Biomedical subjects
Publications and source records attributed to J S Seidel.
The cases are presented of three patients who sustained scald burns after placing their braided hair in boiling water to set the braids. Caretakers and cosmetologists should be warned of the potential danger from scald burns when setting hair braids. Emergency physicians should be aware of this mechanism of injury for scald burns to the scalp, face, back, and neck regions.
Cardiopulmonary arrest in childhood is usually due to respiratory failure leading to hypoxemia, acidosis, cardiac dysfunction, and terminal asystole. Respiratory failure is the end result of either impaired oxygenation, impaired ventilation, or both. We report a case of severe fecal impaction in an eight year old that resulted in a significant depression of ventilation by severely restricting respiratory mechanics and that ultimately progressed to respiratory failure and circulatory compromise. Physicians should be aware of this rare but possible etiology for life-threatening events in children.
Curricula in pediatric resuscitation must be based on adult learning principles. The Pediatric Basic and Advanced Life Support Courses (PBLS, PALS) should use educational strategies fostering positive interactions between the instructor and learners and should take into consideration the learner's motivation for taking the course. Materials should be developed for a specific target audience; course design should be flexible to meet individual needs. The PBLS and PALS courses have different audiences. PBLS is targeted toward caretakers of children. This course will continue to emphasize primary injury prevention as the major strategy but also will give learners the knowledge and skills to perform CPR. To optimize retention of knowledge and skills, the course content must be simplified, and the sequencing of steps in basic life support must be modified. Health care providers caring for pediatric patients in acute care settings are the primary audience for the PALS course. This course already incorporates adult learning principles; only minor revisions are anticipated. Discussion of the trauma patient is limited in the PALS course; additional trauma education could be facilitated by the addition of a trauma module or by other educational courses. All aspects of the PBLS and PALS educational programs must be evaluated continually to determine whether learning objectives have been met and whether the teaching format is appropriate. The answers to evaluation questions will help determine the degree to which the American Heart Association is meeting its educational objectives and how to allocate resources for development and training.
This study analyzed incoming telephone calls to an urban county pediatric emergency department (PED). Data were collected by reviewing recorded incoming calls and written logs for two separate months, six months apart. Eight hundred seventeen calls were reviewed. The largest number of calls for both months (15%) was for upper respiratory infection symptoms. Information, fever, and diarrhea were in the next three ranks for both months. Fifty-three percent were about children under one year of age. Over 50% of the calls were received from 4:00 PM to 12:00 AM during both months. The average length of calls was 4.0 minutes. A review of the logs identified 221 (27%) calls to be emergent or urgent; 197 (89%) of these callers were advised to bring the child to the PED. These data suggest that content for a curriculum should be directed toward common pediatric problems regarding young children, focusing on children under one year of age.
Infection with the roundworm Ascaris lumbricoides is common in children and may mimic an acute abdomen. The cases of two pediatric patients who presented to the emergency department with signs and symptoms of a surgical abdomen are presented to highlight the presentation of this infection. Both cases were diagnosed by physical examination and radiographs and were treated successfully without surgical intervention. These cases illustrate the need for heightened awareness by the emergency physician of ascariasis in the differential diagnosis of acute abdomen.
A study of 10,493 prehospital care report forms from 11 counties in California demonstrated that the adolescent age group (ages 12 to 18 years) accessed prehospital care through the emergency medical service (EMS) system more frequently than other pediatric patients (5978 reports). They did so most commonly for trauma (87.6%), but also for behavioral emergencies such as suicide and psychiatric problems. The most common cause of injury was automobiles, and care rendered was most commonly wound care and splinting. The most common substances given to adolescents in the prehospital setting were naloxone and 50% dextrose. EMS systems need to address the need for triage and care of adolescent patients.
Ambulatory care centers have emerged as a new health care resource in many communities. Little information is available about the services that these centers offer to pediatric patients. A national survey of 254 ambulatory care centers was undertaken to determine their characteristics, including the number of pediatric patients seen, staffing patterns, and pediatric equipment and supplies available. Most clinics were located in urban areas and were within 5 miles of a hospital. They were staffed primarily by physicians who were board certified in emergency medicine, internal medicine, or family medicine. Not all centers had registered nurses on duty and few used extended-role nurses or physicians's assistants. The centers saw an average of 18 patients younger than 18 years of age per day. Some ambulatory care centers received emergency medical service and private ambulance calls and encountered serious illness such as chest pain, seizures, and anaphylaxis; the majority, however, handled mainly minor injuries and illnesses. Although most had pediatric equipment and supplies, some did not have a complete set of pediatric resuscitation equipment even though they were part of the emergency system offering care to the pediatric population.
There are limited data concerning pediatric prehospital care, although pediatric prehospital calls constitute 10% of emergency medical services activity. Data from 10,493 prehospital care reports in 11 counties of California (four emergency medical services systems in rural and urban areas) were collected and analyzed. Comparison of urban and rural data found few significant differences in parameters analyzed. Use of the emergency medical services system by pediatric patients increased with age, but 12.5% of all calls were for children younger than 2 years. Calls for medical problems were most common for patients younger than 5 years of age; trauma was a more common complaint in rural areas (64%, P = .0001). Frequency of vital sign assessment differed by region, as did hospital contact (P less than .0001). Complete assessment of young pediatric patients, with a full set of vital signs and neurologic assessment, was rarely performed. Advanced life support providers were often on the scene, but advanced life support treatments and procedures were infrequently used. This study suggests the need for additional data on which to base emergency medical services system design and some directions for education of prehospital care providers.
Twenty-four percent of all medical care contacts are made on the telephone. Practicing pediatricians and emergency physicians often manage children's illnesses by telephone. Studies have shown that there is a need for improved communication between physicians and patients, and it is believed that quality of, and satisfaction with, health care services will improve with increased emphasis on interpersonal communication skills in medical training. The Department of Pediatrics at Harbor-UCLA Medical Center includes interpersonal telephone communication as part of residency training. This article describes the telephone program, which differs from other programs in medical settings in that it focuses on communication process skills only. A conceptual framework around the acronym T.A.L.K. is outlined. Topic sessions in the pediatric emergency department and individual resident review sessions are discussed. The guidelines designed to follow the conceptual framework are presented.
Vital signs are an integral part of the field assessment of patients. A two-part study was undertaken to determine which vital signs are taken in the field assessment of pediatric patients and to determine whether the frequency of vital signs taken is influenced by base station contact, patient's severity of illness or injury, or paramedic demographic factors such as parenting and field experience. An initial pilot study of prehospital care records (run sheets) from two base hospitals in Los Angeles County revealed that there were significant differences between field vital sign assessment in pediatric and adult patients (P less than .0001). A retrospective review of 6,756 pediatric run sheets from Los Angeles County showed that the frequency of vital sign assessment varied with the age of the pediatric patient (P less than .05) (ie, the frequency of vital sign assessment increased correspondingly with the age of the patient). Base hospital contact occurred in 26% of the runs; when contact was made, vital signs were more likely to be taken in all age groups studied. Vital signs often were not assessed in children less than 2 years old, even if the patient's chief complaint suggested the possibility of a major illness or trauma. The second part of the study was a field assessment survey that was distributed to 1,253 active paramedics in Los Angeles County; the results showed that paramedics were less confident in their ability to assess vital signs in children less than 2 years old. Confidence increased with age of the patient.(ABSTRACT TRUNCATED AT 250 WORDS)
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Violent death (homicide and suicide) in the pediatric age group is a major public health problem. A descriptive study was undertaken to review retrospectively the 1077 pediatric coroner's cases in 11 California counties for differences between urban and rural violent death rates. Pediatric violent death was more prevalent in the urban region than in the rural region (P less than 0.0007). High urban homicide rates accounted for most of this difference. Suicide rates were not significantly different (P = 0.18). Seventy-four percent of the violent deaths were in the 15- to 18-year age group, and most of these deaths were caused by firearms (81%). Blacks had the highest homicide and suicide rates. Child abuse was an important cause of death for young children in the urban area only. Socioeconomic factors, cultural differences, high population density, and the availability of firearms were proposed as factors affecting violent death in the pediatric age group.
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A total of 1078 pediatric coroners' cases in 11 rural and urban California counties were reviewed as they relate to emergency medical services (EMS). Pediatric coroners' death rates per 100,000 population varied from an average of 2.17 in the rural region to 30.4 in the urban region. Vehicular accidents caused the majority (66%) of the accidental deaths, and firearms caused 61% of the violent deaths. Violent deaths (homicide and suicide) were significantly more common in the urban region (P less than 0.001), and vehicular deaths (excluding auto versus pedestrian) were more common in the rural region (P less than 0.001). EMS provider usage was greater in the urban areas (84 vs 66%, P less than 0.001), as was the number of cases receiving advanced life support (97 vs 66%, P less than 0.001). Urban and rural differences in place of death were significant for two places of death; street and highway, and inhospital deaths. A significantly greater number of children died on the street/highway in rural areas (P less than 0.05). Hospital deaths were more likely to occur on the ward in the rural region, versus the intensive care unit in the urban region (P less than 0.001). Proposed factors which may explain these findings include differences in medical resources and in local transfer policies. The study demonstrates that EMS providers are involved in the care of children who have had a fatal emergency. Further evaluation of rural and urban differences in prehospital care of the pediatric patient is indicated.
Drug dosages used during pediatric emergencies and resuscitation are often based on estimated body weight. The Broselow Tape, a tape measure that estimates weight and drug dosages for pediatric patients from their length, has been developed to facilitate proper dosing during emergencies. In our study, 937 children of known weight were measured with this tape. Weight estimates generated by the tape were found to be within 15% error for 79% of the children. The tape was found to be extremely accurate for children from 3.5 to 10 kg, and from 10 to 25 kg. Regression lines of estimated compared with actual weight for these children have slopes of 0.98 and 0.96, respectively, not significantly different from the ideal slope of 1.00 (P = 28 and .13). Accuracy was significantly decreased for measured children who weighed more than 25 kg. In a separate group of children (n = 53), the tape was shown to be more accurate than weight estimates made by residents and pediatric nurses (P less than .0001). Use of the Broselow Tape is a simple, accurate method of estimating pediatric weights and drug doses and eliminates the need for memorization and calculation.
Children who have been sexually abused develop a variety of emotional and physical complaints, often unrelated to the genital area. Emergency department records of children diagnosed as being sexually abused were reviewed for the period covering January 1984 through June 1985. Of 26,000 patients seen, 300 cases of sexual abuse were identified. Of these, 57 were patients who presented with initial complaints other than sexual abuse. The data were analyzed for age, sex, chief complaint, time of presentation, physical findings, and person accompanying the child. The most common presenting complaints of these 57 patients were abdominal pain (26%) and vaginal symptoms (26%) The latter included pruritus, discharge, and bleeding. Other complaints included rectal bleeding or constipation (9%), chronic urinary tract infection (5%), straddle injury (4%), and suicide attempt (2%). The remaining 26% included fever, respiratory infections, sore throat, asthma, bronchitis, obesity, mastoiditis, and weight loss. Because resident physicians are instructed to conduct complete anal and genital examinations on all patients, sexual misuse was often diagnosed with seemingly unrelated complaints. A protocol developed for use in the emergency department is described.
Emergency medical services have been organized to meet the needs of adult patients. A study was undertaken to determine the training in pediatrics offered to paramedics and emergency medical technicians throughout the United States and the equipment carried by prehospital care provider agencies. Most training (50%) takes place at colleges and universities and the remainder at hospitals and emergency medical services agencies. Many programs (40%) have less than ten hours of didactic training in pediatrics and 41% offer ten hours or less of clinical experience. Some programs offer no training in pediatric emergency medicine. The most common deficiencies in pediatric equipment included backboards, pediatric drugs, resuscitation masks, and small intravenous catheters. More attention to training and equipping prehospital personnel for pediatric emergencies may help to improve outcomes of out-of-hospital resuscitations of infants and children.
The outcome from cardiopulmonary arrest in children in the prehospital and hospital setting is generally poor. The event that compromises the cardiac status is often respiratory embarrassment, and the presenting rhythms are often bradyarrhythmias and asystole. Emergency medical services (EMS) systems have primarily an adult focus and may not be organized to manage optimally the critically ill and injured child. Data from a survey of training programs demonstrate that paramedic and EMT education in pediatric emergencies may be inadequate. Forty-one percent of the programs surveyed had less than 10 hr of pediatric training. Data suggest that EMS providers may not be equipped to manage children effectively. The Los Angeles EMS System for children is described. There are two levels of receiving facilities: Emergency Departments Approved for Pediatrics and Pediatric Critical Care Centers. The system is voluntary and has 85% of the hospitals in compliance with the guidelines. Early recognition of the prearrest state, improved training, and equipping of prehospital care personnel, development of EMS services for children, dissemination of an advanced pediatric life support course, as well as research in pediatric CPR may improve the outcome of resuscitation in the pediatric population.