Injury Prevention – Booster Seats

Formalized injury prevention education in the emergency department have addressed bicycle helmets,31,32 car seats,95 home safety,38,96 water safety,67 and poisoning prevention, among others.36 In these studies, education was given in the form of handouts, videos, or brief face-to-face counseling. Education alone has not been consistently effective, but when combined with provision of safety devices, referrals, or other incentives, it has led to better safety knowledge and behaviors. Such combined programs are described here. Studies showing positive results from standalone education include two that involved the inclusion of safety information on printed discharge instructions given to all families seen in the pediatric emergency department. Quan et al reported that water safety information was considered useful or very useful by 88% of parents receiving it, and that 35% of those not owning a life vest considered purchasing one because of the information.67 In a randomized, controlled trial, Zonfrillo et al printed the National Highway Traffic Safety Administration’s child passenger safety recommendations on discharge instructions, finding that 57% of parents in the intervention group remembered reading the information and 25% felt it was educational. 68 Another randomized, controlled trial studied poisoning prevention advice given to parents in the pediatric emergency department, resulting in increased poison prevention practices at home.36 An uncontrolled study of injury prevention advice tailored to a family’s reported risks showed positive change in the safety of a child’s environment at two weeks after intervention.96 None of these studies’ outcomes can be clearly linked to better injury outcomes. 

Negative results have been reported in studies of bicycle helmet and booster seat education in the pediatric emergency department. Cushman et al randomized families of bicycle-injured children to receive either targeted counseling plus pamphlets on bicycle safety or usual care.30 The rate of helmet purchase two to three weeks after the visit was the same in both groups. Gittelman et al also found that education about booster seats was no more effective than standard discharge instructions for a convenience sample of families who reported on booster seat use one month after their visits.95  

The authors also wanted to know if education combined with booster seat provision was a superior means to affect booster seat use; this was studied in a third, combined arm, which showed that providing booster seats in community settings withor without education increased use.97-99 Booster seats have also been given away in the pediatric emergency department with some evidence of success. In a randomized controlled trial, booster seat distribution combined with education increased parents’ self-reported booster seat use at one month after intervention to over 98%.95 Only 6% of families in two comparison groups (no education and booster seat education alone) reported using a booster seat at follow-up. The primary limitation in the study was self-reporting of behavior, making the results prone to acquiescence and social desirability biases, but such biases would have to be unusually strong in this case to account for such a large difference between groups. A similar program implemented at a Head Start center increased directly-observed booster seat use from 3% to 38%.97 The 60% difference between the two studies’ results might be evidence of the superiority of the pediatric emergency department for this type of injury prevention, but could also be explained (at least partially) by the previously mentioned self-reporting biases which would tend to increase positive results.

This was excerpted from the October 2007 Pediatric EM Practice article, “Preventing Childhood Injury: The Role Of The Emergency Physician.”

Abdominal Trauma Risk Management Pitfalls

1. “I didn’t think I had to evaluate for intraabdominal organ injury after the child fell off the bicycle handle.” Children have intra-abdominal organs that are proportionally larger and not well protected by their weaker abdominal musculature and cartilaginous ribs. Therefore, minor traumatic forces can easily cause injury to these intra-abdominal organs.

2. “I didn’t get a lumbar x-ray of that child involved in a car accident who was restrained in a lap-belt.” Children in motor vehicle accidents who wear a lap-only seat belt are prone to intra-abdominal solid organ, hollow viscous, and lumbar spine injuries. Due to their underdeveloped pelvis, the seat belt rides higher on the abdomen and rapid deceleration causes the child to sustain a hyperflexion injury of the upper lumbar spine and compression of the abdominal organs between the seat belt and the spine.

3. “I didn’t suspect that child would go into shock from her inflicted abdominal injuries.” Children who sustain intra-abdominal injuries from abuse are usually younger. The injuries are usually severe and because the history is inadequate and the time to presentation is usually delayed, these children frequently present in shock.

4. “The emergency medical technician told me the child had a PTS score of 4, and I told him it was okay to bring the child to my level 3 hospital.” A PTS score less than 8 is the recommended threshold for diverting children to a designated trauma center. Children with a PTS score greater than 8 have virtually no mortality. Significantly injured children have a better outcome in a dedicated trauma center.

5. “I didn’t think the child was in shock since his blood pressure was normal.” The heart rate is the most sensitive indicator of intravascular volume status in infants and young children. Hypovolemic shock is heralded by tachycardia long before hypotension becomes apparent.

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Conference Update

Pediatric Academic Societies And Asian Society for Pediatric Research Join Meeting is being held May 2-6, 2008 in Hawaii. For more information visit their website at http://pediatrics.hawaiiconvention.com/ 

The 2008 SAEM Annual Meeting will be held May 29-June 1 in Washington, D.C. at the Marriott Wardman Park. For more information visit their website at http://www.saem.org/SAEMDNN/Default.aspx?tabid=639 

CAEP 2008 is being held June 6-11 in Ontario, Canada. For more information visit their website at http://www.caep.ca/template.asp?id=C456968713BA406AB19F49F1E58D0ADA 

Evidence-Based Guidelines From The American Society for Gastrointestinal Endoscopy For The Role Of ERCP In Pancreatic And Biliary Diseases

……………………………………………………………..

1. Endoscopic retrograde cholangiopancreatography (ERCP) is primarily a therapeutic procedure.

2. Diagnostic ERCP should not be undertaken in the absence of objective findings of obstruction from other imaging modalities.

3. ERCP is recommended for: a. Post-operative biliary leaks or strictures.b. Acute or chronic pancreatitis.c. Palliation of malignant biliary obstruction.d. Pancreatic duct stones or leaks.e. Drainage of pancreatic pseudocysts.f. Diagnosis of pancreatic malignancies.

4. ERCP is not recommended prior to routine laparoscopic cholecystectomy.

5. ERCP is safe in children and pregnancy.

From: Baron TH, Davila RE, Egan J, et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and pancreas. Gastrointestinal Endoscopy. 2005;62(1). (Practice Guideline)

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Jaundice Case Study

Case study:

You’re in the middle of a busy Monday afternoon shift. The next chart simply states “other complaint,” but one look at the patient tells you why he is here. The patient is a middle-aged male with no prior medical history who states that his family has been telling him his eyes are yellow for the last two to three weeks. He initially thought nothing of it but became concerned when the discoloration spread to his face. He also admits to occasional nausea, vomiting, poor appetite, weight loss, and diffuse itching. There is no history of fever, abdominal pain, heavy alcohol use, or recent acetaminophen ingestion. The physical exam is remarkable for icteric sclerae, jaundice of his face and upper chest, and mild non-tender hepatomegaly. Your history and physical have helped to develop the differential diagnosis related to the patient’s presentation your challenge is directing the ED work-up so that the appropriate initial interventions can be made before disposition

Conclustion of the above case study…
Your patient’s lab profile was significant for elevated direct bilirubin and alkaline phosphatase as well as mildly elevated transaminases, consistent with biliary obstruction. Based on the history and physical, you were more concerned about a malignant obstruction, so you ordered a CT of the abdomen and pelvis with contrast. This study showed a distended gallbladder with no cholelithiasis, a dilated common bile duct, and a mass at the head of the pancreas. Surgery was called and you made arrangements to admit the patient for ERCP and biliary decompression. You informed the patient of the CT results and let him know that he would be admitted for further work-up of the mass.

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Risk Management Pitfalls

1. “The patient denied taking any acetaminophen.” Patients, especially suicidal ones, may not be truthful about the amount of acetaminophen they ingested. Additionally, patients who have been treating chronic pain with acetaminophen around the clock may have chronic toxicity. Because acetaminophen-induced liver toxicity is one of the few treatable forms, an acetaminophen level should be checked for any undifferentiated cause of hepatocellular injury. 

2. “The kid didn’t appear that jaundiced, so I just told his mom to have him seen by his pediatrician.” The physical examination alone is a poor predictor of serum bilirubin levels, especially in the low light of an emergency department. Even well appearing neonates should have a total and direct serum bilirubin checked. 

3. “She appeared so comfortable; I wouldn’t have thought she had a pancreatic head mass.” Painless jaundice can often indicate biliary obstruction. The chemistry panel can also help narrow the differential and determine which patients should be imaged in the ED. 

4. “The patient wasn’t encephalopathic the other day when I saw her; now she is back and obtunded.” The initial stages of hepatic encephalopathy can be subtle starting with agitation and poor memory. Patients may also be good at hiding their difficulties in public. Questioning the family about a patient’s behavior might help to detect signs of early hepatic encephalopathy. A mini mental status examination may aid in documenting a patient’s cognitive impairment. All patients with jaundice and hepatic encephalopathy should be admitted. 

5. “The patient had no abdominal tenderness, so I didn’t consider cholangitis as a possibility.” Only 50-75% of patients with acute cholangitis manifest Charcot’s triad (fever, jaundice, and right upper quandrant tenderness). These signs can be absent, especially in the elderly and immunocompromised. A high index of suspicion should be maintained in patients with fever and jaundice, especially if they have a history of gallstones or prior biliary instrumentation

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