[Show abstract][Hide abstract] ABSTRACT: Plain chest x-ray (CXR) is often the initial screening test to identify pneumothoraces in trauma patients. Computed tomography (CT) scans can identify pneumothoraces not seen on CXR ("occult pneumothoraces"), but the clinical importance of these radiographically occult pneumothoraces in children is not well understood. The objectives of this study were to determine the proportion of occult pneumothoraces in injured children and the rate of treatment with tube thoracostomy among these children.
This was a planned substudy from a large prospective multicenter observational cohort study of children younger than 18 years old evaluated in emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network (PECARN) for blunt torso trauma from May 2007 to January 2010. Children with CXRs as part of their trauma evaluations were included for analysis. The faculty radiologist interpretations of the CXRs and any subsequent imaging studies, including CT scans, were reviewed for the absence or presence of pneumothoraces. An "occult pneumothorax" was defined as a pneumothorax that was not identified on CXR, but was subsequently demonstrated on cervical, chest, or abdominal CT scan. Rates of pneumothoraces and placement of tube thoracostomies and rate differences with 95% confidence intervals (CIs) were calculated.
Of 12,044 enrolled in the parent study, 8,020 (67%) children (median age = 11.3 years, interquartile range [IQR] = 5.3 to 15.2 years) underwent CXRs in the ED, and these children make up the study population. Among these children, 4,276 had abdominal CT scans performed within 24 hours. A total of 372 of 8,020 children (4.6%; 95% CI = 4.2% to 5.1%) had pneumothoraces identified by CXR and/or CT. The CXRs visualized pneumothoraces in 148 patients (1.8%; 95% CI = 1.6% to 2.2%), including one false-positive pneumothorax, which was identified on CXR, but was not demonstrated on CT. Occult pneumothoraces were present in 224 of 372 (60.2%; 95% CI = 55.0% to 65.2%) children with pneumothoraces. Tube thoracostomies were performed in 85 of 148 (57.4%; 95% CI = 49.0% to 65.5%) children with pneumothoraces on CXR and in 35 of 224 (15.6%; 95% CI = 11.1% to 21.1%) children with occult pneumothoraces (rate difference = -41.8%; 95% CI = -50.8 to -32.3%).
In pediatric patients with blunt torso trauma, pneumothoraces are uncommon, and most are not identified on the ED CXR. Nearly half of pneumothoraces, and most occult pneumothoraces, are managed without tube thoracostomy. Observation, including in children requiring endotracheal intubation, should be strongly considered during the initial management of children with occult pneumothoraces.
Academic Emergency Medicine 04/2014; 21(4):440-448. DOI:10.1111/acem.12344 · 2.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study aimed to compare children diagnosed with cervical spinal cord injury without radiographic abnormality (SCIWORA) relative to whether there is evidence of cervical spinal cord abnormalities on magnetic resonance imaging (MRI).
We conducted a planned subanalysis of a cohort of children younger than 16 years with blunt cervical spine injury presenting to Pediatric Emergency Care Applied Research Network centers from January 2000 to December 2004 who underwent cervical MRI and did not have bony or ligamentous injury identified on neuroimaging. We defined SCIWORA with normal MRI finding as children with clinical evidence of cervical cord injury and a normal MRI finding and compared them with children with SCIWORA who had cervical cord signal changes on MRI (abnormal MRI finding).
Of the children diagnosed with cervical spine injury, 55% (297 of 540) were imaged with MRI; 69 had no bony or ligamentous injuries and were diagnosed with SCIWORA by clinical evaluation; 54 (78%) had normal MRI finding, and 15 (22%) had cervical cord signal changes on MRI (abnormal MRI finding). Children with abnormal MRI findings were more likely to receive operative stabilization (0% normal MRI finding vs. 20% abnormal MRI finding) and have persistent neurologic deficits at initial hospital discharge (6% normal MRI finding vs. 67% abnormal MRI finding).
Children diagnosed with SCIWORA but with normal MRI finding in our cohort presented differently and had substantially more favorable clinical outcomes than those with cervical cord abnormalities on MRI.
Epidemiologic study, level III.
[Show abstract][Hide abstract] ABSTRACT: Objective:
Cranial computed tomography (CT) scans are frequently obtained in the evaluation of blunt head trauma in children. These scans may detect unexpected incidental findings. The objectives of this study were to determine the prevalence and significance of incidental findings on cranial CT scans in children evaluated for blunt head trauma.
This was a secondary analysis of a multicenter study of pediatric blunt head trauma. Patients <18 years of age with blunt head trauma were eligible, with those undergoing cranial CT scan included in this substudy. Patients with coagulopathies, ventricular shunts, known previous brain surgery or abnormalities were excluded. We abstracted radiology reports for nontraumatic findings. We reviewed and categorized findings by their clinical urgency.
Of the 43,904 head-injured children enrolled in the parent study, 15,831 underwent CT scans, and these latter patients serve as the study cohort. On 670 of these scans, nontraumatic findings were identified, with 16 excluded due to previously known abnormalities or surgeries. The remaining 654 represent a 4% prevalence of incidental findings. Of these, 195 (30%), representing 1% of the overall sample, warranted immediate intervention or outpatient follow-up.
A small but important number of children evaluated with CT scans after blunt head trauma had incidental findings. Physicians who order cranial CTs must be prepared to interpret incidental findings, communicate with families, and ensure appropriate follow-up. There are ethical implications and potential health impacts of informing patients about incidental findings.
[Show abstract][Hide abstract] ABSTRACT: Study objective:
We determine whether intra-abdominal injury is rarely diagnosed after a normal abdominal computed tomography (CT) scan result in a large, generalizable sample of children evaluated in the emergency department (ED) after blunt torso trauma.
This was a planned analysis of data collected during a prospective study of children evaluated in one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The study sample consisted of patients with normal results for abdominal CT scans performed in the ED. The principal outcome measure was the negative predictive value of CT for any intra-abdominal injury and those undergoing acute intervention.
Of 12,044 enrolled children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95% confidence interval [CI] 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647; 95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% CI 0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received a diagnosis of an intra-abdominal injury, and 6 of these underwent acute intervention for an intra-abdominal injury (0.2% of total sample; 95% CI 0.06% to 0.3%). The negative predictive value of CT for any intra-abdominal injury was 99.6% (3,803/3,819; 95% CI 99.3% to 99.8%); and for injury undergoing acute intervention, 99.8% (3,813/3,819; 95% CI 99.7% to 99.9%).
In a multicenter study of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries were rarely diagnosed after a normal abdominal CT scan result, suggesting that safe discharge is possible for the children when there are no other reasons for admission.
Annals of emergency medicine 04/2013; 62(4). DOI:10.1016/j.annemergmed.2013.04.006 · 4.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine if patient race/ethnicity is independently associated with cranial computed tomography (CT) use among children with minor blunt head trauma.
Secondary analysis of a prospective cohort study.
Pediatric research network of 25 North American emergency departments.
In total, 42 412 children younger than 18 years were seen within 24 hours of minor blunt head trauma. Of these, 39 717 were of documented white non-Hispanic, black non-Hispanic, or Hispanic race/ethnicity. Using a previously validated clinical prediction rule, we classified each child's risk for clinically important traumatic brain injury to describe injury severity. Because no meaningful differences in cranial CT rates were observed between children of black non-Hispanic race/ethnicity vs Hispanic race/ethnicity, we combined these 2 groups.
Cranial CT use in the emergency department, stratified by race/ethnicity.
In total, 13 793 children (34.7%) underwent cranial CT. The odds of undergoing cranial CT among children with minor blunt head trauma who were at higher risk for clinically important traumatic brain injury did not differ by race/ethnicity. In adjusted analyses, children of black non-Hispanic or Hispanic race/ethnicity had lower odds of undergoing cranial CT among those who were at intermediate risk (odds ratio, 0.86; 95% CI, 0.78-0.96) or lowest risk (odds ratio, 0.72; 95% CI, 0.65-0.80) for clinically important traumatic brain injury. Regardless of risk for clinically important traumatic brain injury, parental anxiety and request was commonly cited by physicians as an important influence for ordering cranial CT in children of white non-Hispanic race/ethnicity.
Disparities may arise from the overuse of cranial CT among patients of nonminority races/ethnicities. Further studies should focus on explaining how medically irrelevant factors, such as patient race/ethnicity, can affect physician decision making, resulting in exposure of children to unnecessary health care risks.
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to estimate the sensitivity of plain radiographs in identifying bony or ligamentous cervical spine injury in children.
We identified a retrospective cohort of children younger than 16 years with blunt trauma-related bony or ligamentous cervical spine injury evaluated between 2000 and 2004 at 1 of 17 hospitals participating in the Pediatric Emergency Care Applied Research Network. We excluded children who had a single or undocumented number of radiographic views or one of the following injuries types: isolated spinal cord injury, spinal cord injury without radiographic abnormalities, or atlantoaxial rotary subluxation. Using consensus methods, study investigators reviewed the radiology reports and assigned a classification (definite, possible, or no cervical spine injury) as well as film adequacy. A pediatric neurosurgeon, blinded to the classification of the radiology reports, reviewed complete case histories and assigned final cervical spine injury type.
We identified 206 children who met inclusion criteria, of which 127 had definite and 41 had possible cervical spine injury identified by plain radiograph. Of the 186 children with adequate cervical spine radiographs, 168 had definite or possible cervical spine injury identified by plain radiograph for a sensitivity of 90% (95% confidence interval, 85%-94%). Cervical spine radiographs did not identify the following cervical spine injuries: fracture (15 children) and ligamentous injury alone (3 children). Nine children with normal cervical spine radiographs presented with 1 or more of the following: endotracheal intubation (4 children), altered mental status (5 children), or focal neurologic findings (5 children).
Plain radiographs had a high sensitivity for cervical spine injury in our pediatric cohort.
Pediatric emergency care 04/2012; 28(5):426-32. DOI:10.1097/PEC.0b013e3182531911 · 1.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To estimate sample sizes available for clinical trials of severe traumatic brain injury (TBI) in children, we described the patient demographics and hospital characteristics associated with children hospitalized with severe TBI in the United States.
We analyzed the 2006 Kids' Inpatient Database. Severe TBI hospitalizations were defined as children discharged with TBI who required mechanical ventilation or intubation. Types of high-volume severe TBI hospitals were categorized based on the numbers of discharged patients with severe TBI in 2006. National estimates of demographics and hospital characteristics were calculated for pediatric severe TBI. Simulation analyses were performed to assess the potential number of severe TBI cases from randomly selected hospitals for inclusion in future clinical trials.
The majority of children with severe TBI were discharged from either a children's unit in general hospitals (41%) or a nonchildren's hospital (34%). Less than 5% of all hospitals were high-volume TBI hospitals, which discharged >78% of severe TBI cases and were more likely to be a children's unit in a general hospital or a children's hospital. Simulation analyses indicate that there is a saturation point after which the benefit of adding additional recruitment sites decreases significantly.
Children with severe TBI are infrequent at any one hospital in the United States, and few hospitals treat large numbers of children with severe TBI. To effectively plan trials of therapies for severe TBI, much attention has to be paid to selecting the right types of centers to maximize enrollment efficiency.
[Show abstract][Hide abstract] ABSTRACT: Purpose: Little is known regarding factors that influence parents to consent for their children to participate in emergency department (ED) research. We sought to confirm that the mental process of consent is a multi-faceted construct and to validate a survey for future use in identifying factors associated with parents’ decisions to consent or decline their child’s participation in research.
Methods: An anonymous, voluntary survey was given to parents/guardians (PG) who either consented or declined research for a study that entailed collecting an extra 1 ml of blood from febrile infants < 60 days, already undergoing blood draw to rule out sepsis, that required written informed consent. Six EDs in Michigan, Ohio and Illinois participated. These included tertiary children’s hospitals and community hospitals with pediatric EDs. This survey study had a waiver from informed consent at all sites. The current survey was derived from a previously validated survey that yielded 7 factors associated with PG consent for children in the peri-operative setting: Altruism, Consent Form Readability, Decisional Uncertainty and Effectiveness, Environment, Trust, Understanding, and Researcher Characteristics. These factors described components of the consent process, or construct. We tested the same factors in the ED population using Exploratory Factor Analysis to psychometrically validate the survey. Questions also elicited information on PG race, ethnicity, socioeconomic status and educational background. Surveys missing >10% of answers were excluded. Completed surveys were scanned and sent to a central Access database (Microsoft, Redmond, WA) and results were tabulated in Excel (Microsoft, Redmond WA). Based on prior research, the 7 factors were analyzed using an EFA with varimax rotation. Eigen values were used to describe the weighted variance of the factors, values < 1 were omitted.
Results: 286 surveys were returned, 24 were incomplete and excluded leaving 262 for analysis. Of these, 250 (95.4%) PGs consented and 12 (4.6%) did not consent to the blood draw study. PG demographics were: mean age 27.3 years, female 47.5%, White 57%, Black 23%, Asian 3%, Hispanic 18% and other 17%. In comparison to prior research, the EFA demonstrated 3 factors with 5 themes including the following (eigen values): Factor 1, Environment (time/privacy) and Communication Clarity from researcher and consent document (11.2); Factor 2, Trust in Researchers/Medicine and Understanding (2.2); Factor 3, Altruism (1.3).
Conclusion: This study validated a survey on factors associated with parental consent for children recruited for ED research and supports that consent in the ED is a multi-faceted construct for parents. Further research utilizing this survey in a larger ED population will contribute to better understanding of the factors that relate to parents who consent or refuse to consent for their children to participate in ED research.
2011 American Academy of Pediatrics National Conference and Exhibition; 10/2011
[Show abstract][Hide abstract] ABSTRACT: The objectives were to characterize physician beliefs and practice of analgesia and anesthesia use for infant lumbar puncture (LP) in the emergency department (ED) and to determine if provider training type, experience, and beliefs are associated with reported pain intervention use.
An anonymous survey was distributed to ED faculty and pediatric emergency medicine (PEM) fellows at five Midwestern hospitals. Questions consisted of categorical, yes/no, descriptive, and incremental responses. Data were analyzed using descriptive statistics with confidence intervals (CIs) and odds ratios (ORs).
A total of 156 of 164 surveys (95%) distributed were completed and analyzed. Training background of respondents was 52% emergency medicine (EM), 30% PEM, and 18% pediatrics. Across training types, there was no difference in the belief that pain treatment was worthwhile (overall 78%) or in the likelihood of using at least one pain intervention. Pharmacologic pain interventions (sucrose, injectable lidocaine, and topical anesthetic) were used in the majority of LPs by 20, 29, and 27% of respondents, respectively. Nonpharmacologic pain intervention (pacifier/nonnutritive sucking) was used in the majority of LPs by 67% of respondents. Many respondents indicated that they never used sucrose (53%), lidocaine (41%), or anesthetic cream (49%). Physicians who thought pain treatment was worthwhile were more likely to use both pharmacologic and nonpharmacologic pain interventions than those who did not (93% vs. 53%, OR = 10.98, 95% CI = 4.16 to 29.00). The number of LPs performed or supervised per year was not associated with pain intervention use. Other than pacifiers, injectable lidocaine was the most frequently reported pain intervention.
Provider beliefs regarding infant pain are associated with variation in anesthesia and analgesia use during infant LP in the ED. Although the majority of physicians hold the belief that pain intervention is worthwhile in this patient group, self-reported pharmacologic interventions to reduce pain associated with infant LP are used regularly by less than one-third. Strategies targeting physician beliefs on infant pain should be developed to improve pain intervention use in the ED for infant LPs.
Academic Emergency Medicine 02/2011; 18(2):140-4. DOI:10.1111/j.1553-2712.2010.00970.x · 2.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma.
We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity.
We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses.
We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.
Annals of emergency medicine 10/2010; 58(2):145-55. DOI:10.1016/j.annemergmed.2010.08.038 · 4.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: The term SCIWORA was introduced prior to widespread use of MRI in the evaluation of spinal injuries. The objective of our study was to compare presenting characteristics and outcomes of children managed with MRI and diagnosed as SCIWORA to those with isolated spinal cord injuries on MRI.
Methods: We performed a retrospective cohort study of children <16 years of age with blunt cervical spine injury, who presented to participating PECARN hospitals from 1/00-12/04. Cases were identified by query of electronic databases and verified on structured chart review. For this substudy, we only included patients who had MRIs performed. We excluded patients with bony and/or ligamentous injuries on radiological imaging. Children were assigned to the SCIWORA group if diagnosed by a neuro-consultant and had a normal MRI. Isolated spinal cord injury on MRI was defined as any non-bony and/or non-ligamentous spinal cord abnormality diagnosed on MRI. We compared children in these two groups for differences in presenting characteristics, interventions and neurological outcomes.
Results: 540 children had cervical spine injuries, of whom 297 (55%) were imaged with MRI. Of these, 60 (20%) had SCIWORA and 15 (5%) had an isolated spinal cord injury. The table below compares their presenting characteristics:
Isolated spinal cord injury
Median age (IQR)
12.6 (11, 14)
8.7 (4, 14)
MECHANISM OF INJURY*
Altered mental status*
Complaint of Neck pain*
Neck tenderness on exam*
Focal neurological findings (any)
Other neurological findings
*Chi-Square test for association p<0.05.
Percents calculated from different totals due to missing data
Children with isolated spinal cord injury were more likely to have persistent neurological deficits at discharge (67% vs. 7%) and to require surgical stabilization of the spinal column (20% vs. 0%).
Conclusions: There were differences in the history, clinical presentation, and outcomes in patients with SCIWORA and isolated spinal cord injuries. Our data suggest that the diagnosis of SCIWORA should be restricted to those children with persistent neurological deficits referable to the cervical spinal cord and no imaging abnormalities on MRI.
2010 American Academy of Pediatrics National Conference and Exhibition; 10/2010
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to utilize the electronic medical record system to identify frequent lower acuity patients presenting to the Pediatric Emergency Department and to evaluate their impact on Pediatric Emergency Department overcrowding and resource utilization. The electronic medical records (EMR) of two pediatric emergency centers were reviewed from August 2002 to November 2004. Pediatric Emergency Department encounters that met any of the following criteria were classified as Visits Necessitating Pediatric Emergency Department care (VNEC): Disposition of admission, transfer or deceased; Intravenous fluids (IVF) or medications (excluding single antipyretic or antihistamine); Radiology or laboratory tests (excluding Rapid Strep); Fractures, dislocations, and febrile seizures. All other visits were classified as non-VNEC. ICD-9 (International Classification of Diseases, Ninth Revision) codes from the Pediatric Emergency Department encounters were defined as representing chronic or non-chronic conditions. Patients were then evaluated for utilization patterns, frequency of Emergency Department (ED) visits, chronic illness, and VNEC status. There were 153,390 patients identified, representing 255,496 visits (1.7 visits/patient, range 1-49). Overall, 189,998 visits (74%) required defined ED services and were categorized as VNEC, with the remaining 65,498 visits (26%) categorized as non-VNEC. With increasing visits, a steady decline in those requiring ED services was observed, with a plateau by visit six (VNEC 77% @ one visit, 64% @ six visits, p < 0.001). There were 141,765 patients seen fewer than four times, representing 92% of the patients and 74% of all visits (1.3 visits/patient, 225 visits/day). In contrast, 2664 patients disproportionately utilized the ED more than six times (maximum 49), representing 1.7% of patients and 9.8% of visits (9.4 visit/patient, 30 visits/day, p < 0.001). Excluding patients with chronic illness, 1074 patients also disproportionately utilized the ED more than six times (maximum 28), representing 0.7% of patients and 3.6% of visits (8.6 visit/patient, 11 visits/day, p < 0.001). While representing < 2% of patients, frequent lower acuity utilizers of ED services accounted for nearly 10% of all visits (30/day). Low acuity patients may require only limited additional marginal resources for their individual care. However, in aggregate, inefficiencies occur, especially when systems reach capacity constraints, at which point these patients utilize limited resources (manpower and space) that could more effectively be directed toward the more acutely ill and injured patients. Therefore, identification of these patients utilizing the electronic medical record will allow for targeted interventions of this subgroup to improve future resource allocation.
Journal of Emergency Medicine 04/2009; 36(3):311-6. DOI:10.1016/j.jemermed.2007.10.090 · 0.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives: To determine whether an oral sucrose solution improves pain response for infants undergoing bladder catheterization in an emergency department (ED) population.Methods: A randomized, double-blinded study comparing the analgesic effects of a sucrose solution to placebo for infants ≤90 days of age and requiring bladder catheterization. Infants with prior bladder catheterization, previous painful procedures that day, or neurological or genital abnormalities were excluded. Infants were assigned baseline pain scores and then given 2 mL of sucrose or water 2 minutes before catheterization. Trained pediatric ED nurses rated the infants for pain, presence of cry, and time to return to baseline.Results: Eighty-three patients were enrolled; 40 were randomized to sucrose, and 40, to placebo. Baseline pain scores were similar within each age group. Overall, sucrose did not produce a significant analgesic effect. In subgroup analysis, infants 1–30 days of age receiving sucrose showed a smaller change in pain scores (2.9 vs. 5.3, p = 0.035), were less likely to cry with catheterization (29% vs. 72%, p = 0.008), and returned to baseline more rapidly after catheter removal (10 seconds vs. 37 seconds, p = 0.04) compared with infants who received placebo. Infants older than 30 days of age who received sucrose did not show statistically significant differences in pain scores, crying, or time to return to baseline behavior.Conclusions: There was no overall treatment effect when using an oral sucrose solution before bladder catheterization in infants younger than 90 days of age. However, infants younger than or equal to 30 days of age who received sucrose had smaller increases in pain scores, less crying, and returned to baseline more rapidly than infants receiving placebo. Older infants did not show an improved pain response with oral sucrose.
[Show abstract][Hide abstract] ABSTRACT: The objectives of this study were to determine the effect of Limited English Proficiency (LEP) visits and acuity status on admission rates from a pediatric ED. A retrospective cohort study was performed using a fully computerized medical record, which includes information on language spoken, triage acuity, and disposition. Data was collected on all patient visits from July 2002 to November 2002 from a tertiary-care pediatric ED. Admission rates and acuity status for LEP and non-LEP patients were compared. A total of 13,585 patient visits were identified, of which 12,416 fit the study criteria. There were 244 LEP patient visits, of which 206 were Spanish-speaking. There were 12,172 English-speaking patient visits. Compared with English-speaking visits, LEP visits were more likely to be triaged as high acuity (25.8% vs. 16.1%, P < .001). LEP patients were more likely to be admitted to the hospital (22.1% vs. 13%, P < .001). For high- and low-acuity patients, no significant differences in admission rates were seen between LEP and English-speaking patients. In contrast, moderate-acuity LEP visits showed a significantly increased admission rate compared to moderate acuity English visits (22.5% vs. 12.4%, P = .005). Similar trends were seen among Spanish-speaking LEP patients. Differences in medical disposition from the ED were found between English-speaking and LEP patient visits. There were higher rates of admission for LEP patients, particularly among moderate-acuity visits. This highlights disparities of care for this vulnerable population.
American Journal of Emergency Medicine 12/2004; 22(7):534-6. DOI:10.1016/j.ajem.2004.08.012 · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Much attention has been paid to the long-term toxic and carcinogenic effects of nicotine-containing substances, particularly tobacco. Although rare, acute ingestions of large amounts of nicotine can produce rapid and dramatic toxicity. We present a case of an ingestion of a nicotine sulfate solution by a 15-year-old boy resulting in hypoxia and irreversible encephalopathy. The diagnosis of acute nicotine toxicity potentially could be delayed due to the fact that nicotine and cotinine are so commonly found on drug screens that they are considered "normal variants."
Journal of Emergency Medicine 03/2004; 26(2):169-72. DOI:10.1016/j.jemermed.2003.05.006 · 0.97 Impact Factor