DC Child Accident & Safety Blog

If you can’t stand the idea of your children eating all that candy they collected on Halloween, maybe you can find consolation that at least they had to take a walk to get it.

OK, maybe not. But too much sugar might not be your biggest concern on this popular kid holiday.

"Nothing is scarier than a trip to the emergency room," Dr. Mark Cichon, chairman of Department of Emergency Medicine at Chicago’s Loyola University Health System, told ScienceDaily.com. "In a season devoted to frights, it is our goal to keep everyone safe."

Here, as published on ScienceDaily, are Cichon's tips to help keep your child from becoming one of the 9.2 million U.S. youngsters injured seriously enough every year to require ER treatment.

• Don’t use common kitchen knives to carve a pumpkin—they’re difficult for an adult, much less a child, to manipulate on a hard rind. Invest in a pumpkin-carving kit.
• Supervise anything that is burning, from candles to carved pumpkins to firepits. Fires ignite quickly and behave erratically.
• Make sure costumes offer visibility and ease of movement. Masks, hats, wigs, glasses and hoods can obstruct vision, and restricting the legs and feet can cause trips and falls.
• Dress for the weather. Make sure footgear is waterproof and has treads if it’s wet during the trick-or-treating adventure.
• Make sure one adult in the trick-or-treating group wears a reflective safety vest. Make sure each child has a glow stick or flashlight. In other words, see and be seen. If you’re traveling with a group, stay together and put kids on the buddy system.
• Drive slowly and cautiously on Halloween, especially on side streets.
• Inspect the treats when you get home. Make sure the haul is age-appropriate—tiny pieces of candy are choking hazards for younger children. Reject anything unwrapped or, sadly, homemade, unless you know the chef.

It might be the result of a bee sting or the ingestion of a peanut, but whatever the cause, when anaphylaxis occurs it can be life-threatening.

Anaphylaxis is an acute allergic reaction to a specific antigen (food, pollen, drugs, etc.); it’s the immune system’s whole-body response to the presence of an allergen it perceives as a threat. Symptoms generally occur immediately after exposure and might include respiratory distress, swelling of the lips, eyes and throat, rash, low blood pressure, bleeding and/or vomiting. It can result in cardiac arrest.

Parents of children with known allergies should ensure that their child’s school authorities are aware of the allergy and have a prescription on file for epinephrine in case of emergency. (Epinephrine is the hormone adrenaline and is the primary treatment for anaphylaxis.)

Epinephrine is generally safe, with few adverse effects, if given even when it is not needed.

But according to a recent story in the New York Times, school nurses can find themselves in a horrifying position if a child without such a prescription develops a sudden reaction to an undiagnosed allergy. If they inject epinephrine, they risk losing their nursing license for dispensing it without a prescription. Their only other option is to call 911 and hope the paramedics arrive in time.

Some states have passed laws to enable school caregivers to have epinephrine injectors on hand and to give a shot to any child with an emergency. Mylan, which markets Pfizer’s EpiPen, the most commonly used injector, is lobbying for such federal legislation. The company has lobbied individual state legislatures and has distributed free EpiPens this year to schools.

Sure, it’s a naked grab for market share, but it also makes medical sense.

As The Times reports, Mylan has spent millions on consumer advertising and has hired scores of sales representatives to help promote the product. It’s estimated that EpiPen sales will total $640 million this year, a 76 percent increase over last year, according to one analyst.

A study last year in the journal Pediatrics found that about 1 in 13 children had a food allergy, and nearly 40 percent of those with allergies had severe reactions.

Efforts to make epinephrine more widely available, The Times says, are an acknowledgment of the rising rates of food allergies among children and the handful of deaths from allergies across the country. Some children with known allergies carry their own epinephrine injectors to use themselves, if they’re old enough, or the devices are kept in their school nurse’s office.

It’s unclear why the rate of food allergies among children appears to be increasing. “I don’t think it’s overdiagnosis,” Dr. Scott H. Sicherer, a researcher at the Jaffe Food Allergy Institute at Mount Sinai Medical Center in Manhattan, told The Times.

A Mylan executive said schools were just the first place to make emergency epinephrine injectors more widely available. The company would like to see them as available as defibrillators—in restaurants, airplanes and other public places.

The Food Allergy and Anaphylaxis Network (FAAN) has not taken a position on placing injectors in public places other than schools, and Sicherer wondered about their suitability in settings such as restaurants, where staff might not be able to tell the difference among choking, a heart attack or anaphylaxis.

Next month, Sanofi plans to introduce a rival epinephrine delivery device, and in 2015, Teva may win approval of a less expensive generic version of the EpiPen, according to The Times. Sanofi’s Auvi-Q features voice instructions and Teva’s product, if approved by the FDA would closely mimic the EpiPen design and, like a generic drug, could be substituted by pharmacists even if doctors prescribed the EpiPen.

To learn about the latest developments in food allergies, visit the NAAN site. To learn about the widespread practice of bogus testing, see our blog about free allergy tests. To learn about the early signs of allergy, see our blog here.

Of the 27 million trips children make to U.S. emergency departments each year, about 7 million are at a rural ED or one that’s a considerable distance from a dedicated children’s hospital. For children critically ill with certain problems, of course, prompt transfer to a pediatric intensive care until improves the chances for positive outcomes.

In recent years, according to Christopher Johnson, a pediatric intensive care physician writing on KevinMd.com, the medical establishment has begun to establish a system of transporting these sick kids to regional critical care centers. That’s good. Not so good, Johnson says, is an increasing tendency to routinely transfer children from an ED not dedicated to pediatric care to one that is. Such transfers aren’t always necessary from a medical point of view, and present unnecessary risks and costs.

This kid shuffle, Johnson warns, might be signaling an unwillingness of general purpose EDs to provide basic pediatric care. That’s unacceptable. Misfortune is an equal age-opportunity reality.

Johnson refers to a recent article published in the journal Pediatrics that studied what happened to children after they arrived at an emergency department. Researchers wanted to know how ED resources were being used in the younger demographic.

Of the children transferred from the facility where they presented to another that provided specialized care, nearly 1 in 4 was discharged directly from that ED, and 17 in 100 were admitted to the hospital for less than 24 hours.

Because a significant number of the transferred kids had been discharged to go home, they probably could have been treated appropriately at the ED that sent them someplace else.

Johnson says you shouldn’t overlook the fact that sometimes a pediatric subspecialist at the second facility (say, a pediatric cardiologist), simply has the expertise to make the call for discharge that a less qualified doctor doesn’t.

But, he adds, “I have certainly seen children flown in by helicopter from another hospital and then get sent home. They didn’t need the expensive (and sometimes dangerous) helicopter ride.”

Johnson suggests that continuing to regionalize pediatric care is important in addressing the potential patient harm of such resource abuse. Regionalizing, he says, enables doctors in nonpediatric EDs to have easy access to specialists by phone or telemedicine links for remote consultation. This happens now, but only informally; codifying the process would improve care.

Medical emergencies are difficult enough without having to wonder if the care you get is sufficient or the advice to transfer is sound. But if you find yourself in a situation in which the emergency department wants to send your child to a facility that specializes in pediatric care, ask why. Find out what the doctors suspect is the problem and why they are unable to treat it. Ask about the availability of a remote consultation with a specialist.

Sometimes, that’s not possible and sometimes a transfer is the best medicine. But if it’s not, there’s no reason to assume unnecessary risk or cost.

To learn more about emergency medicine—what requires immediate, critical attention—see our backgrounder.

The No. 1 killer of children is accidents. More than 9,000 children in the U.S. died in 2009 from what the Centers for Disease Control and Prevention (CDC) call “unintentional injury.”

As grim as is the reality of children who don’t live to see adulthood, the cold statistics are actually good news—death rates from unintentional injuries among people from birth to 19 declined almost 30 percent from 2000 to 2009, according to the CDC.

Despite the overall good news, a couple of causes of death did see an increase—suffocation rose 54 percent among babies younger than 1 year, and poisonings increased a whopping 91 percent among teenagers 15 to 19. The CDC attributes that stark reality to prescription drug overdoses.

The graphically colorful report in the CDC’s April issue of Vital Signs is the first such study to depict fatal unintentional injury trends by cause and by state for this age group.

The most common cause of accidental death is motor vehicle crashes. Other leading causes are:

• suffocation;


• drowning;


• poisoning;


• fires;


• falls.

Thomas Frieden, director of the CDC, said, “Kids are safer from injuries today than ever before. In fact, the decrease in injury death rates in the past decade has resulted in more than 11,000 children’s lives being saved.”

Significantly, death rates from motor vehicle crashes declined 41 percent during the decade of study. The CDC attributes that improvement to improvements in the use of child-safety and booster seats, and the implementation of graduated licensing systems for teen drivers.

Differences in injury death rates varied enormously from state to state. Massachusetts notched fewer than five deaths per 100,000 children, versus New Jersey, South Dakota and Mississippi, which tallied 23 deaths per 100,000 kids.

Addressing the problem of infant suffocation the CDC says, requires widespread adherence to the American Academy of Pediatrics’ guidelines for safe sleeping environments. Those measures include infants sleeping alone, on their backs in cribs with no loose bedding or soft toys.

To reduce prescription drug poisoning, the agency says, providers must prescribe drugs appropriately, and parents must ensure their teens store and dispose of drugs properly, and they should monitor these practices. Also, teens must be discouraged from sharing medications. The CDC also recommends that states establish prescription drug monitoring programs. We recently wrote about prescription drug misadventures being responsible for a disproportionate number of childrens’ emergency room visits.

“Every four seconds,” said Linda C. Degutis, director of the CDC’s National Center for injury Prevention and Control, “a child is treated for an injury in the emergency department, and every hour, a child dies as a result of an injury. Child injury remains a serious problem in which everyone–including parents, state health officials, health care providers, government and community groups–has a critical role to play to protect and save the lives of our young people.”

For more information about preventing injuries to children and a copy of the CDC’s National Action Plan on Child Injury Prevention, compiled in conjunction with 60 partner organizations, link here.

From high-profile former NFL players to soldiers returning from Afghanistan, the emerging picture of head trauma is not pretty. And of course the lingering, often-delayed effects of traumatic brain injury (TBI) aren’t limited to adults.

We’ve talked about children at risk of concussion when they play sports, and how manufacturers are developing “anti-concussion” athletic equipment.

Writing on KevinMD.com, malpractice attorney Maxwell S. Kennerly suggested that some practitioners still aren’t taking head injuries to children seriously enough.

Last year, he noted, the Centers for Disease Control and Prevention (CDC) reported “a growing awareness among parents and coaches, and the public as a whole, about the need for individuals with a suspected TBI to be seen by a health-care professional.” He pointed to the CDC’s Heads Up initiative as exemplary of efforts to raise consciousness that seeing stars isn’t a badge of athletic honor, it’s a reason to seek medical care.

What remains questionable, Kennerly wrote, is how prepared emergency and primary care physicians are to handle the increased number of head trauma cases they’ll see as a result of greater awareness of the problem.

“Viewed through a narrow lens, the solution to a suspected brain injury is obvious,” he wrote. “[I] f a kid complains about anything relating to their head, give them a CT scan. But CT scans come with their own costs and risks, not least exposing a developing brain to a year’s worth of background radiation.”

Too often medicine overtreats patients because technology enables it, insurance pays for it and/or doctors are worried about being challenged if they fail to perform every test within reach. Often a more conservative approach is better for the patient.

But when it comes to kids and head injuries, in deciding whether to order a CT scan for a kid with new head trauma, Kennerly says the conservative treatment approach is wrong.

“I’m not here to tell you where the CT / no-CT line should be drawn,” Kennerly claimed. “I can tell you, however, how I would draw that line as a medical malpractice lawyer when a parent comes in and tells me their doctor didn’t order a CT scan after a minor head trauma and their child later developed serious sequelae [i.e., a brain injury]."

In the world of medical malpractice, such a circumstance is known as “failure to diagnose.” As Kennerly explained, laypeople—like jurors—might well respond to the concept of incremental risk a witness might offer to defend against the charge of failure to diagnose. “One head CT scan,” the witness might say, “has more radiation than 20,000 trips through the TSA scanner at the airport.”

That sounds scary. But is it scarier than risking chronic, lifelong problems with the ability to think, loss of memory, headaches, attention deficit, mood swings and the other markers of brain injury?

Kennerly cited an article published in the January issue of Critical Decisions in Emergency Medicine, “Evaluation of Minor Head Trauma in Pediatric Patients," that argues for CT scans for children who present with any evidence of brain trauma.

If you’re the parent of a child who has fallen from a great height, who has emerged woozy from a collision in soccer, who claims his or her vision is blurred from a bang on the noggin, take him or her to your physician or emergency room immediately. And if the child doesn't show full recovery of normal consciousness very quickly, without any symptoms of brain trouble, a CT scan could be in order.

A British website offers guidelines for CT scans for anyone younger than 16 with a head injury, and the CDC's Heads-Up site helps observers spot the signs of concussion. They are:

• loss of consciousness;


• loss of memory;


• abnormal drowsiness or sluggishness;


• nausea or vomiting;


• bruise, swelling or laceration on the head, behind the ears;


• bruising around the eyes ("panda" eyes);


• fluid leakage from ears or nose;


• confused, dazed or stunned appearance;


• personality changes;


• headache;


• problems balancing or abnormal clumsiness;


• double or blurry vision; or


• abnormal sensitivity to light or noise.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Emergency Care , Head Injury , Sports Injuries

Hospital infections have been a hot topic for a few years now, and most hospitals have made strides toward cleaning up their microbial act. A recent story in Consumer Reports, however, presents a bad news-goods news scenario about hospital-acquired infections in pediatric intensive care units.

Pediatric ICUs, the consumer group found, often have higher infection rates than ICUs for adults. The most threatening infections are delivered by catheters, tubes that provide nutrition, fluids and medication. If not inserted and managed under completely sterile conditions, they can spread infection throughout the body. In 2009, 1 in 4 of such infections were fatal.

Children are more susceptible to infection because their immune systems are less developed. And the very ill kids in ICUs are particularly vulnerable.

Part of the difficult of infection control, Consumer Reports said, concerns lack of information: “Of the 423 pediatric intensive-care units in the U.S., information on bloodstream infection rates is publicly available for less than half.” You cannot solve a problem of which you’re unaware.

By analyzing information from 92 pediatric ICUs in 31 states and Washington, D.C., Consumer Reports concluded that they carried an infection rate 20 percent higher than national rates for adult ICUs.

That’s the bad news. The good news is that parents can do something to minimize the chances of their child contracting an infection courtesy of the ICU.

If your child requires ICU care, and if your proximity, doctor’s admitting privileges and insurance coverage permit you to choose among hospitals, examine their respective infection rates as charted on the Consumer Reports website.

In choosing a pediatrician, find out where he or she has admitting privileges, and how those hospitals have performed.

If you don’t have the luxury of choice—and even if you do—here’s the Consumer Reports prescription for keeping infections at bay.

Ask the staff how you can help. A nurse has several patients to care for; parents have one. Watch that the central line stays clean, and that everyone in contact with it scrubs it clean and uses sterile equipment to access it.

Make sure the hospital follows best practices for inserting and maintaining central lines. This means disinfecting the site and changing the dressings regularly and standardizing procedures for changing the catheter caps and tubes. Following a regular routine with the proper tools is more protective than re-inventing the wheel each time. It’s not your job to know each of the steps; simply asking about them can remind staff to be extra vigilant about adhering to the safety measures.

Ask if the central line is still needed. Smaller veins can make it more difficult to insert catheters into a child, so sometimes doctors prefer to leave it in until they’re sure it’s no longer necessary. And once a child has a central line, often it’s used for blood samples, reducing a child’s exposure to traumatic needle sticks. Those practices can be good medicine, but they’re not without risk.

Keep hands clean. Make sure you, visitors and the hospital staff wash their hands with soap or an alcohol-based solution before touching your child or the catheter.

Watch the catheter. The line can come into contact with a diaper; a fidgeting child might put the lines in his or her mouth.

Take notes. Keep track of how often hospital staff change the catheter or dressing and how long the catheter has been in.

Raise an alarm. If something seems amiss, trust your instincts. Voice them and make sure someone responds.

Share your story. If you or someone you care for has been harmed by a hospital-acquired infection, contact Consumer Union’s Safe Patient Project, which raises awareness about hospital safety. That site offers a wealth of information about how patients can influence their care and that of their loved ones in positive ways.

Another resource for hospital patients, and potential patients, is Consumer Reports hospital survival guide.

Also, see our Web page on hospital monitoring.

Every year, more than 1.8 million people find themselves in a hospital emergency room to treat an asthma attack. Children account for nearly half that number, and of asthmatic people who go from the ER to an overnight hospital stay, more than 1 in 3 are kids.

As reported in the Patient Safety America Newsletter, three criteria to analyze the quality of care for children hospitalized for an asthma attack have been defined by the Joint Commission, an agency charged with assessing and regulating hospital practices. It also certifies health-care organizations and programs.

The measures of acceptable emergency treatment for asthma are:

• drugs to relieve the acute symptoms;


• administering corticosteroids to reduce inflammation; and


• development of a complete home management plan.

These measures were studied and the results published in the Journal of the American Medical Association. Investigators looked at the records of more than 37,000 children treated in 30 children’s hospitals to determine how well those facilities complied with the treatment criteria and whether compliance reduced hospital readmissions or subsequent ER visits.

The news, mostly, was good—the first two measures notched 97% and 90% rates of compliance respectively.

The bad news lay in the follow-up: Compliance with a home management plan averaged only about 4 in 10 cases. But investigators determined that failure to comply with this measure had no effect on the rates of readmission or visits to the emergency room seven, 30 or 90 days after discharge from the hospital. Compliance did increase over the time in which measurements were compiled (early 2008 through the third quarter of 2010), so the state of this art appears to be improving.

But this curious outcome begs the question: If readmission/ER visits didn’t appear to be affected by noncompliance, why is No. 3 a quality measure at all?

Study authors offered several possible reasons for the lack of association between home-care follow-up and finding yourself back at the hospital.
1. The study didn’t look at how well the plan was implemented at home, nor could the investigators determine whether asthma patients were admitted to another hospital after their visit to the initial hospital.
2. Patients or their parents might not have understood the home-care plan and how to implement it. A commentary on this study noted that there is a "gulf" between patient-centered plans involving coaching and timely follow-up with parents, and often there is no written plan.
3. Readmission measures might be insensitive to the quality of care a child with asthma receives at home. Is it is time to search for other quality measures of care received by hospitalized children with asthma?

So if you’re the parent of a child with potentially life-threatening asthma, here’s how you can improve the chances of getting the best care should the need for an ER visit arise.

• Identify in advance a nearby children’s hospital; it’s more likely to follow quality measures than a general hospital.


• When your child is discharged, make sure you understand the follow-up care plan. There is no such thing as a dumb question. If the information isn’t offered in printed form, ask for it or take careful notes.


• Get the name and contact information of someone who can answer any questions you have after you leave.


• Inform your pediatrician of the care plan.

Anyone who has suffered a broken bone knows how painful it can be. Long bone fractures—those involving arms and legs—are common among children. Any parent wants to spare his or her kid from the intense pain of such an injury, but a recent study published in Academic Emergency Medicine has bad news in that regard.

Thanks to the crowded conditions in hospital emergency rooms, administering pain medication to children with long bone fractures is less effective and not as timely as it should be.

Researchers from the University of Colorado School of Medicine studied 1,229 patients treated in the emergency department of an academic children’s hospital for one year. They found that patients were 4 to 47 percent less likely to receive timely care and 3 to 17 percent less likely to receive effective care when the ER was crowded.

Previous studies have shown that adults consigned to crowded emergency rooms also get lower levels of pain meds. This study appears to be the first to investigate the affect of crowding on children with fracture-related pain.

It’s pretty much a no-brainer. As the lead author said, “When the emergency department gets busier, staff may be less responsive to the needs of individual patients, and as a result, patients have a higher likelihood of nontreatment and delays in treatment.”

Still, it’s not simply a function of too many people seeking care in an overburdened ER: Sometimes it’s hospital procedure. In some emergency departments, only doctors are authorized to prescribe pain meds, in others nurses are allowed to administer them to patients meeting certain criteria.

If the ER is crowded, the solution is to hire more staff. If that’s not feasible in this era of cut, cut, cut, the researchers say hospitals must “leverage the staff [they] have,” which means revising pain-management procedures by allowing nurses to administer analgesics and computers or phones to signal under-treated pain.

Because overcrowding is often the result of people seeking treatment for something that isn’t an emergency, the solution must be one of policy as well as practice. As the researchers said, “We as a nation need to get serious about this. Crowding needs to be a policy priority at every level.”

There should be incentives for patients to seek care at their own doctor’s office, including better compensation for primary care and disincentives for nonemergency use of emergency departments.

The best a parent can do is to anticipate the routine, if painful, medical emergencies children are disposed to experience. Call your doctor before you ever need ER attention, and ask him or her how you can ensure that your child receives pain mitigation in the event he breaks his leg at 9 o’clock at night.

• Should you leave a message with his or her answering service asking him or her to run interference before you reach the hospital?


• Are there are other measures you should take to cut through the crowd and get some relief?


• Is being a squeaky wheel in the ER a good thing, or counterproductive?

No one wants to prolong a child’s pain; it’s a matter of finding a work-around when too many voices are clamoring for too few ears.