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ABSTRACT: We present a case of a teenage patient with new-onset cardiac symptoms discovered to have primary pulmonary arterial hypertension. Point-of-care ultrasound used early in the patient's presentation identified significant right-sided heart dilatation and dysfunction despite the patient's relatively unrevealing physical examination. This article emphasizes the utility of performing focused cardiac ultrasound in pediatric patients early in their presentation. We briefly review focused cardiac ultrasound technique and highlight relevant literature.
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Hipertensión Arterial Pulmonar , Humanos , Adolescente , Niño , Sistemas de Atención de Punto , Pruebas en el Punto de Atención , Ultrasonografía , EcocardiografíaRESUMEN
OBJECTIVE: Lidocaine (4%), epinephrine (0.1%), and tetracaine (0.5%) topical gel (LET) is a safe and effective method of providing anesthesia for laceration repair. Some patients, however, require additional infiltrated local anesthetic. We sought to determine if 3 applications of LET 10 minutes apart (triple LET) result in lower pain scores with suturing than one application for 30 minutes (single LET). METHODS: We performed a randomized single-blind controlled trial of pediatric emergency department patients 7 to 17 years old with simple lacerations requiring sutures. Patients received either triple or single LET, and the first suture was placed or attempted within 15 minutes of removing the LET. Visual analog pain score on a 100-mm scale was obtained by a blinded nurse. Pain scores between groups were compared using the Wilcoxon rank sum test. RESULTS: Forty-eight patients were enrolled: 21 for single LET and 27 for triple LET. Mean visual analog pain scale (VAS) score for single LET patients was 16 (SD, 17; range, 0-48), and that for triple LET patients was 16 (SD, 24; range, 0-95), with the difference not significant at 0.37 (95% confidence interval, -11.9 to 12.6). There was no significant difference in requirement for additional anesthesia between single LET (4 of 21 [19%]) and triple LET (5 of 27 [19%]) patients. CONCLUSIONS: Lidocaine (4%), epinephrine (0.1%), and tetracaine (0.5%) topical gel every 10 minutes for 3 applications was not superior in anesthetic efficacy to applying it once for 30 minutes.
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Laceraciones , Tetracaína , Adolescente , Niño , Epinefrina , Humanos , Laceraciones/tratamiento farmacológico , Laceraciones/cirugía , Lidocaína , Método Simple CiegoRESUMEN
BACKGROUND: Orthopedic reductions are commonly performed procedures requiring sedation in the pediatric emergency department (PED). Ketamine is a widely used agent for pediatric procedural sedation, but its use may present difficulties in select populations, such as those with psychiatric diagnoses. In such a case, alternative agents that are safe and effective are needed. Etomidate is a commonly used induction agent for rapid-sequence intubation in the PED. Several retrospective and few prospective studies support etomidate's safety and efficacy in pediatric procedural sedation. OBJECTIVE: The objective was to compare etomidate/fentanyl (E/F) with ketamine/midazolam (K/M) for procedural sedation during orthopedic reductions in the PED. METHODS: Prospective, partially blinded, randomized controlled study comparing intravenously administered K/M with intravenously administered E/F. A convenience sample of patients, aged 5 to 18 years, presenting to an urban PED with fracture requiring reduction was enrolled. Outcome measures included guardian and staff completion of visual analog scale and Likert scales for observed pain and satisfaction, blinded OSBD-r (Observational Scale of Behavioral Distress-Revised) scoring of digital recordings of reductions, and sedation and recovery times. Descriptive tracking of adverse effects, adverse events, and interventions were recorded at the sedation. RESULTS: Twenty-three patients were enrolled, 11 in the K/M group and 12 in the E/F group. The K/M group had significantly lower mean OSBD-r scores compared with the E/F group (0.08 vs 0.89, P = 0.001). Parents rated lower visual analog scale scores with K/M than with E/F (13.7 vs 50.5, P = 0.003) and favored K/M on a 5-point satisfaction scale (P = 0.004). The E/F group had significantly shorter total sedation times (49.6 vs 77.6 minutes, P = 0.003) and recovery times (24.7 vs 61.4 minutes, P = 0.000). There were no significant differences with respect to procedural amnesia and orthopedic practitioner satisfaction. Adverse effects noted in the K/M group included dysphoric emergence reaction and vomiting. Vomiting, injection-site pain, myoclonus, airway readjustment, and supplemental oxygen use were observed in the E/F group. CONCLUSIONS: This is a small study that strongly suggests that, for pediatric orthopedic reductions, K/M is more effective at reducing observed distress than E/F, although both provide equal procedural amnesia. With its significantly shorter sedation and recovery times, E/F may be more applicable for procedural sedation for shorter, simpler procedures in the PED.