergey Kunkov, Ellen F. Crain. Department of Pediatrics (Emergency Medicine), Jacobi Medical Center/AECOM, Bronx, NY.

BACKGROUND: High rates of morbidity among children receiving pediatric emergency department (PED) care for asthma may be associated with poor adherence following the PED visit. However, the relationship between adherence and morbidity has received little attention.

OBJECTIVE: To explore the utility of two published measures, Risk for Nonadherence (RN) and Admitted Nonadherence (AN), developed in a national sample of children with chronic asthma, for predicting short-term morbidity among children following a PED visit for acute asthma.

DESIGN/METHODS: We performed a prospective randomized cohort study of children 3 to 11 years presenting to a PED with an acute asthma exacerbation. A 25-item questionnaire addressing the childs asthma severity classification, demographic information and RN (range 0-11) and AN (range 0-3) was completed by the parent or administered by a research assistant (RA). Following discharge from the PED five asthma morbidity indicators were collected by follow-up telephone calls at 2, 4 and 8 weeks by an investigator blinded to the results of the baseline questionnaire.

RESULTS: 100 patients were enrolled; 88 had complete follow up, 48 (54.5%) in the self-completion group and 40 (45.5%) in the RA administered group. The mean age was 7.6 years ( 3.6); 54.5% were male. There were no significant differences in asthma severity, number of baseline surveys completed or subsequent morbidity by method of questionnaire administration. The median RN score was 4 (25-75% 3,5). During the 8-week follow-up period, 52.2% of children with an RN score > 4 had an unscheduled visit for asthma, and 45.7% awoke > 3 nights due to asthma symptoms. Controlling for gender and asthma severity, if the childs RN score was > 4, the adjusted odds of having an unscheduled visit for asthma was 3.94 (95% CI 1.23, 12.61) and 9.46 (95%CI 2.77-32.31) for waking > 3 nights. The median AN was 0 (25,75% 0,1). By the 8-week follow-up, patients with AN > 0 were 5.19 (95% CI 1.82, 14.7) times more likely to report needing > 6 days of rescue asthma medication. Neither measure was associated with days of asthma symptoms or school days missed.

CONCLUSIONS: Obtaining RN and AN scores by either self-completion or staff questionnaire administration may be useful for predicting risk for short-term morbidity following PED visits for asthma and for guiding the allocation of resources to improve outcomes.