Medscape Medical News

Rabiya S. Tuma, PhD

May 4, 2006 (San Francisco) — Four high-risk factors identify children who are most likely to require neurologic intervention and should undergo computed tomography (CT) after minor head injury, according to a report presented here at the annual meeting of the Pediatric Academic Societies.

Emergency room physicians increasingly use CT for diagnosing children with minor head injuries and for help identifying those who require neurologic intervention. However there is concern that this practice is exposing an unnecessarily large number of children to radiation.

In an effort to limit such exposure, Martin H. Osmond, MD, an associate professor of pediatrics in the Division of Emergency Medicine at Children’s Hospital of Eastern Ontario in Ottawa, Canada, and colleagues designed a prospective cohort study to define a clinical decision rule. It was part of the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) study.

The main outcome measures were the need for neurologic intervention or any lesion on CT. Because not all children would undergo CT, patients were followed up on day 14 with a telephone call. If they did not have any neurologic symptoms, such as headaches or memory problems, and had returned to normal activities, they were considered not to have had significant neurologic insult. If they still had symptoms, they were called back into the hospital for reevaluation and CT.

A total of 3781 children were enrolled in the study, all of whom were aged 16 years or younger and were seen at 1 of 10 Canadian pediatric teaching hospitals. To be included in the study, patients had to be in the emergency department because of a blunt head trauma and have a Glasgow Coma Scale (GCS) score between 13 and 15, as well as 1 of the following variables: known loss of consciousness, disorientation, or confusion; amnesia; persistent vomiting; or irritability in children aged 2 years or younger. Of these, 172 children (4.5%) had acute brain injury as determined by CT and 25 children (0.7%) required neurologic intervention.

Using data from the 28-point questionnaire, which attending physicians filled out for each patient prior to seeing CT results, the researchers identified variables most closely associated with likely brain injury as detected by CT.

They then entered those features into the Chi-squared recursive partitioning model to identify high-risk criteria for determining which child would have a high need for neurologic intervention. Four high-risk variables were found to be most important: a GCS score less than 15 at 2 hours after injury, suspected skull penetration or depressed skull fracture, worsening headache on history, and irritability on examination.

When the researchers tested the performance of the decision rule on the patient population, they found that it correctly identified all 25 patients who had required neurologic intervention as well as 1119 others. The sensitivity was 100% (95% confidence interval, 86 – 100) and specificity was 70.4% (95% CI, 69-72). The rate of CT scans in the population would have been 29.6% of patients.

The team then asked if the decision rule could be modified to identify all patients who had acute brain injury as detected by CT scanning. To accomplish this, three medium-risk variables were incorporated, including any sign of basilar skull fracture, large boggy scalp hematoma, and a dangerous mechanism of injury, which was defined as a fall from 3 or more feet or 5 or more stairs or an automobile-related accident.

When the group tested this version of the decision rule, they found that it correctly identified 169 of the 172 patients found to have a visible lesion on CT, as well as 1887 others. The sensitivity was 98.3% and the specificity was 50.1%. The CT rate would have been 49.9% in the population.

Right now the rule is not recommended for clinical use, said Dr. Osmond, emphasizing that it must first be prospectively validated in a separate patient population prior to being used in the clinic. “It does point out key predictors that clinicians might want to keep in mind,” he told Medscape.

Although no one knows, at this point, what to make of minor lesions found on CT, the fact that 3 of these patients were missed makes Michael G. Tunik, MD, associate professor of pediatrics and emergency medicine at New York University in New York City, think clinicians might hesitate to use the rule even after it is validated. “I want to see a very narrow confidence interval” for the rule’s sensitivity, he told Medscape. “I’m unwilling to miss a patient,” although it is a trade-off with radiation exposure for the child.

PAS 2006 Annual Meeting: Abstract 5156.1. Presented May 2, 2006.

Reviewed by Peggy Keen, PhD, FNP

Nationwide Recall of Insulin Syringe Product because of bacterial
contamination with Paenibacillus.  Boca Medical Products, Inc.
http://www.fda.gov/medwatch/safety/2006/closercare_recall.htm

(Elsevier Global Medical News – 04/21/2006)
A single oral dose of the antiemetic ondansetron significantly reduced vomiting in children treated in a pediatric emergency room for gastroenteritis and mild-to-moderate dehydration, allowing more children to be rehydrated orally rather than intravenously, Dr. Stephen B. Freedman reported.

A prospective, double-blind study randomized 215 children aged 6 months through 10 years to receive a disintegrating tablet of oral ondansetron (Zofran) or placebo administered by a nurse while the physicians and research assistants were out of the room. Five seconds after placing the tablet on the patient’s tongue, the nurse asked or helped the child to swallow. Children who vomited within 15 minutes received a second dose.

Fifteen minutes later, clinicians started a 1-hour period of intense oral rehydration, and oral rehydration could be continued until the patient was sent home or admitted. After the first hour of oral rehydration, the treating physician could choose to give intravenous fluids.

The investigators primarily assessed how many children vomited during oral rehydration therapy by conducting phone interviews with the families 3-7 days later and reviewing patients’ records.

Among 107 children in the ondansetron group, 14% vomited while receiving oral rehydration therapy, compared with 35% of 107 children in the placebo group. One child in the ondansetron group was not included in the analysis because parental consent had not been obtained before randomization, said Dr. Freedman, of the division of pediatric medicine at the University of Toronto, and his associates (N. Engl. J. Med. 2006;354:1698-705).

Ondansetron also significantly reduced the mean number of episodes of vomiting, compared with placebo (0.18 vs. 0.65 episodes, respectively). Significantly fewer children in the ondansetron group received intravenous rehydration–14%, compared with 31% in the placebo group.

Among the children who did not vomit during oral rehydration in either group, intravenous fluids were started in 5% given ondansetron and 17% given placebo, a significant difference.

A previous study reported similar benefits in children with gastroenteritis who were given six doses of liquid ondansetron or placebo over a 2-day period. However, the ondansetron regimen was associated with increased rates of diarrhea and return visits to the emergency department. In the current study, the single dose of ondansetron did not cause any clinically significant adverse events, and the groups did not differ in the rate of return visits to the emergency department (19% with ondansetron and 22% with placebo).

Children in the ondansetron group received a larger volume of oral rehydration fluid and a smaller volume of intravenous fluid, compared with the placebo group. Children given ondansetron had shorter stays in the emergency department, but the rate of hospitalization did not differ between groups (4% each), perhaps because the study was not large enough to detect a significant difference in hospitalizations, the investigators suggested.

The ondansetron group did have more episodes of diarrhea during the oral rehydration than the placebo group–1.4 vs. 0.5 episodes–but this difference was not considered clinically significant.

Other antiemetic agents used to treat pediatric gastroenteritis have substantial side effects or have not been well studied, the investigators added.

GlaxoSmithKline, which makes ondansetron, provided the tablets but had no other role in the study, and the investigators did not report any other potential conflicts of interest.

The ondansetron dosing was 2 mg for children weighing 8-15 kg, 4 mg for those weighing 16-30 kg, and 8 mg for heavier children.

At a cost of $35.75 per 4-mg tablet, the ondansetron in the study cost a total of $3,825 but saved the hospital $4,145 by avoiding insertion of intravenous catheters (at a cost of $124.74/child) and hospitalizations ($1,900/admission).

By Sherry Boschert
(Elsevier Global Medical News – 05/04/2006)
SAN FRANCISCO (EGMN)-Osmotic therapy using hypertonic saline reduced intracranial hypertension in 24 patients with traumatic brain injury while improving cerebral perfusion pressure and brain tissue oxygen levels, Dr. Archie Defillo reported.

The treatments caused no complications in these patients. Judging from the findings of this small series of patients, hypertonic saline appears to be a safe alternative to mannitol for osmotic therapy to control intracranial pressure after traumatic head injury, Dr. Defillo said at the annual meeting of the American Association of Neurological Surgeons.

With his associates, Dr. Defillo reviewed records on head trauma patients with intracranial pressure greater than 20 mm Hg for longer than 20 minutes in the absence of response to nociceptive stimuli, and who had not received other osmotic agents after traumatic brain injury. The 24 patients were infused with 30 ml of 23.4% sodium chloride solution over a 15-minute period. Patients with low hemoglobin levels received blood transfusion to maintain a constant oxygen delivery.

The hypertonic saline decreased intracranial pressure absolute values by a mean of 35% from baseline, consisting of a 10 mm Hg decrease in the first hour and an 8 mm Hg decrease sustained in hours 2-6, said Dr. Defillo of Hennepin County Medical Center, Minneapolis.

“Six millimeters of mercury can be the difference between profound ischemia and normal brain tissue oxygen values,” he noted.

Cerebral perfusion pressures and brain tissue oxygen levels improved over the course of osmotic therapy. Cerebral perfusion pressures increased by a mean 14% (8 mm Hg/hr). Brain tissue oxygen levels showed a steady, linear increase ranging from 3% after the first hour of hypertonic saline to 25% by 6 hours after infusion.

Mean arterial pressures remained stable, with the only significant change being a 4 mm Hg decrease 6 hours after infusion.

The greatest benefit from hypertonic saline osmotic therapy was seen in patients with higher intracranial pressure or lower cerebral perfusion pressure.

Hypertonic saline does not cause the rebound effect that can be seen with mannitol, Dr. Defillo noted. Repeat doses of hypertonic saline were not associated with fluid depletion, hypovolemia, or hypertension.

The next research step should be a prospective trial comparing hypertonic saline with mannitol for osmotic therapy in head trauma patients, commentators suggested.

Wondering whatever happened to the bill about crowding in the ED? The latest word is that HR 3875, the Access to Emergency Medical Services Act of 2005, has been referred to the House Ways and Means Committee and the House Energy Commerce Committee. HCPro learned the status from information gained this month from an employee of one of the bill’s 15 sponsors, Bart Gordon (D-TN).

We covered the topic in the February 7 edition.

The bill was created at the behest of the American College of Emergency Phyisicans (ACEP). Last year, members of ACEP approached Gordon and Pete Sessions (R-TX ) to mitigate a problem physicians were calling a “crisis” which the Emergency Medical Treatment and Labor Act of 1986 (EMTALA) could not wholly address. 

If approved, HR 3875 would

• extend liability protection to on-call specialists and emergency physicians who provide
  EMTALA–mandated care to the uninsured
• supplement Medicare payments for physician services in the ED
• give hospitals incentives to cease the practice of boarding patients admitted to the ED

“We feel we have been doing everything we can to attract the attention of policymakers to look at the welfare of the American people,” said Robert Suter, DO, president-elect of ACEP and associate professor at the University of Texas Southwestern Medical Center in Dallas. Suter spoke to HCPro last fall as part of a story for the monthly newsletter Medical Staff Briefing.

Over the past few months hospitals have thwarted several people posing as inspectors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Associated Press reports. There is no evidence to suggest the cases are linked, and no arrests have been made.

Genuine inspectors report to hospital security or the front desk upon arrival. They will have a letter signed by JCAHO’s executive vice president. Accredited hospitals can sign on to a secure Web site to compare the inspectors’ badges with a replica posted there.

Comment:  You may want to pass this along to your security people.