Publications

Scholarly Journals--Published

  • Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD; For the Emergency Department Ketamine Meta-Analysis Study Group. Predictors of Emesis and Recovery Agitation with Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children. Ann Emerg Med 2009 Aug; 54(2): 171-80.e1-4. Epub Jun 6 PMID: 19501426. STUDY OBJECTIVE:Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies.METHODS:We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events.RESULTS:In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation.CONCLUSION:Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration. (08/2009)
  • Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD; For the Emergency Department Ketamine Meta-Analysis Study Group. Predictors of Airway and Respiratory Adverse Events with Ketamine SEdation in the Emergency Department: An Individual-Patient Data Meta-Analysis of 8,282 Children. Ann Emerg Med 2009 Aug; 54(2): 158-68.e1-4. Epub 2009 Feb 7. PMID: 19201064 STUDY OBJECTIVE:Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.METHODS:We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.RESULTS:In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route.CONCLUSION:Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines. (08/2009)
  • Thorp AW, Brown L, Green SM. Ketamine-associated vomiting: is it dose-related? Pediatr Emerg Care 2009 Jan;25(1):15-8. PMID: 19116497 OBJECTIVE:Vomiting is a common adverse event after emergency department ketamine sedation in children. We sought to determine if the rate of vomiting is dose related to intravenous ketamine.METHODS:Treating physicians administered intravenous ketamine to children requiring sedation for a procedure in a pediatric emergency department using doses of their discretion in this prospective observational study. We compared initial and total ketamine doses between children with and without vomiting directly and after controlling for age and coadministered drugs using multiple logistic regression analysis.RESULTS:A wide range of initial (0.2 to 2.4 mg/kg) and total (0.3 to 23.8 mg/kg) ketamine doses were administered in the 1039 sedations studied. Vomiting occurred in 74 (7%) overall. Initial and total ketamine dose distributions were similar in children with and without vomiting (medians 1.6 vs 1.6 mg/kg and 2.2 vs 2.1 mg/kg, respectively). Our multivariate analysis found no significant association between emesis and initial dose; however, it did reveal an association with total dose that was explained by a minority (3.5%) of children who received high cumulative doses (>7 mg/kg). The rate of emesis was 7.0% when the total ketamine dose was 7 mg/kg or less and 11.1% when greater than 7 mg/kg.CONCLUSIONS:Within a wide range of intravenous doses, ketamine-associated vomiting is not related to either the initial loading dose or the total dose--except for a modest increase for those receiving high cumulative doses (>7 mg/kg). (01/2009)
  • Brown L, Christian-Kopp S, Sherwin TS, Khan A, Barcega B, Denmark TK, Moynihan JA, Kim GJ, Stewart G, Green SM. Adjunctive atropine is unnecessary during ketamine sedation in children. Acad Emerg Med 2008 Apr;15(4):314-8. PMID: 18370983 BACKGROUND:The prophylactic coadministration of atropine or other anticholinergics during dissociative sedation has historically been considered mandatory to mitigate ketamine-associated hypersalivation. Emergency physicians (EPs) are known to omit this adjunct, so a prospective study to describe the safety profile of this practice was initiated.OBJECTIVES:To quantify the magnitude of excessive salivation, describe interventions for hypersalivation, and describe any associated airway complications.METHODS:In this prospective observational study of emergency department (ED) pediatric patients receiving dissociative sedation, treating physicians rated excessive salivation on a 100-mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation.RESULTS:Of 1,090 ketamine sedations during the 3-year study period, 947 (86.9%) were performed without adjunctive atropine. Treating physicians assigned the majority (92%) of these subjects salivation visual analog scale ratings of 0 mm, i.e., "none," and only 1.3% of ratings were >or= 50 mm. Transient airway complications occurred in 3.2%, with just one (brief desaturation) felt related to hypersalivation (incidence 0.11%, 95% confidence interval = 0.003% to 0.59%). Interventions for hypersalivation (most commonly suctioning) occurred in 4.2%, with no occurrences of assisted ventilation or intubation.CONCLUSIONS:When adjunctive atropine is omitted during ketamine sedation in children, excessive salivation is uncommon, and associated airway complications are rare. Anticholinergic prophylaxis is not routinely necessary in this setting. (04/2008)
  • Hasty, MB, Klasner A, Kness S, Denmark TK, Ellis D, Herman MI, Brown L.. "Cutaneous community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among all skin and soft tissue infections in two geographically distant pediatric emergency departments." Academic Emergency Medicine 23.8 (2007): 549-552. OBJECTIVES: To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California. METHODS: Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0-686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities. RESULTS: Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA-positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensativities at both institutions were similar. CONCLUSIONS: The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings. (08/2007)
  • Babl FE, Lewena S, Brown L. "Vaccination related adverse events." Pediatr Emerg Care 2006;22:514-21. PMID: 16871116 AbstractVaccine-related adverse events are uncommon and typically mild. Children may experience conditions such as rashes, fevers, syncope, protracted crying, or seizures shortly after receiving their routine immunizations. When children are brought to the emergency department or clinic to be evaluated for one of these conditions, the health care provider may be called upon to determine the likelihood that it was caused by a recently administered set of vaccines. This determination has substantial implications for medical care, including the safety of administering future vaccines. This article reviews the current understanding of vaccine-related adverse events. Using this information, clinicians should be able to identify those events likely to be related to vaccine administration and those that are not. The appropriate management of vaccine-related adverse events is also discussed. (07/2007)
  • Kim TY, Brown L, Stewart G. "Test Characteristics of Parent's Visual Analog Scale Score in Predicting Ventricuoperieoneal Shunt Malfunction in the Pediatric Emergency Department." Pediatric Emergency Care 23.8 (2007): 549-552. Objectives: Many parents of children with ventriculoperitoneal shunts present to the emergency deparment for evaluation of a possible shunt malfunction. No study to date has evaluated their ability to predict a shunt malfunction. Our study objective was to evaluate parents' accuracy for predicting a shunt malfunction in their child. We hypothesize that parents more experienced with prior shunt malfuctions are better able to predict subsequent malfunctions in their child. Methods: We conducted a prospective, descriptive study on children younger than 18 years presenting to our tertiary care pediatric emergency department with a possible ventriculoperitoneal shunt malfunction. Parents rated the likelihood of a shunt malfunction using an unmarked 100-mm visual analog scale marked definitely malfunctioning at the high end. An experienced parent was defined as one who had previously experienced at least 3 shunt malfunctions in their child. Results: We enrolled 85 parent-child dyads in our study. Twenty-four children were diagnosed with a malfunction. The predictive ability of parents to determine a shunt malfunction was found at a threshold visual analog scale score of 66 (sensitivity, 88.9%, and specificity 62.2%). At a determined threshold value of 85 or more, experienced parents had a high specificity of 89.2% with a positive likelihood ratio of 5.1. Experienced parents showed an area under the curve of 0.7928 (95% confidence interval, 0.6037-0.9819); and inexperienced parents, 0.5611 (95% confidence interval, 0.3646-0.7576) (P = 0.096). Conclusions: Experienced parents are better able to predict a shunt malfunction in their child. (01/2007)
  • Thorp A, Brown L. "An assessment of the inaccessibility of internet references in the Annals of Emergency Medicine: Is it time to require archiving?." Annals of Emergency Medicine 50.2 (2007): 188-192, 192.e1-33. Study objective: We seek to evaluate the accessibility of all Internet references appearing in Annals of Emergency Medicine from 2000, 2003, and 2005. Secondary objectives are to determine whether the number of Internet references is increasing and to describe how Internet references are inaccessible. Methods: We visually scanned all articles for references made in the printed version of Annals of Emergency Medicine for 2000, 2003, and 2005. We identified the Internet references and grouped them into 11 categories according to the results of entering the uniform resource locator (URL) into the Internet browser. Results: We identified 15,745 references published in Annals of Emergency Medicine. The proportion of Internet references increased from 1% of the total references in 2000 to 5.4% in 2005. Internet references were not readily accessible for 40 of 51 Internet references in 2000 (78%; 95% confidence interval [CI] 65% to 88%), 161 of 286 Internet references in 2003 (56%; 95% CI 50% to 62%), and 111 of 249 Internet references in 2005 (45%; 95% CI 39% to 51%). Inaccessibility was most commmonly manifested by URLs that no longer link to active Web sites (172 of 312 inaccessible Internet referneces [55%; 95% CI 50% to 61% and URLs that linnked to generic home pages where the authors' references material could not be found (115 of 312 inaccessible Internet references [37%]; 95% CI 32% to 42%). Conclusion: In Annals of Emergency Medicine, older Internet references appear to be less accessible than newer references. Internet reference archiving is one solution to preserving this information for future readers. (01/2007)
  • Denmark TK, Crane HA, Brown L. "Ketamine to avoid mechanical ventilation in severe pediatric asthma." Journal of Emergency Medicine 30.2 (2006): 163-166. Children experiencing severe asthma exacerbations may deteriorate to respiratory failure requiring endotracheal intubation and mechanical ventilation. Mechanical ventilation is often life saving in this setting, but also exposes the asthmatic child to substantial iatrogenic risk. We present two cases of severe asthma exacerbations in prepubertal children for whom the administration of a bolus of intravenous ketamine followed by a continuous infusion of a relatively large dose of ketamine led to prompt improvement, obviating the need for mechanical ventilation. These cases suggest that for children experiencing severe asthma exacerbations, intravenous ketamine may be an effective temporizing measure to avoid exposing these children to the risks associated with mechanical ventilation. (01/2006)
  • Rivera ML, Kim TY, Stewart GM, Minasyan L, Brown L.. "Albuterol nebulized in heliox in the initial ED treatment of pediatric asthma: A blinded, randomized controlled trial ." American Journal of Emergency Medicine 24.1 (2006): 38-42. OBJECTIVE: A prospective blinded, randomized controlled trial was undertaken to compare the initial response of albuterol nebulized in heliox or control in the treatment of moderately severe asthma in children presenting to a pediatric ED. METHODS: Patients were randomized to receive heliox (n = 20) or control (n = 21). The primary outcome was to compare a modified dyspnea index score at 10 and 20 minutes after randomization. Secondary outcomes were to determine if heliox decreased admission rates or endotracheal intubation. RESULTS: There was no statistically significant difference found at 10 or 20 minutes after randomization with heliox (P = .169 and P = .062, respectively). No statistical difference in admission rate was found, and no patients required endotracheal intubation in either group. CONCLUSIONS: Our results demonstrate that albuterol nebulized with heliox offered no clinical benefit over standard therapy in the initial treatment of moderately severe asthma in the ED. (01/2006)
  • Checchia PA, Moynihan JA, Brown L. "Cardiac troponin I as a predictor of mortality for pediatric submersion injuries requiring out of hospital cardiopulomonary resuscitation." Pediatric Emergency Care 22.4 (2006): 222-225. BACKGROUND: It is difficult to predict ultimate survivors to hospital discharge in children who are successfully resuscitated after a cardiorespiratory arrest associated with a submersion injury. Serum measurements of organ injury or dysfunction may serve as a surrogate marker of the degree of hypoxic injury. We designed a prospective study whose purpose was to assess the predictive value for outcome of serum cardiac troponin I measurements after submersion injury and cardiorespiratory arrest. METHODS: This is a prospective, observational study of children admitted to a postintensive care unit after experiencing an out-of-hospital cardiorespiratory arrest associated with a submersion event. Cardiac troponin I measurements were examined upon admission to the postoperative intensive care unit after successful emergency department resuscitation. RESULTS: Nine patients were admitted, and 2 patients (22%) survived to hospital discharge. The area under the receiver operating characteristic curve is 0.786 (95% confidence interval, 0.481-1.0). This suggests that cardiac troponin I has a moderate degree of discriminatory power in selecting children who did not survive to hospital discharge. (01/2006)
  • Kim TY, Stewart G, Moynihan JA, Voth M, Brown L. "Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department." Pediatric Emergency Care 22.1 (2006): 28-34. OBJECTIVES: Pediatric patients with cerebrospinal fluid shunts frequently present to the emergency department for evaluation of possible shunt malfunction. Most shunt studies appear in the neurosurgical literature. To our knowledge, none have reviewed presenting signs and symptoms of shunt malfunction in patients who present to the pediatric emergency department. The study objective was to evaluate the medical record of children with cerebrospinal fluid shunts who presented to a pediatric emergency department to determine if any signs and/or symptoms were predictive of shunt malfunction. METHODS: A retrospective chart review was conducted on 352 pediatric patients aged 0 to 18 years, who presented to the pediatric emergency department between January 1, 1998, and December 31, 2002, with signs and/or symptoms that prompted an evaluation for possible shunt malfunction. RESULTS: Univariate analysis of all signs and symptoms revealed lethargy (odds ratio, 1.99; 95% confidence interval, 1.15-3.42; P = 0.02) and shunt site swelling (odds ratio, 2.56, 95% confidence interval, 1.08-6.07, P = 0.03) to be significantly predictive of shunt malfunction. Logistic regression analysis continued to show significance for lethargy (odds ratio, 2.20; bias-corrected 95% confidence interval, 1.11-3.63) and shunt site swelling (odds ratio, 3.10; bias-corrected 95% confidence interval, 1.38-9.05), but found no other study variable to be significant. Bootstrap resampling validated the importance of the significant variables identified in the regression analysis. CONCLUSIONS: In this study, lethargy and shunt site swelling were predictive of shunt malfunction. Other signs and symptoms studied did not reach statistical significance; however, one must maintain a high index of suspicion when evaluating children with an intracranial shunt because the presentation of malfunction is widely varied. A missed diagnosis can result in permanent neurological sequelae or even death. (01/2006)
  • Thorp A, Hurt TL, Kim TY, Brown L. "Tracheoinnominate artery fistula: A rare and often fatal complication of indwelling tracheostomy tubes." Pediatric Emergency Care 21.11 (2005): 763-766. Fistula formation between the innominate artery and the trachea is a rare but potentially catastrophic complication after tracheostomy. Although surgery is the definitive treatment of tracheoinnominate artery fistula, the responsibility for making the proper diagnosis and stabilizing the patient before surgery often falls on the personnel in the emergency department. We describe the emergency department management of a 14-year-old girl with a tracheoinnominate artery fistula. A discussion of the risk factors, diagnostic considerations, and emergency department management strategies of tracheoinnominate artery fistula is presented. (01/2005)
  • Brown L, Shaw T, Wittlake WA. "Does leukocytosis identify bacterial infections in febrile neonates presenting to the emergency department?." Emergency Medicine Journal 22. (2005): 256-259. AbstractOBJECTIVE: This study was undertaken to evaluate the discriminatory power of the peripheral white blood cell (WBC) count to identify bacterial infections in a cohort of febrile neonates (<or=28 days of age) presenting to an emergency department. METHODS: Retrospective medical record review using descriptive statistics and a receiver operating characteristic (ROC) curve. Neonates who presented to a tertiary care paediatric emergency department between 1 January 1999 and 22 August 2002, had a temperature >or=38 degrees C, underwent lumbar puncture, and had a WBC count obtained were included. They were divided according to microbiological and radiographic findings into four groups: bacterial infections, viral infections, pneumonia, and negative sepsis evaluations. RESULTS: A total of 69 febrile neonates met the inclusion criteria. The number of neonates in each group was as follows: 8 with bacterial infections, 10 with viral infections, 3 with pneumonias, and 48 with negative sepsis evaluations. There was substantial overlap in WBC counts among the groups. The area under the ROC curve was 0.7231 (95% CI 0.5665 to 0.8797). CONCLUSION: In a cohort of febrile neonates evaluated in the emergency department, the WBC count had modest discriminatory power in identifying neonates with bacterial infections and demonstrated substantial overlap among groups. The present data suggest against the use of any WBC count threshold to identify bacterial infections in febrile neonates presenting to the emergency department. (01/2005)
  • Brown L. "Mandating automated external defibrillators in schools: Fire, ready, aim!." Canadian Journal of Emergency Medicine 6.6 (2004): 431-433. (11/2004) (link)
  • Vargas EJ, Mody AP, Kim TY, Denmark TK, Moynihan JA, Barcega BB, Khan A, Clark RT, Brown L. "Pediatric upper esophageal coin removal by emergency physicians: A pilot study." Canadian Journal of Emergency Medicine 6.6 (2004): 434-440. ABSTRACT Objective: There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure. Methods: This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004. Results: Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems. Conclusions: This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended. (11/2004) (link)
  • Brown L, Shaw T, Moynihan JA, Denmark TK, Mody A, Wittlake WA. "Investigation of afebrile neonates with a history of fever." Canadian Journal of Emergency Medicine 6.5 (2004): 343-348. ABSTRACT Objective: Our objective was to describe clinically significant infections in a cohort of afebrile neonates who underwent an emergency department (ED) septic workup because of the history of a measured fever at home. Methods: Retrospective medical record review of all infants ¾28 days of age who presented to our tertiary care pediatric ED between Jan. 1, 1999, and Aug. 22, 2002, underwent lumbar puncture in the ED, had a reported temperature at home of >=38°C, and an ED triage temperature of (09/2004) (link)
  • Brown L, Denmark TK, Wittlake WA, Vargas EJ, Watson T, Crabb JW. "Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies." American Journal of Emergency Medicine 22.4 (2004): 310-314. This is the first report of which we are aware that describes the use of procedural sedation for the emergency department management of ear and nose foreign bodies in children < 18 years of age. During a 5.5-year period, we identified 312 cases of children with a foreign body in a single orifice (174 ear, 138 nose). Procedural sedation was performed in 23% of cases (43 ear, 28 nose) and ketamine was used most commonly (92%). Emergency physicians had a high rate of success in removing foreign bodies (84% ear, 95% nose) and a low complication rate. Procedural sedation had a positive effect on the success rate as more than half of the sedation cases had undergone failed attempts without sedation by the same physician. Emergency physicians should have familiarity with this indication for procedural sedation. (07/2004)
  • Denmark TK, Hargrove JR, Brown L. "Intramuscular ketamine to facilitate pediatric central vascular access." Canadian Journal of Emergency Medicine 6.4 (2004): 259-262. ABSTRACT Objectives: Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. The objective of our study was to describe our experience using intramuscular (IM) ketamine to facilitate the placement of central venous catheters in children presenting to our ED needing vascular access in a timely fashion. Methods: We performed a retrospective medical record review of all pediatric patients (07/2004) (link)
  • Denmark TK, Hargrove JR, Brown L. "Intramuscular ketamine to facilitate pediatric central vascular access." Canadian Journal of Emergency Medicine 6. (2004): 259-262. OBJECTIVES:Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. The objective of our study was to describe our experience using intramuscular (IM) ketamine to facilitate the placement of central venous catheters in children presenting to our ED needing vascular access in a timely fashion.METHODS:We performed a retrospective medical record review of all pediatric patients <18 years of age who presented to our tertiary care pediatric ED between May 1, 1998, and August 7, 2003, and underwent the placement of a central venous catheter facilitated by the use of IM ketamine.RESULTS:Eleven children met our inclusion criteria. Most of the children were young and medically complicated. The children ranged in age from 6 months to 8 years. The only complication identified was vomiting experienced by an 8-year-old boy. Emergency physicians successfully obtained central venous access in all subjects in the case series.CONCLUSIONS:The use of IM ketamine to facilitate the placement of central venous catheters in children who do not have peripheral venous access appears to be helpful. Emergency physicians may find it useful to be familiar with this use of IM ketamine. (01/2004)
  • Vargas EJ, Mody AP, Kim TY, Denmark TK, Moynihan JA, Barcega BB, Khan A, Clark RT, Brown L. The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study. Canadian Journal of Emergency Medicine 6. (2004): 434-440. OBJECTIVE:There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure.METHODS:This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004.RESULTS:Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems.CONCLUSIONS:This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended. (01/2004)
  • Brown L, Tomasi A, Salcedo G. "An attractive approach to magnets adherent across the nasal septum." Canadian Journal of Emergency Medicine 5. (2003): 356-358. We report a case of an 8-year-old boy who presented to the emergency department with small jewelry magnets adherent across his nasal septum. Prompt removal of these foreign bodies is important to avoid septal necrosis and perforation. We report our success in using the metal handle of bayonet forceps to break the attraction between the magnets. The magnets were removed painlessly and without trauma to the nasal septum. (01/2003)
  • Brown L, Reiley DG, Jeng A, Green SM. "Objective criteria fail to predict which children with bronchiolitis are eligible for brief hospitalization." 5. (2003): 239-244. OBJECTIVE: To determine if 3 objective criteria - pulse oximetry, respiratory syncytial virus (RSV) testing, and age - could be used to predict which children hospitalized with bronchiolitis will have brief (<36 hour) hospitalizations and therefore be potential candidates for admission to short-stay observation units. METHODS: This was a retrospective medical record review of medically uncomplicated children 3 to 24 months of age with emergency department and hospital discharge diagnoses consistent with bronchiolitis who were admitted to a general pediatric ward in our university-based, tertiary care hospital between Jan. 1, 1992, and Nov. 12, 2002. Multiple logistic regression was used to assess the predictor variables. RESULTS: Our study consisted of 225 patients (45% female) with a median age of 7 months (interquartile range [IQR], 4-11 mo; range, 3-22 mo). Median pulse oximetry value was 94% (IQR 91%-96%; range 76%-100%), and 71% of the patients tested positive for RSV. Thirty children (13%) had brief hospitalizations <36 hours, and the median hospital length of stay for the entire study group was 70 hours (IQR 46-108 h; range 6-428 h). None of the 3 predictor variables were independently associated with brief hospitalization. CONCLUSIONS: Pulse oximetry, RSV testing and age do not predict which children will have brief hospitalizations and are appropriate candidates for admission to short-stay observation units. (01/2003)
  • Moynihan JA, Brown L, Sehra R, Checchia PA. "Cardiac troponin I as a predictor of respiratory failure in children hospitalized with respiratory syncytial virus (RSV) infections: A pilot study." American Journal of Emergency Medicine 21. (2003): 479-482. BACKGROUND:It is difficult to predict ultimate survivors to hospital discharge in children who are successfully resuscitated after a cardiorespiratory arrest associated with a submersion injury. Serum measurements of organ injury or dysfunction may serve as a surrogate marker of the degree of hypoxic injury. We designed a prospective study whose purpose was to assess the predictive value for outcome of serum cardiac troponin I measurements after submersion injury and cardiorespiratory arrest.METHODS:This is a prospective, observational study of children admitted to a postintensive care unit after experiencing an out-of-hospital cardiorespiratory arrest associated with a submersion event. Cardiac troponin I measurements were examined upon admission to the postoperative intensive care unit after successful emergency department resuscitation.RESULTS:Nine patients were admitted, and 2 patients (22%) survived to hospital discharge. The area under the receiver operating characteristic curve is 0.786 (95% confidence interval, 0.481-1.0). This suggests that cardiac troponin I has a moderate degree of discriminatory power in selecting children who did not survive to hospital discharge. (01/2003)
  • Brown L, Moynihan J, Denmark TK. "Blunt pediatric head trauma requiring neurosurgical intervention: How subtle can it be?." American Journal of Emergency Medicine 21. (2003): 467-472. Recent literature on pediatric head injuries has suggested that important intracranial injuries might present to the ED without typical signs or symptoms. The objective of our study was to review our institutional experience with head-injured infants and young children to assess the subtlety of the ED presentation. We performed a retrospective medical record review of head-injured children </=10 years of age who underwent neurosurgical procedures from January 1, 1985, through November 28, 2001. We identified 110 children who met our inclusion criteria. All of the children had at least 2 signs or symptoms indicative of head injury. No single sign or symptom was present in all cases. Altered mental status was identified 85% of the time and was the most common sign or symptom. Eighteen children presented with a Glasgow Coma Scale score of 15 or the absence of abnormal mental status documented, but all of these children had other indications for head computed tomographic scanning. Emergency physicians should feel confident that standard history and physical examination skills are adequate to identify head-injured children who require neurosurgical procedures. (01/2003)
  • Brown L, Dannenberg B. "Pulse oximetry in discharge decision making: A survey of emergency physicians." 4. (2002): 388-393. OBJECTIVE: Our primary objective was to describe the pulse oximetry discharge thresholds used by general and pediatric emergency physicians for well-appearing children with bronchiolitis and pneumonia, and to assess the related practice variability. METHODS: This mail-in survey was conducted in August and September 2001 and included the 281 active members of the Pediatric Emergency Medicine Section of the American College of Emergency Physicians. The survey consisted of 2 case scenarios of previously healthy, well-appearing children: a 2-year-old with pneumonia and a 10-month-old with bronchiolitis. Respondents were asked about their years of experience, teaching load, percentage of children in their practice, whether they currently have a written departmental guideline at their institution, and the lowest pulse oximetry reading that they would accept and still discharge the patient directly home. RESULTS: One hundred and eighty-two (65%) physicians answered the survey and met the inclusion criteria. The respondents' median oximetry value and interquartile range (IQR) for the pneumonia and bronchiolitis cases were 93% (92%-94%) and 94% (92%-94%) respectively. With the exception of the 3 physicians practising >1000 metres above sea level, the responses by subgroups were similar. CONCLUSIONS: There does not yet exist a safe, clinically validated pulse oximetry discharge threshold. Emergency physicians from this study sample have a modest degree of practice variability in a self-reported pulse oximetry discharge threshold. Emergency physicians may use this data to compare their own practice with that reported by this group. (01/2002)
  • Brown L, Takeuchi D, Challoner K. "Corneal abrasions associated with pepper spray exposure." American Journal of Emergency Medicine 18. (2000): 271-272. Pepper spray containing oleoresin capsicum is used by law enforcement and the public as a form of nonlethal deterrent. Stimulated by the identification of a case of a corneal abrasion associated with pepper spray exposure, a descriptive retrospective review of a physician-maintained log of patients presenting to a jail ward emergency area over a 3-year period was performed. The objective was to give some quantification to the frequency with which an emergency physician could expect to see corneal abrasions associated with pepper spray exposure. Of 100 cases of pepper spray exposure identified, seven patients had sustained corneal abrasions. We conclude that corneal abrasions are not rare events when patients are exposed to pepper spray and that fluorescein staining and slit lamp or Wood's lamp examination should be performed on all exposed patients in whom corneal abrasions cannot be excluded on clinical grounds. (01/2000)