Alexander J Rogers

University of Michigan, Ann Arbor, Michigan, United States

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Publications (22)50.26 Total impact

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    ABSTRACT: We compare test characteristics of abdominal computed tomography (CT) with and without oral contrast for identifying intra-abdominal injuries. This was a planned subanalysis of a prospective, multicenter study of children (<18 years) with blunt torso trauma. Children imaged in the emergency department with abdominal CT using intravenous contrast were eligible. Oral contrast use was based on the participating centers' guidelines and discretions. Clinical courses were followed to identify patients with intra-abdominal injuries. Abdominal CTs were considered positive for intra-abdominal injury if a specific intra-abdominal injury was identified and considered abnormal if any findings suggestive of intra-abdominal injury were identified on the CT. A total of 12,044 patients were enrolled, with 5,276 undergoing abdominal CT with intravenous contrast. Of the 4,987 CTs (95%) with documented use or nonuse of oral contrast, 1,010 (20%) were with and 3,977 (80%) were without oral contrast; 686 patients (14%) had intra-abdominal injuries, including 127 CTs (19%) with and 559 (81%) without oral contrast. The sensitivity in the detection of any intra-abdominal injury in the oral contrast versus no oral contrast groups was sensitivitycontrast 99.2% (95% confidence interval [CI] 95.7% to 100.0%) versus sensitivityno contrast 97.7% (95% CI 96.1% to 98.8%), difference 1.5% (95% CI -0.4% to 3.5%). The specificity of the oral contrast versus no oral contrast groups was specificitycontrast 84.7% (95% CI 82.2% to 87.0%) versus specificityno contrast 80.8% (95% CI 79.4% to 82.1%), difference 4.0% (95% CI 1.3% to 6.7%). Oral contrast is still used in a substantial portion of children undergoing abdominal CT after blunt torso trauma. With the exception of a slightly better specificity, test characteristics for detecting intra-abdominal injury were similar between CT with and without oral contrast. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
    Annals of emergency medicine 03/2015; DOI:10.1016/j.annemergmed.2015.01.014 · 4.33 Impact Factor
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    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 · 2.20 Impact Factor
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    ABSTRACT: Empiric parenteral ampicillin has traditionally been used to treat listeria and enterococcal serious bacterial infections (SBI) in neonates 28 days of age or younger. Anecdotal experience suggests that these infections are rare. Existing data suggest an increasing resistance to ampicillin. Guidelines advocating the routine use of empiric ampicillin may need to be revisited. This study aimed to describe the epidemiology and ampicillin sensitivity of listeria and enterococcal infections in neonates 28 days of age and younger who presented to 2 pediatric emergency departments (ED) in Michigan. We conducted a 2-center, retrospective chart review (2006-2010) of neonates 28 days of age or younger who were evaluated for SBI in the ED. We abstracted and compared relevant demographic, historical and physical details, laboratory test results, and antibiotic sensitivity patterns to ampicillin from the eligible patient records. We identified SBI in 6% (72/1192) of neonates 28 days of age or younger who were evaluated for SBI, of which 0.08% (1/1192) neonates had enterococcal bacteremia and 0.08% (1/1192) neonates had listeria bacteremia. A total of 1.4% (15/1192) of patients had enterococcal urinary tract infection (UTI). Urinalysis is less helpful as a screening tool for enterococcal UTI when compared with Escherichia coli UTI (P < 0.001). Seventy-three percent (11/15) of urine isolates had an increase of minimal inhibitory concentrations, which indicate gradual development of resistance to ampicillin. Listeria is an uncommon cause of neonatal SBI in febrile neonates who presented to the ED. Empiric use of ampicillin may need to be reconsidered if national data confirm very low listeria and enterococcal prevalence and high ampicillin resistance patterns.
    Pediatric emergency care 03/2014; DOI:10.1097/PEC.0000000000000104 · 0.92 Impact Factor
  • Prehospital Emergency Care 01/2014; 18(1):52-59. DOI:10.3109/10903127.2013.836262 · 1.81 Impact Factor
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    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.
    10/2013; 75(5):843-7. DOI:10.1097/TA.0b013e3182a74abd
  • Pediatrics 08/2013; 132(2):e356-e363. DOI:10.1542/peds.2013-0299 · 5.30 Impact Factor
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    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. METHODS: 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. RESULTS: 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%). CONCLUSION: 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; DOI:10.1016/j.annemergmed.2013.04.006 · 4.33 Impact Factor
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    ABSTRACT: STUDY OBJECTIVE: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.
    Annals of emergency medicine 01/2013; 62(2). DOI:10.1016/j.annemergmed.2012.11.009 · 4.33 Impact Factor
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    ABSTRACT: Purpose: Understanding transfer patterns and associated resource utilization is important to help guide regionalization of emergency care. Characteristics of patients transferred to pediatric emergency departments and their resource utilization has not been well studied. Objective: To compare characteristics of pediatric emergency patients transferred to a tertiary care pediatric ED from an outside ED with those who arrived directly and to evaluate for an association between distance travelled and resource utilization. Methods: We analyzed ED and health system administrative data from all visits in 2010 to a tertiary care pediatric ED. We included patients <18yrs that came from home or were transferred from an ED. Demographic characteristics, including transfer ED and home zip code, were obtained. Labs, imaging and medications were used to determine direct resource utilization. Emergency severity index (ESI) triage level and ED length of stay (LOS) were used as proxies for resource utilization. ICD-9 codes were converted to diagnosis grouping system (DGS) categories using a publicly available system. Results: Of 14,101 included visits, 12% were transferred from an ED and 88% were direct arrivals. Demographics are presented in table 1. Table 1: Demographic Characteristics ED Transfers Direct Arrivals p-value Male 60% 53% <0.001 Medicaid Insurance 16% 10% <0.001 ESI level 1 or 2 59% 23% <0.001 Admitted 61% 14% <0.001 Among ED transfers, greater distance travelled is associated with increased resource utilization (table 2). Table 2: ED Transfers and Resource Utilization 1-10 miles 11-25 miles 26-50 miles 51-100miles 101-150 miles 151+miles p-value Labs 53% 50% 61% 70% 79% 76% <0.001 Imaging studies (mean) 1.7 1.9 3.1 3.2 4.4 4.0 <0.001 Medications given (mean) 3.7 4.1 7.8 8.1 19.0 13.3 <0.001 ED LOS (SD) 4.81(2.70) 4.85(3.05) 4.76(2.79) 5.16(3.27) 4.43(2.61) 3.74(2.1) <0.001 Using the DGS categories, the most common reasons for transfer were: trauma (23% of ED transfers and 17% of direct arrivals), gastrointestinal diseases (20% of ED transfers and 16% of direct arrivals) and respiratory diseases (16% of ED transfers and 13% of direct arrivals). These differences are statistically significant. Conclusion: Among ED to ED transfers in pediatric patients, longer distances travelled are associated with an increase in labs, imaging studies, medications and ED LOS. Ability to predict patients' resource utilization based on distance travelled may allow more effective delivery of services and increased efficiency of care.
    2012 American Academy of Pediatrics National Conference and Exhibition; 10/2012
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    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.
    JAMA Pediatrics 08/2012; 166(8):732-7. DOI:10.1001/archpediatrics.2012.307 · 4.25 Impact Factor
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    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 · 0.92 Impact Factor
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    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.
    PEDIATRICS 12/2011; 129(1):e24-30. DOI:10.1542/peds.2011-2074 · 5.30 Impact Factor
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    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
  • Annals of Emergency Medicine 10/2011; 58(4). DOI:10.1016/j.annemergmed.2011.06.039 · 4.33 Impact Factor
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    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 · 2.20 Impact Factor
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    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 · 4.33 Impact Factor
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    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: SCIWORA n=60 Isolated spinal cord injury n=15 Median age (IQR) 12.6 (11, 14) 8.7 (4, 14) MECHANISM OF INJURY* MVC 0 (0%) 3 (20%) Fall/Dive 15 (25%) 7 (47%) Sports 31 (52%) 0 (0%) Other 14 (23%) 5 (33%) CLINICAL PRESENTATION Altered mental status* 2 (3%) 7 (47%) Complaint of Neck pain* 32 (56%) 2 (14%) Neck tenderness on exam* 34 (60%) 2 (13%) Predisposing condition 2 (3%) 0 (0%) Focal neurological findings (any) 48 (83%) 10 (71%) Paresthesias 30 (53%) 4 (29%) Sensory loss* 30 (51%) 2 (14%) Motor weakness 35 (58%) 7 (47%) Other neurological findings 5 (8%) 4 (27%) *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
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    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 · 1.18 Impact Factor
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    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.
    Academic Emergency Medicine 05/2006; 13(6):617 - 622. DOI:10.1197/j.aem.2006.01.026 · 2.20 Impact Factor