Journal Reviews

Hampers LC, Trainor JL, Listernick R, et al. Setting-based practice variation in the management of simple febrile seizure. Acad Emerg Med 2000; 7:21-27.

Simple febrile seizures are managed differently depending on the setting, says this study from seven EDs in the Chicago area. Two were tertiary academic pediatric EDs (PEDs), and five were community-based general EDs (GEDs).

Four hundred and fifty-five records that met criteria for simple, first-time febrile seizure were reviewed. The two groups did not differ in mean age, vital signs, reported duration of seizure, or prior antibiotic use, yet a significant practice variation was discovered. Here were key differences between the two types of EDs:

• Lumbar puncture was performed more often in the GED group (33% vs. 22%). No patients were found to have bacterial meningitis.

• The patients in the GED group were more likely to receive parenteral antibiotics in the ED (56% vs. 2%).

• The patients in the GED group were more likely to be admitted or transferred (18% vs. 4%).

Because children with febrile seizures usually present to the nearest ED, they are managed by practitioners with varying levels of pediatric training and expertise. As a result, children presenting to GEDs were given more extensive evaluation, such as lumbar punctures and serum electrolytes. They were also managed more conservatively than those in PEDs, with a higher admission rate and higher rate of prescriptions for antibiotics upon discharge.

Further study should be done to determine the reasons for this variation and to find out if practice also varies in other conditions such as croup, asthma, fever in infants, and nonfebrile seizures, say the researchers. "If this finding pertains to other conditions, pediatric emergency medicine specialists may be presented with an educational opportunity to standardize the care of children in all settings."

Mellick LB, Milker L, Egsieker E. Childhood accidental spiral tibial (CAST) fractures. Ped Emerg Care 1999; 15:307-309.

Isolated spiral tibial fractures are a common injury seen in children less than 8 years old, and are most often accidental, according to this study from the Medical College of Georgia in Augusta and Riverside Regional Medical Center in Columbus, OH. Fifty-five patients with isolated spiral tibial fractures were studied. The study’s findings indicated that the "toddler’s fracture" is not a distinct clinical entity, but part of a spectrum of a presentations of childhood accidental spiral tibial (CAST) fractures, say the researchers. Therefore, the term "toddler’s fracture" should be replaced with the CAST terminology, they argue.

The study also notes that child abuse can present as isolated tibial fractures, but those injuries are most often accidental in nature. The most frequent mechanism of this injury is a fall. "When spiral fractures of long bones in young children are considered evidence of child abuse by pediatricians and social workers, the formal investigation of these injuries can result in significant psychological, social, and financial costs," say the researchers. "It’s important to recognize that isolated spiral fractures of the tibia are most frequently accidental in nature."

Lerner EB, Moscati R. Duration of patient immobilization in the ED. Am J Emerg Med 2000; 18:28-30.

Patients are left on backboards for significant periods of time even when no radiographs are taken prior to backboard removal, this study from the State University of New York at Buffalo’s School of Medicine and Biomedical Sciences reports.

The total backboard time of patients brought from the scene of injury by ambulance and immobilized on a backboard in the field was measured for 138 patients. The total ED backboard time was 53.9 minutes for patients who were removed from the backboard prior to radiographs, and 181.3 minutes for patients who had radiographs before being removed from the backboard. The study found that iatrogenic pain is caused from patients spending extended periods of time immobilized on backboards.

"Based upon our observed times and the time required to produce iatrogenic pain in the volunteer studies, this group of initially pain-free patients would be likely to develop pain from immobilization," the researchers report. The iatrogenic pain may cause the patients to need radiographic clearance and still longer immobilization, they add. Here are three possible solutions offered by the researchers:

• Convince ED physicians that these patients must be evaluated promptly after arrival to the ED, or more comfortable immobilization boards could be developed.

• Develop criteria to permit clinical evaluation in the prehospital setting, avoiding immobilization in patients who do not need it.

• Develop more comfortable immobilization boards or techniques to reduce patient discomfort.