A New Approach to Managing Young Non-Toxic-Appearing Febrile Children
Keypoint: Researchers suggest an emphasis on more limited evaluation, now that vaccines have greatly reduced the likelihood of serious bacterial infections.
Citation: Jhaveri R, Byington CL, Klein JO, Shapiro ED. Management of the non-toxic-appearing acute lyfebrile child: a 21stcentury approach. J Pediatr. 2011;59(2):159:181.
Since the 1970s, considerable attention has been paid to the management of febrile children aged £3 years without an obvious focus of infection. Recommendations have emphasized detection of serious bacterial infections (SBIs), including occult bacteremia (OB), and empirical antibiotic treatment for children considered to be at high risk. Management has been determined using a combination of clinical appearance, age, and laboratory tests, with more testing recommended for infants aged <3 months than for those aged 3 to 36 months.
Effective vaccines against Haemophilusinfluenzae type b (Hib) and Streptococcuspneumoniae, the twomajorcausesofoccult SBIs, have been universally available in the US since 1988 and 2000, respectively. The incidence of invasive Hib infection in children aged <5 years dropped by 99% between 1987 and 2007, and the inci- dence ofpneumococcal OB is currently <0.5%. Urinary tract infections (UTIs) are now the most common SBI in febrile children with- out localizing signs. Considering these changes, researchers from four major pediatric departments suggest that recommendations for managing such children be updated.
These researchers state that new guidelines should emphasize the importance of immediate antimicrobial therapy for an infant who is seriously ill or toxic appearingand a complete clinical and laboratory evaluation for high-risk febrile infants aged £30 days, aswehavebeendoing. However, for intermediate-risk infants aged 31 to 90 days, acceptable management can range from complete evaluation to simply observation and follow-up. And for infants aged 3 to 36 months who have received ³2 doses ofboth Hib and pneumococcal conjugate vaccines, evaluation only for UTI is war- ranted.
Published in J Watch Infect Dis. August 17, 2011—Robert S. Baltimore, MD.
Warm Local Anesthetics Prior to Injection
Key point: Warming reduces pain, even when the anesthetic is buffered.
Citation: Hogan ME, vanderVaart S, Perampaladas K, etal. Systematic review and meta-analysis of the effect of warming local anesthetics on injection pain. Ann Emerg Med. 2011;58(1):86- 98.e1.
Injection of local anesthetics causes pain at the injection site be- foreprovidinganesthesia.
Postulatedmethodstomitigatethispain include slowing the rate of injection; avoiding epinephrine, whenpossible; buffering; andwarmingthelocalanesthetictobody temperature prior to injection. These authors assessed injection pain in ameta-analysis of 18 randomized studies involving 831 pa- tientswhoreceivedeitherwarmed(bodytemperature) orunwarmed (room temperature) subcutaneous or intradermal local anesthet- ic injections. The anesthetic was unbuffered in 10 studies.
Patients reported pain on either visual analog or numeric rat- ingscales. Methods ofwarmingincluded water baths, incubators, fluid warmers, baby food warmers, warming trays, and syringe warmers.
Patients reported less pain with warmed anesthetic than with room-temperature anesthetic (mean difference, 11 mm on a 100- mm scale). Even with buffered anesthetic, patients reported less pain with warming (mean difference, 7 mm).Published in J Watch Emerg Med. August 12, 2011—Richard D. Zane, MD, FAAEM. n
When LP Is Not Necessary to Detect Subarachnoid Bleed
Keypoint: CT performed within 6 hours of symptom on set in neurologically intact patients had 100% negative predictive value in this prospective multicenter study.
Citation: Perry JJ, Stiell IG, Sivilotti ML, etal. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of sub arachnoid haemorrhage: prospective cohort study. BMJ. 2011;343:d4277.
Standard teaching is that lumbar puncture (LP) is essential in pa- tientswithsuspectedsubarachnoidhemorrhage(SAH) despitenor- malheadcomputedtomography(CT) scans. Researchersprospec- tively enrolled 3132 consecutive neurologically intact patients old- er than 15 who underwent head CT with third-generation multi- slice scanners to evaluate nontraumatic acute headache or headache with syncope at 11 tertiary emergency departments in Canada from 2000 to 2009. LP was performed at the discretion ofthetreatingphysician.
Experiencedradiologistswhowereblind- ed to the study interpreted all CT scans. SAH was defined by sub- arachnoidbloodon CT, aneurysmoncerebralangiography, orxan- thochromia in cerebrospinal fluid.
Mean headache peak pain severity was 8.7 on a 0–10 scale. LP was performed in 49% of patients after negative CT scans. Over- all, 240 patients (7.7%) were diagnosed with SAH. The sensitivity o fhead CT for SAH was 92.9%, and the negative predictive val- ue(NPV) was 99.4%. Emergency physicians identified all but three cases of SAH; all three patients weres canned>6 hours after headache onset. Among 953 patients who were scanned within 6 hours of symptom on set, head CThad 100% sensitivity and 100% NPV. Fol- low-upat 1 and 6 months did not identify any cases of missed SAH. Published in JWatch Emerg Med. August 5, 2011—Kristi L. Koenig, MD, FACEP. n
Patients Comprehend Clinical Data Best When Expressed as Percentages
Keypoint: In this relatively educate population, one-third fully understood the data. This has implications for leaving treatment decisions solely to patients.
Citation: Woloshin S, Schwartz LM. Communicatingdata about the benefits and harms of treatment: A randomized trial. Ann Intern Med. 2011;155(2):87-96.
To determine how best to present data to patients on the benefits and harms of treatments, researchers randomly assigned nearly 3000 US adults from a nationally representative cohort to receive druginformation in one of five numeric formats. Data were presented in tables as natural frequencies (x in 1000); variable frequencies (x in 100, x in 1000, etc., as needed to maintain the numerator >1); percentages; percentages and natural frequencies; or percentages and variable frequencies. Participants were asked 18 questions that assessed their interpretation of the data, whichout- lined the expected benefits and adverse effects associated with treatment. The study was conducted online.
The mean number of correct responses was between 13 and 14 in all five groups. However, the proportion of participants who correctly answered at least 16 of the 18 questions was greatest for those receiving data as percentages and variable frequencies(35%) or percentages only (34%); it was lowest for data presented only as frequencies (26%). Published in J Watch Gen Med. August 23, 2011—Jamaluddin Moloo, MD, MPH. n
Loss of Consciousness While Swimming: Think of Long QT Syndrome
Keypoint: In a case series of 10 children with LQTS and documented history of water-related syncope, failure to consider LQTS after the eventwas common
Citation: Albertella L, Crawford J, Skinner JR. Presentation and outcome of water-related events in children with long QT syndrome. Arch Dis Child. 2011;96(8):704-707.
Exercise, including swimming, is a known risk factor for dysrhythmia in children with long QT syndrome (LQTS). Investigators examined the presentation, outcomes, and time to final diagnosis in 10 children with LQTS and a history of water-related syncope prior to diagnosis.
Ageatthetimeofthewater-relatedsyncopeeventrangedfrom 3-14years. Sixchildrendevelopedsyncopeduringunderwaterswim- ming(threewhileracing), twodevelopedsyncopeafterswimming, onechildhadlossofconsciousnessandslippedthroughaflotation device, and another had a near drowning that required prolonged resuscitation and caused severe neurocognitive deficits. Diagnosis of LQTSwasmadeatthetimeofthewatereventinsixchildrenand after 1 to 17 years in theothers. Onechildwhohadbeendiagnosed withepilepsyandwasreceivingantiepilepticslaterdiedduringahock- eygame.PosthumousdiagnosisofLQTSwasmadewithgeneticanaly- sis. Five patients had a family history of sudden death or water-re- latedsyncopeevents. Allpatientsweretreatedwith b-blockers, and three required intracardiac defibrillators (two also had left cardiac sympathectomy). Theinitialcorrected QTintervalrangedfrom 450- 600 milliseconds. Ninepatientshad LQTStype 1 withmutationsof the KCNQ1 gene; the genotype could not be identified in one case. Published in JWatch Pediatr and Adolesc Med. August 3, 2011—F. Bruder Stapleton, MD