Abstract: We report a paediatric case of survival following severe hydrogen sulfide (H(2)S) gas intoxication. A 13-year-old boy was found submerged to the neck in a manure tank. He was hypothermic, unresponsive with bilateral mydriasis, and had poor oxygen saturation. After intubation, he was transferred to the paediatric intensive care unit of a tertiary care children's hospital. He developed acute respiratory distress syndrome (ARDS) requiring high frequency percussive ventilation. Cardiac evaluation was significant for myocardial infarction and left ventricular function impairment. He completely recovered from the respiratory and cardiac failure. Neurological examinations showed abnormal signals on MRI in the semi-oval center and in the frontal cortex. Follow-up detected partial impairment of axonal fibers of the right external popliteal sciatic nerve. Paediatric cases of survival after H(2)S intoxication have been rarely reported. Such exposures can evolve to severe ARDS and benefit from high frequency percussive ventilation. Hypothermia and other metabolic abnormalities are now better explained thanks to actual knowledge about endogenous H(2)S function. Lessons learned from paediatric accidents should result in better information about this threat for farmers and families living in houses with septic tanks, reducing the risk to their own and their children's safety.
Abstract: STUDY OBJECTIVE: The clinical manifestations and outcome of infants and children with confirmed 2009 H1N1 influenza in emergency departments is described. METHODS: We conducted a prospective multicenter case series involving children with symptoms of influenza-like illness in whom 2009 H1N1 influenza was diagnosed on reverse-transcriptase polymerase chain reaction assay on a nasopharyngeal swab or nasal aspirates and who were admitted to the ED of four university pediatric hospitals. The following data were collected: age, gender, preexisting chronic conditions (PECs) associated with a high risk for influenza-related complications, clinical symptoms, outcome, antiviral treatment, and complications. We recorded length of cough and fever during a phone-call on day 8. RESULTS: Between 1st October and 31st December 2009, 466 children were included. Their median age was 4 years (range, 1 day to 17years). The median time to consultation was 24h. Of these 466 infants and children, 55 were aged less than three months and 153 had one or more PECs. Asthma was the most frequent condition. Children at risk and children without risk did not differ for complications (28% vs 31%, P>0.05). Respiratory complications (17%) and decompensations of preexisting disease were the most frequent. Infants aged less than three months did not have more complications than infants without PECs. At-risk infants and children were more frequently hospitalized (P<0.02) and the duration of the pediatric ward stay was longer (P<0.02). This was true only for children aged less than three months. Of the hospitalized children, 17 (9%) were admitted to an ICU. Duration of fever (3.8days) and duration of cough (6.3days) did not differ according to whether or not children received oseltamivir. CONCLUSION: Infants younger than three months of age are not a group at risk for influenza-related complications. Oseltamivir did not reduce duration of symptoms in this population.
Abstract: Although the reliable and valid Peritraumatic Distress Inventory (PDI-C) and Peritraumatic Dissociative Experiences Questionnaire (PDEQ) are useful for identifying adults at risk of developing acute and chronic posttraumatic stress disorder (PTSD), they have not been validated in school-aged children and their predictive values remain unknown in this population. This study aims to assess the psychometric properties of the children versions of these two measures (PDI-C and PDEQ-C) in a sample of French-speaking school-children.
Abstract: Adder bites and their progression to severe envenomations are more frequent in children than in adults. AIM: To describe the clinical, biological, and therapeutic characteristics of children bitten by adders and to identify risk factors associated with severe envenomations corresponding to grades II and III of the Audebert et al. classification (Toxicon 1992). MATERIAL AND METHODS: A retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary children's hospital. The data collected were: age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity based on the Audebert et al. classification; presence of fang marks; prehospital care; use of specific immunotherapy (Viperfav(®)), associated treatments; length of stay; orientation, progression, and any complications. RESULTS: Fifty-eight children were included (43 boys, 15 girls). The mean age was 7.8±4.1 years (range, 1.8-15 years). Bites occurred more often between 12:00 pm and 6:00 pm (62%), and were most often located in the lower extremities (77%). The classification of envenomation was: 83% low grade (grade 0, absence of envenomation, fang marks present; grade I, minor envenomation) and 17% high grade (grades II and III, moderate and severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav(®) F(ab')(2) fragments against Vipera aspis, Vipera berus, and Vipera ammodytes). The mean time from bite to Viperfav(®) injection was 23±11h (range, 8-36h). Being bitten on the upper extremities (p<0.001), during the afternoon (p=0.025), feeling an immediate violent pain (p=0.037), and high initial glycemia (p=0.016) were associated with a significant risk of progressing to high-grade envenomation. There was no significant correlation between age, gender, and upper extremity bite. In the final model of the multivariate statistical analysis, three factors remained associated with this risk: bite location in the upper extremities (relative risk [RR]=60.5 [3.5-1040[; p=0.005), immediate violent pain (RR=21.5 [1.3-364.5[; p=0.03), and female gender (RR=17.5 [0.9-320.3[; p=0.053). CONCLUSION: A certain number of criteria seem related with a more significant risk of progression to high-grade envenomation following an adder bite. These results need to be studied on a larger cohort of patients. Bites to the upper extremities should be handled with caution because of the association with more severe envenomation.
Abstract: To analyze the accuracy of estimates made by medical staff and parents regarding fees for consultations and frequently prescribed medical exams.
Abstract: OBJECTIVE: Describe the epidemiology of tourniquet syndromes and a cohort of such children admitted to the pediatric emergency department (PED), analyze the family's social situation to detect neglect behaviors, and analyze subsequent hospital admissions. PATIENT AND METHODS: From 1st January 2003 to 31st May 2009 in the PED, all patients admitted for tourniquet syndrome were included in the study. The data collected were day and time of admission, age, sex, length of stay, medical coverage, type and location of the constrictive agent, therapeutic management, progression, and complications. PED social workers in relation with child protective services (CPS) recovered information on the family's social situation. RESULTS: During the study period, 57 children were registered. The mean number of admissions per year was 8 (range: 2-15). The mean age was 5.5+/-4 months. The toe was the most frequent location (95%). The penis was injured in 2 cases and labia majora in 1 case. The constrictive agent was often a hair (95%). One case of abuse was detected. The analysis of family social situations showed that 53% had no or incomplete medical coverage, 67% were already followed by CPS with extreme poverty or lived in dilapidated housing. Insufficient hygiene or neglect was found in 67% of the families with incomplete or no social coverage. The analysis of 2003-2007 period for later admissions identified that 15 accidents in the home occurred in 12 children. Among these families, 58% were already known by CPS for neglect behavior. CONCLUSION: Although most tourniquet syndromes seem accidental, this entity is often associated with a lack of hygiene. Several and distant locations (e.g., toes and genitals), multiple and/or separated knots, constrictive agents inconsistent with a safe environment for the child, and penile location in an infant require meticulous investigation because of a higher incidence of child neglect.
Abstract: OBJECTIVE: The purpose of this study is to investigate the power of self-reported peritraumatic distress and dissociation to predict the development of posttraumatic stress disorder (PTSD) symptoms in school-aged children. METHODS: School-aged children aged 8 to 15 years admitted to an emergency department after a road traffic accident were enrolled (n=103). Participants were assessed with the child versions of the Peritraumatic Distress Inventory and the Peritraumatic Dissociative Experiences Questionnaire within 1 week. Posttraumatic stress disorder symptoms were then assessed at 5 weeks. RESULTS: A significant association between peritraumatic variables and two measures of PTSD symptoms was demonstrated. However, in a multivariate analysis, peritraumatic distress was the only significant predictor of acute PTSD symptoms (beta=.33, p<.05). CONCLUSIONS: As has been found in adults, peritraumatic distress is a robust predictor of who will develop PTSD symptoms among school-aged children.
Abstract: AIM: Analysis of domestic low-voltage (220-240 V) electrical injury in children admitted to a pediatric emergency department to illustrate the low risk of initial or delayed risk of arrhythmia. MATERIAL AND METHODS: Retrospective study between 2001 and 2008 analyzing all children aged less than 15 years admitted for a low-voltage electrical injury. The data collected were age, sex, time and circumstances of the accident, time and day of admission, transport modalities, presence of risk factors for arrhythmia (transthoracic current, wet skin, tetany, loss of consciousness or neurological symptoms, and initial EKG abnormalities), injuries, EKG, muscular and/or cardiac enzyme values, progression and complications. For statistical analysis, data were entered in Microsoft Excel tables. Analysis was done with StatView5.1 (SAS Institute) and Epi Info 6.04fr (VF, ENSP epiconcept). In the descriptive analysis, the data are presented as mean values with SD, median and range. RESULTS: Forty-eight children were included. The mean annual number of admissions was equal to 6 (range, 3-12). The mean age was 6.2 + or - 4.3 years (median, 4.6 years). There was a male predominance: the overall sex ratio was 1.5, i.e., 3 before the age of 2 and 2.6 before the age of 10. The electrical injury occurred after contact with a wire or a connected cord or after the introduction of a metallic object in a wall socket. Ten children had risk factors of arrhythmia (mainly wet skin or thoracic pain). Twenty-nine children suffered from burns to the extremities (digits and hands, 70 %). At admission, 45 children had an EKG performed. The initial EKG was considered abnormal in 8 cases showing: sinusal tachycardia (n=4), incomplete right bundle branch block (n=4), and V(1) negative T waves (n=1). The EKG normalized within the first 12h. Hospitalization for cardiac monitoring was required for 18 children. No delayed arrhythmia occurred. In a mean time of 3.5h after the accident, a troponin dosage was given to 15 children and was normal in all cases. One child developed rhabdomyolysis and evolved without needing dialysis. CONCLUSION: After a low-voltage electrical injury, initial arrhythmia is not frequent, with often a nonspecific and transitory EKG expression; delayed arrhythmia is very rare. Children presenting to the emergency department after such an electrical accident, who are asymptomatic, without any risk factors for arrhythmia (wet skin, tetany, vertical pathway of the current, preexistent cardiological conditions, loss of consciousness) and with a normal initial EKG do not require cardiac monitoring.
Abstract: We report a case of extrapulmonary tuberculosis with oligoarthritis and synovitis in a 6-year-old girl with undiagnosed disseminated tuberculosis. CLINICAL CASE: The child, adopted from Ethiopia, was admitted to the pediatric rheumatology unit for suspected idiopathic juvenile arthritis. She presented with clinical signs of subacute arthritis of the right knee. Joint symptoms began insidiously and followed a short period of fever and pain in the right hip. Clinical examination showed voluminous cervical lymphadenitis, night sweats, and a moderate alteration of the child's general condition. The medical history revealed that since her arrival in France, 2 years before, she had had febrile subacute pneumonia. A review of the chest x-ray diagnosed primary pulmonary tuberculosis. An intradermal tuberculin test confirmed the diagnosis with a phlyctenular response and a diameter exceeding 20mm. Additional evaluation showed cervical lymphadenitis and intense synovitis of the right hip and knee joints. With an appropriate antitubercular regimen, her condition improved within a few months. After 1 year of treatment, magnetic resonance imaging (MRI) showed normalization of the impaired joints with no functional sequelae. DISCUSSION: Although the spine is a common target for osteoarticular tuberculosis (OAT), peripheral involvement in this case underlines the polymorphism of OAT in children. It illustrates a case of OAT strictly located to the synovial membranes, which usually occurs in one-third of OAT cases. In addition, MRI showed tenosynovitis of the quadriceps. The child presented with unilateral oligoarthritis instead of chronic insidious monoarthritis or symmetrical oligoarthritis as usually described in pediatric OAT. When available, MRI is the best way to evaluate OAT lesions. Mycobacterium tuberculosis can be isolated from sputum, gastric aspiration, and joint fluid or synovial biopsy. Histological lesions can reveal advanced tuberculosis with the presence of caseous follicular lesions. Rapid bacterial detection using polymerase chain reaction remains insufficiently useful in those situations. The recommended therapeutic regimen consists of 3 months with four antitubercular agents (rifampicin, isoniazid, pyrazinamide, and ethambutol) followed by 9 months of a dual therapy (isoniazid, rifampicin).
Abstract: BACKGROUND: Motor vehicle accidents (MVAs) are the main cause of Posttraumatic stress disorder (PTSD) in industrialized countries. This includes the frequently occurring but understudied situation of parents learning that their children were injured. However, unlike in other types of trauma survivors, little is known about the predictors of PTSD symptoms in mothers whose child has suffered an MVA. METHODS: A group of 72 mothers and 28 fathers were prospectively assessed for peritraumatic distress, peritraumatic dissociation, and PTSD symptoms 1 and 5 weeks after their child had suffered an MVA. RESULTS: Levels of peritraumatic distress and dissociation were comparable to other trauma victims, 18% of the mothers were considered to be suffering from probable PTSD. In mothers, significant positive correlations were found between PTSD symptoms and peritraumatic distress (r=.34) and dissociation (r=.37), whereas mothers' PTSD symptoms were associated with decreased peritraumatic dissociation in fathers (r=-.37). Even after controlling for covictim/witness status, peritraumatic distress was a predictor of mothers' PTSD symptoms, explaining 14% of the variance. CONCLUSIONS: Peritraumatic response and PTSD symptoms should be routinely assessed among parents whose child has experienced a traumatic event.
Abstract: AIMS: Analyze the epidemiology and the distribution of judo injuries in a pediatric population. PATIENTS AND METHODS: A retrospective study was conducted from May 2006 to May 2008, including all patients aged less than 15 years admitted to a tertiary-level pediatric emergency unit. The data collected were age, sex, geographic origin, time and day of admission, duration in the pediatric emergency department, body weight, type and location of injuries, and progression. For statistical analysis, data were entered in Microsoft Excel tables. In the descriptive analysis, data are presented as mean values with SD. To compare qualitative variables, a chi(2) test was used and the two-tailed Fisher exact test if the expected value was lesser or equal to 5. Statistical significance was considered at P<0.05. RESULTS: During the study period, 173 patients were included, with a male:female ratio of 2.46. The mean age was 10.6+/-2.4 years. Most children were admitted during the weekend (59 %). The distribution of lesions was contusions (44 %), fractures (31 %), sprains (19 %), dislocations (3 %), and wounds (3 %). The upper extremities were more frequently affected than the lower extremities (46 % vs. 25 %), with a significant male prevalence (78 %) (P<0.0001), dominated by fractures (54 %), especially clavicle fractures (72 %). Compared to the other injuries, the male population had a significantly higher risk of fractures (P=0.04). Thirteen children required hospitalization for surgical repair of fractures. CONCLUSION: Frequent and often benign, judo accidents in children are different from adult injuries in their mechanisms and injury distribution. There is also an additional risk of growth plate damage. Risk factors have been attributed to an increased injury incidence: body weight loss over 5 % or overweight, age and judo experience, and male gender. During competition and training sessions, the evaluation and prevention of these factors could decrease the occurrence of such injuries.
Abstract: AIMS: Provide a descriptive analysis of children admitted to a tertiary care pediatric emergency department (PED) for a nasal foreign body (NFB) and describe the current knowledge and management of such accidents. MATERIAL AND METHODS: A retrospective study was conducted from January 2003 to May 2008, including all patients aged less than 15 years admitted for a NFB. The data collected were age, sex, geographic origin, time and day of admission, duration in PED, duration of NFB insertion, nostril location, symptoms and clinical signs, prehospital extraction attempts, facial x-ray, extraction mode, referral to an ENT specialist, progression, and complications. For statistical analysis, the data were entered in Microsoft Excel spreadsheets. The data were analyzed with StatView 5.1 (SAS Institute) and EpiInfo 6.04fr (VF, ENSP Epiconcept). In the descriptive analysis, the data are presented as mean values with standard deviation, median with extreme values or with 95% confidence intervals where appropriate, unless otherwise indicated. To compare qualitative variables, a chi(2) test (Mantel-Haenszel) was used and the two-tailed Fisher exact test if the expected value was 5 or less. Statistical significance was set at p<0.05. RESULTS: A total of 388 patients were included (393 NFB). The annual mean number of cases was 68. The annual distribution showed a higher number in January, March, April, and October following Christmas, Easter and Halloween celebrations, totaling 40% of all NFB admissions. The sex-ratio was 0.95. Children aged less than 4 years accounted for 71% of the studied population. The mean age was 3.5+/-1.6 years (range, 1.4-13 years). The majority of accidents occurred at home (95%). The length of time spent in the PED was 78+/-57 min. The NFB duration of insertion was unknown in one-quarter of cases, present for less than 4 h in 65% of cases. No symptoms were described in most cases (88%). When symptoms were described, bleeding, pain or nasal discomfort, and foul nasal odor were the principal symptoms. The right nostril was the predominant location (60%). This difference tended to disappear in the group of children aged less than 4 years. Five children had bilateral NFB. Nonorganic compounds accounted for 80% of the NFB: plastic beads or balls (39%), plastic or toy parts (20%), stones or pebbles (11%), and paper (6%). The extraction was instrumental in 82% of cases, and 26% of patients were referred to an ENT specialist when PED attempts were unsuccessful. One child needed hospitalization for extraction under general anesthesia of two beads located deep in the same nostril. No complication occurred. Five children had repeated accidents within an average delay of 6 months. CONCLUSION: Often benign, this frequent accident can be serious in case of batteries or neodymium magnet insertion: the extraction becomes an emergency because of risks of nasal mucosa necrosis and/or nasal septum perforation. In other cases, positive pressure techniques (the parent's kiss or its variants) could be tried first in the emergency department or at home at the time of a call to emergency services before a medical visit.
Abstract: AIM: To analyze the changes in the management of retropharyngeal and parapharyngeal infections and propose a decisional algorithm for their diagnosis and treatment. PATIENTS AND METHODS: A retrospective survey was carried out in a tertiary care pediatric hospital between January 2001 and December 2005. All children aged less than 15 years and affected by a retro- or parapharyngeal infection were included. Clinical, biological, and radiological data, medical and surgical treatment, and complications were extracted from the review of medical charts. The results of the surgical findings were correlated with a cervical computed tomographic scan (CT scan). RESULTS: Thirty-one patients were included, 64.5% during the last 2 years of the study period. All children presented fever and a stiff neck. The pharyngeal examination revealed a retropharyngeal bulge in a quarter of the population and an upper respiratory tract infection was concomitant in 68% of cases. A CT scan was carried out in 29 of 31 children (93.5%), with the radiological diagnosis of an abscess in 16 children (55.2%), presuppurative adenitis in 8 children (27.6%), and cellulitis in 5 children (17.2%). The CT scan was performed within 0.75 days of admission in 2001 and 2.3 days in 2005. All children were treated with intravenous antibiotic therapy: an association of amoxicillin/clavulanic acid and an aminoglycoside in most cases. The mean duration of intravenous antibiotic therapy was 5.2 days. Seventeen patients (93.5%) underwent surgical drainage and purulent material was found in 82.3% of cases. The accuracy of the CT scan, confirmed by surgical finding of a purulent material, was 71.4% in correctly identifying an abscess. The mean duration of surgical treatment after admission increased from 1.7 days in 2001 to 3.3 days in 2005. The number of patients who underwent surgery was divided by a factor of 3 in the second period of the study. Two groups were compared: group A (n=12) treated with antibiotic therapy and group B (n=17) treated with antibiotics and surgical drainage. No significant difference was found between the two groups considering the duration of parenteral and oral antibiotic therapy, the standardization of cervical mobility, the mean time for apyrexia, and the length of hospitalization. There was one recurrence in group B 1 month later, and one case of sepsis in group A. None of the patients with retropharyngeal infection died. CONCLUSION: Without clinical evidence of severe sepsis, parenteral antibiotic therapy is recommended as the first-line treatment for children over 6 months of age presenting with retropharyngeal and parapharyngeal infections. If the clinical and/or biological conditions do not improve within 48-72h, a CT scan is indicated to assess the extent of infection and exclude complications. The decision to initiate surgical drainage depends on the patient's clinical status and the accessibility of the abscess.
Abstract: A 2-year-old boy who ingested 0.8-1.5 g of amantadine developed status epilepticus. One hour later, the child presented with agitation, diaphoresis, and vomiting. He was admitted to the pediatric emergency department 2 hours later. Generalized seizures evolved to status epilepticus, with alternating generalized tonic-clonic and partial seizures, over a period of 7 hours. Other initial clinical signs were sinusal tachycardia and reactive bilateral mydriasis. All symptoms resolved within 20 hours, with a good recovery; the child was released from the hospital on day 3.
Abstract: BACKGROUND: Saddleback caterpillar sting has been very rarely reported in European countries. We report a French case of a stung toddler. CASE: A 2-year-old girl was brought to the pediatric emergency department after being stung by a caterpillar in a furniture store. The emergency department physical examination revealed an inflammatory edema of the stung finger, normal vital signs, and no fever. Three hours after presentation, she was discharged with local ointment prescription. The caterpillar brought in by the parents was unusual compared to common French caterpillar species. The regional poison center was unable to identify it. With the help of the Internet, we succeeded in its identification as a saddleback caterpillar. Tracing its transatlantic importation was the most difficult. CONCLUSIONS: Saddleback caterpillars can be imported to France and carried across the Atlantic Ocean on house or garden plants especially Areca trees. French garden store owners should be informed about this risk and should check and treat host plants (especially Areca trees) at the arrival time.
Abstract: OBJECTIVE: Describe the epidemiology of a pediatric resuscitation room (PRR). METHODS: A prospective study was performed in a pediatric emergency department (PED) from June 17, 2004 to March 19, 2006. Collected data were date and time of admission in the unit and, in the PRR, age and sex, geographical origin, mode of transportation, PED referral mode, diagnosis, evolution, and resuscitation techniques. Statistical analysis included a univariate analysis of hypothetical links between variables and their relation to the risk of death or transfer to the pediatric intensive care unit, then a multivariate analysis by logistical regression where the dependant variable was this risk. RESULTS: Three hundred sixty-one patients totaled 370 admissions. The male-female ratio was 1.3. Mean (SD) age was 5.5 (5.2) years. A quarter of the population was recommended for admission by a physician. Main causes were cardiocirculatory (32%), neurological (26%), respiratory (23%), and traumas (18%), and 17% were hospitalized in an intensive care unit and 4 died. Sixteen technical resuscitation procedures were performed. Children from 0 to 2 years old were more often admitted for cardiocirculatory insufficiency (P < 0.001). The children who were at higher risk for pediatric intensive care unit transfer or death were children from 0 to 2 years old (P < 0.001), an admission for respiratory insufficiency (P < 0.001), and an arrival by medicalized transport (P = 0.003). CONCLUSIONS: In addition to national guidelines for PRR management, the teaching and knowledge of the different diagnosis admitted in the PRR and their resuscitation technical procedures warranty a serener approach of those stressful situations.
Abstract: AIM: Epidemiological analysis in a universitary paediatric emergency unit of children admitted after accidental injuries resulting from fingers crushed in a door. MATERIAL AND METHODS: Prospective, descriptive cohort study from September 6th, 2004 to July 1st, 2005 included all children admitted for finger injuries crushed in a non-automatic door. Exclusions: included accidents due to automatic doors, toy's or refrigerator doors, families who refused to participate to the study or families who had left the waiting area before medical examination. Collected data were patient and family characteristics, accident characteristics and its management. RESULTS: Three hundred and forty children affected by 427 digital lesions were included. The mean age was 5.5+/-3.8 years (range 4 months - 15.5 years). Male/female ratio was equal to 1.2: 1. Fifty-eight percent of patients belonged to families composed of 3 or more siblings. Ninety-three per cent of families came to hospital within the first 2 hours after the accident (mean delay 99+/-162 min, median range 54 minutes). Location of the accident was: domestic (62%, at home (64%)), at school (17%). Locations within the home were: the bedroom (33%), bathroom and toilets (21%). An adult was present in 75% of cases and responsible for the trauma in 25% of accidents, another child in 44%. The finger or fingers were trapped on the hinge side in 57% of patients. No specific safeguard devices were used by 94% of families. Among victims, 20% had several crushed digits; left and right hand were injured with an equal frequency. The commonest involved digits were: the middle finger (29%), the ring finger (23%). The nail plate was damaged in 60% of digital lesions, associated with a wound (50%), a distal phalanx fracture (P3) (12%). Six children had a partial or complete amputation of P3, 2 children a lesion of the extensor tendon, 1 child had a rupture of the external lateral ligament. Three percent of children required an admission to the paediatric orthopaedic surgery unit. Post-traumatic pain was mainly limited to the first 48 h (64%). Early complications included: 16 cases of infected injuries, 3 cases of pulpar necrosis. The total cost of hospital care was 71,500 euros, the average cost for hospitalised patient equal to 2100 euros and for ambulatory cases equal to 141 euros; the annual cost was estimated at 81,600 euros. CONCLUSION: Associated with potentially serious digital injuries, functional or inesthetic sequelae, this painful experience still remains too frequent in toddlers for a home accident that could be often prevented by the acquisition of specific protective doors devices and for a reasonable cost compared to the cost of hospital care.
Abstract: We report on a case of severe hypercalcemia due to vitamin D intoxication in a 4-month-old infant, CASE REPORT: A 4-month-old boy was admitted for anorexia, weakness, hypotonia, constipation and lethargy. Initial physical examination evidenced a severe axial hypotonia, signs of moderate intracellular dehydration, polyuria and leucocyturia. Hemodynamic parameters were normal. The infant's origin was Turkish. Basic blood chemistry showed a high serum calcium concentration of 4.28 and 4.55 mmol/l on a second control. The EKG showed a short QTc interval calculated at 0.34 s. Due to worsening neurological condition, the infant was referred to the pediatric intensive care unit. Because of the association of neurological impairment, EKG abnormality and high serum calcium level, haemodialysis was performed. Treatment included hyperhydration, high doses of intravenous of loop diuretics and sodium pamidronate infusion. Hormonal, radiological, abdominal and cardiac investigations combined with a new parental interview led to the diagnosis of vitamin D intoxication due to excessive daily administration. We were unable to determine the exact total amount because of the language barrier. Clinical outcome was marked by nephrocalcinosis without renal function impairment, iliac venous thrombosis secondary to the dialysis catheter and a full neurological recovery without sequelae after 3 months. DISCUSSION: Fear of rickets, especially in Turkish families residing in France, can lead some parents to administer massive daily quantities of vitamin D. This practice is facilitated by the possibility of purchasing high dosage forms of vitamin D via the Internet. When faced with an infant presenting with digestive disorders such as vomiting and constipation, associated with neurological troubles (lethargy, hypotonia) and hypercalcemia, vitamin D intoxication should be considered after tumoral, hormonal or malformative (Williams-Beuren syndrome) causes have been eliminated. Combined with hyperhydration and loop diuretics, biphosphonate infusion often allows to control hypercalcemia. Nephrocalcinosis seems correlated to chronic administration while cardiovascular disorders are more likely associated with massive acute vitamin D administration, severe dysrhythmia being rare in children in this context.
Abstract: The increase in B-natiuretic peptide (BNP) is well correlated with cardiovascular symptoms in adults. Its use in children is recent and only partially evaluated. The authors undertook a prospective study of BNP concentrations and its kinetics in 54 children with an average age of 15 months (5 days to 11 years) admitted as paediatric emergencies. The symptoms were dyspnoea (60%), shock (15%), suspicion of Kawasaki disease (15%) and other (10%). Twenty children had BNP levels of more than 100 pg/ml related to decompensation of known congenital heart disease in 7 patients (average BNP 462 +/- 323 pg/ml), due to neonatal coarctation in 2 patients (BNP > 3000 pg/ml), due to cardiomyopathy in 6 patients (BNP= 2576 +/- 1215 pg/ml), due to an arrhythmia in 1 patient (BNP= 3754 pg/ml) and to Kawasaki disease in 4 patients (BNP= 521 +/- 448 pg/ml). Thirty-four children had BNP values of less than 100 pg/ml; 29 had no cardiac disease and 5 had known congenital heart disease with other symptoms. Measuring BNP is quick and economical and is a valuable aid in the diagnosis of cardiac dysfunction in symptomatic children in the emergency room. High BNP values seem to be correlated with the severity of the cardiac disease. Low BNP values seem to have a good negative predictive value in children without underlying cardiac disease. The interpretation of intermediary values, especially when there is previous cardiac disease, is more difficult in view of the absence of known threshold values for different haemodynamic situations. Further studies are required to determine the value of this test for the follow-up and setting up of prognostic values in children with congenital heart disease.
Abstract: Staphylococcal necrotizing pneumonia producing the Panton Valentine leukotoxin (PVL) has been described for many years. The french reference center for staphylococcal toxaemia defined it with precision in 1999. A 10-year-old child, died in 36 hours from respiratory distress and shock. Staphylococcal pneumonia was suspected then confirmed: S. Aureus producing PVL was isolated in lung, blood and articulations.
Abstract: We report a case of an accidental intoxication in a 20-month-old boy resulting from the ingestion of a rodenticide containing alpha-chloralose. CASE REPORT: Three hours after initial admission to the pediatric emergency department for wheezing bronchitis, this patient was readmitted with a clinical presentation of respiratory insufficiency, a Glasgow coma score of 9 alternating with agitation, areflexia and unilateral mydriasis. Parental interview revealed he had episodes of shaking in the afternoon. Chest x-ray showed thoracic distension. Blood investigations, electrocardiogram, cardiac echography, brain CT scan and CSF were normal. Electroencephalography registered slow delta waves 2-3 cycles/min and an aspect of degraded waves and spikes. The patient was transferred to the intensive care unit where he fully recovered within 48 hours. A second parental interview and clinical presentation confirmed an intoxication with a rodenticide containing alpha-chloralose. The late clinical orientation did not allow us to perform a urinanalysis. DISCUSSION: Clinical association of coma, spontaneous or triggered myoclonias and bronchial hypersecretion are indicative of chloralose intoxication. Presence of specific abnormalities on electroencephalogram and a positive Fujiwara-Ross reaction in an urine sample are additional elements for the diagnosis. The prognosis is usually good after early management which combines gastric lavage, activated charcoal, sedation with benzodiazepines, tracheal intubation and artificial ventilation if required. Severe clinical cases described in voluntary intoxications in adults and teenagers occur very rarely in toddlers.
Abstract: AIM: Epidemiological analysis of accidents related to babywalker use admitted to a pediatric emergency department. METHODS: Retrospective, descriptive study of injuries related to babywalkers admitted to the pediatric emergency department between January 1st, 2003 and December 31st, 2005. RESULTS: One hundred and seventy-eight children were admitted due to an accident related to babywalker use. The sex ratio was 1.7 with a male prevalence. Mean age was 11+/-4 months. Seventy-eight percent of babywalker-related injuries were attributable to fall down a flight of stairs. The mean number of steps that a child fell down was 7 (range 1-20 steps). The repartition of accidents was bimodal: during the year, 1 peak in May and 1 in October; during the week: 54% of the cases occurred on Thursday or on the weekend; during the day (1 peak between 10 a.m. and 1 p.m. and 1 peak between 4 p.m. and 7 p.m.). Non-severe head traumas represented the most frequent injury (72%). Twenty-one children were hospitalised for concussion (N=15), cranial fractures (N=3), forearm fracture (N=1), dental subluxation (N=1) and extradural hematoma (N=1). A social problem (families with unsafe domestic practices) was identified in 26 children (15%), 16 of these situations were recognized due to the retrospective character of the study and the analysis of hospital admissions after the first accident. CONCLUSION: Stairway related falls associated with babywalker use and fall down in the stairs are very frequent in children less than 1 year-old. This resulted in babywalkers being prohibited in Canada since 2004. In several countries, advocates are working to ban babywalkers. Active or passive prevention methods have shown their limits. This unsafe and dangerous practice should be banned in France.
Abstract: Vascular Ehlers-Danlos syndrome(EDS) is at high risk of death by arterial rupture. CASE REPORT: A 13-year-old boy with vascular EDS and aortic dissection was admitted in pediatric emergency care unit. The children died after surgery by massive hemorrhage and prosthetic rupture. DISCUSSION: The precocity of this vascular accident EDS is uncommon. It occurred despite clinical and echocardiographic follow-up. The death of the children confirmed the difficulties in surgery of vascular manifestation, even if appropriate and rapid management was already done. CONCLUSION: Patients with vascular EDS must be identified because of its lethal complications. Friability of the vessels makes surgical treatment difficult. A trial using beta blockers therapy is ongoing.
Abstract: BACKGROUND: Evaluate, by radiographic analysis, tibial growth after an intraosseous infusion (IOI) in a pediatric population. METHODS: We performed a prospective simple blind study, between January 1, 1994, and July 1, 2001, which included pediatric patients who needed an intraosseous trocar in emergency situations. During the follow-up, roentgenographs were performed. On each radiologic view, different measurements were carried out: anterior and lateral tibial length, anterior and lateral width at 2 diaphyseal levels. We compared the anterior length values to those published in the Anderson et al tables. When only one tibia was punctured, the mean measurements were compared with the control leg measurements using a paired t test. RESULTS: The initial population included 78 patients. Of these 78 subjects, 42 died, 10 families could not be contacted, and one refused to participate. Two children were excluded because they had other conditions that could influence tibial growth. The study included 23 children. The puncture site was the proximal tibia. The mean age was 18.6 months at the time of IOI, the mean time of infusion was 5 hours, and the mean perfused volume was 225 mL. The mean radiologic follow-up time was 29.2 months. When compared with the Anderson et al tables, all the anterior length values were within the 95% confidence interval. For the other measurements, the statistical analysis showed no significant difference between punctured and control legs. CONCLUSION: There is no long-term effect on tibial growth after an IOI when the IO trocar is properly placed.
Abstract: In patients with acute exacerbations of chronic obstructive or restrictive pulmonary disease, noninvasive ventilation can be used in an attempt to avoid endotracheal intubation and complications associated with mechanical ventilation. The main obstructive pathology concerned is bronchopulmonary dysplasia: bronchial hyperreactivity is a main feature of the situation, leading eventually to acute or prolonged assisted ventilation. Usually performed by tracheostomy, ventilation can possibly be managed through a nasal mask. The use of noninvasive ventilation is also indicated when symptoms of hypoventilation and daytime hypercarbia develop in a variety of neuromuscular disorders.
Abstract: We present a neonate with a cervicofacial haemangioma complicated by the Kasabach-Merritt syndrome, respiratory distress due to airway compression and high-output heart failure. This haemangioma and intravascular disseminated coagulation, treated initially by aspirin, ticlopidine and corticosteroids, required more invasive treatment with superselective embolisation and interferon alpha-2a. The clinical outcome was good.
Abstract: BACKGROUND: We studied all intraosseous infusions performed between 1994 and 1997 by the pediatric intensive care unit and by the pre-hospital emergency medical staff in the Hôpital d'Enfants, Toulouse, France. POPULATION AND METHODS: We report 32 cases of intraosseous infusions in 30 children aged 2 weeks to 9 years. RESULTS: In our population, such a technique has been used in about 60% of all cardiopulmonary arrest, drowning or traffic accident cases. Intraosseous infusion was successful in all cases, on the first attempt in more than 80% of cases. Nine children recovered without any sequelae. No major complications have been observed. CONCLUSIONS: Intraosseous infusion is safe, rapid and effective. It is an essential alternative route in pediatric resuscitation when no other venous access can be performed quickly. An effort must be made on behalf of its diffusion and teaching.
Abstract: It is easy to use Internet tools with a computer's mouse but it is more difficult to obtain available addresses in order to reply to concrete and accurate search. The aim of this article is to help new Internet users in their quest for pediatric informations and medical knowledge.
Abstract: BACKGROUND: Imidazoline derivatives are alpha-adrenergic agents used in nose drops and collyria. Intoxication in children can cause severe central nervous system depression and cardiovascular adverse effects, especially in very young children. CASE REPORT: A 1-month old girl was admitted after nose-drop instillation of naphazoline. At the time of admission, she was comatose, pale, hypothermic and presented arterial hypertension, bradycardia and apnea. Arterial hypertension was corrected after intravenous infusion with phentolamine mesylate, an alpha-antagonist agent. All other symptoms disappeared spontaneously 9 hours after the initial instillation. CONCLUSIONS: Imidazoline intoxication due to overdose or accidental ingestion is frequent in children. Because nose drops are widely available without any medical prescription, nasal vasoconstrictors which contain imidazolin derivatives should be discouraged under 7 years of age and kept out of children's reach.
