جديد اسعاف الأطفال والبالغين

AIRWAY MANAGEMENT IN ADULTS
• A multicenter randomized trial of critically ill adult patients requiring emergent rapid sequence intubation compared etomidate and ketamine as induction agents [1]. Both agents appeared safe and effective, with no difference in organ failure score, 28 day mortality, or intubating conditions. No serious, drug-related adverse events were reported for either medication, although adrenal insufficiency occurred in 86 percent of those receiving etomidate and in 48 percent of patients receiving ketamine. (See "Sedation or induction agents for rapid sequence intubation in adults".)
CHILD ABUSE
• In a multicenter observational study of 536 children undergoing evaluation for sexual abuse, positive tests for a sexually transmitted infection (STI) were found in 13 of 53 girls (25 percent) with vaginal discharge and 27 of 432 of girls (6.5 percent) with normal or nonspecific physical findings [2]. Thus, more sexually abused girls with STIs had normal or nonspecific findings on physical examination. These findings suggest that broader criteria for STI screening in girls who report sexual abuse may be warranted. (See "Evaluation of sexual abuse in children and adolescents", section on 'STI testing'.)
• The use of a urine nucleic acid amplification technique (NAAT) significantly increased the detection of chlamydia and gonorrhea infection in prepubertal girls undergoing evaluation for sexual abuse (4.5 percent positive by NAAT versus 3.3 percent positive by culture) [3]. Urine NAAT appears to be more accurate than culture for detecting chlamydia or gonorrhea infection and is less invasive. Thus, it may be the preferred test in prepubertal girls who report sexual abuse, have normal or nonspecific findings, and live in legal jurisdictions that accept such methods as a forensic standard. (See "Evaluation of sexual abuse in children and adolescents", section on 'Prepubertal victims'.)
EMERGENCY MEDICAL SERVICES FOR CHILDREN
• An observational study of interfacility transport found a significantly decreased rate of unplanned adverse events or mortality during transport when a specialized pediatric team was used, compared to a nonspecialized team, despite a longer time for arrival at the pediatric center when the specialized team was used [4,5]. (See "Prehospital pediatrics", section on 'Inter-facility transport'.)
FEBRILE INFANT
• Rapid diagnostic tests for the detection of viral neuraminidase are commercially available for influenza A and B viruses and can be used for rapid point of care testing when evaluating febrile infants.
In a multicenter trial of 844 febrile infants ≤60 days of age, a significantly lower rate of serious bacterial illness (SBI) was noted in the 123 infants who were influenza-positive compared to the 721 infants who were influenza-negative (2.5 percent versus 11.7 percent) [6]. The three infants with SBI in the influenza-positive group all had a urinary tract infection (UTI); none had bacteremia or meningitis. However, the use of a rapid influenza test to modify the laboratory testing in a febrile infant should only be considered if the rapid influenza test in use has high specificity and is obtained during a time of high prevalence of influenza infection in the region, thereby maximizing the positive predictive value. (See "Evaluation and management of fever in the neonate and young infant (less than three months of age)", section on 'Influenza'.)
HEAD TRAUMA IN INFANTS AND CHILDREN
• The decision to obtain neuroimaging for children with minor head trauma must balance the importance of identifying significant, but rare, injuries with the estimated cancer risk of radiation exposure from computed tomography (CT).
A multicenter, prospective observational study has derived and validated a prediction rule that identifies children at low risk for clinically important traumatic brain injury (table 1) [7]. Study findings suggest that the use of low risk criteria and judicious observation of patients can allow the clinician to avoid head CT in a significant number of children undergoing evaluation for minor head injury. (See "Minor head injury in infants and children", section on 'Indications for neuroimaging'.)
PEDIATRIC PAIN MANAGEMENT
• A trial of 336 children with arm fractures and between four and 18 years of age found that initial at-home therapy with oral ibuprofen, compared to acetaminophen with codeine, was more effective in achieving adequate analgesia during the first three days after fracture reduction and immobilization [8]. Patients receiving ibuprofen also had fewer adverse effects. (See "Distal forearm fractures in children", section on 'Home pain management'.)
PROCEDURAL SEDATION IN ADULTS
• It may not be necessary to combine propofol with a short-acting opioid when performing procedural sedation if a patient's pain is adequately treated prior to the procedure. This approach is supported by an unblinded randomized trial in which patients given procedural sedation consisting of propofol alone had pain levels identical to those treated with both propofol and alfentanil [9]. Pain was controlled with intravenous morphine at least 20 minutes prior to the procedure. Patients given both propofol and alfentanil required stimulation to induce respiration more often than those given only propofol. (See "Procedural sedation in adults".)
SHOCK IN CHILDREN
• The following studies emphasize the importance of early goal-directed therapy for decreasing mortality in children with shock [10,11]. (See "Initial management of shock in children", section on 'Evidence for improved outcomes'.)
• - An observational study of 1422 children with signs of shock (abnormal capillary refill, tachycardia, and/or hypotension) who were transferred from a community hospital setting to a tertiary care pediatric facility found that death occurred in 16 percent without early shock reversal versus 5 percent with early shock reversal [10]. In addition, death occurred in 15 percent not receiving Pediatric Advanced Life Support(PALS)/Advanced Pediatric Life Support (APLS) intervention versus 9 percent receiving PALS/APLS intervention.
• - An observational study of 136 children with septic shock found that mortality was 6 percent (3 of 53 patients) in those who were not in shock on admission to a pediatric intensive care unit versus 19 percent (21 of 83 patients) in those with shock on arrival [11]. Mean transfer time was not different between the two groups. Fluid and vasopressor management was consistent with 2002 American College of Critical Care Medicine/Pediatric Advanced Life Support consensus guidelines in only 38 percent of children in shock.

Use of UpToDate is subject to the Subscription and License Agreement.

Authors
Jonathan Grayzel, MD, FAAEM
James F Wiley, II, MD, MPH

REFERENCES

1. Jabre, P, Combes, X, Lapostolle, F, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet 2009; 374:293.
2. Girardet, RG, Lahoti, S, Howard, LA, et al. Epidemiology of sexually transmitted infections in suspected child victims of sexual assault. Pediatrics 2009;124:79.
3. Black, CM, Driebe, EM, Howard, LA, et al. Multicenter Study of Nucleic Acid Amplification Tests for Detection of Chlamydia trachomatis and Neisseria gonorrhoeae in Children Being Evaluated for Sexual Abuse. Pediatr Infect Dis J 2009; 28:608.
4. Orr, RA, Felmet, KA, Han, Y, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics 2009;124:40.
5. McPherson, ML, Graf, JM. Speed isn't everything in pediatric medical transport. Pediatrics 2009;124:381.
6. Krief, WI, Levine, DA, Platt, SL, et al. Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Pediatrics 2009; 124:30.
7. Kuppermann, N, Holmes, JF, Dayan, PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160.
8. Drendel AL, Gorelick, MH, Weisman, SJ, et al. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain. Ann Emerg Med 2009; :.
9. Miner, JR, Gray, RO, Stephens, D, Biros, MH. Randomized Clinical Trial of Propofol With and Without Alfentanil for Deep Procedural Sedation in the Emergency Department. Academic Emergency Medicine 2009; 16:825.
10. Carcillo, JA, Kuch, BA, Han, YY, et al. Mortality and functional morbidity after use of PALS/APLS by community physicians. Pediatrics 2009; 124:500.
11. Inwald, DP, Tasker, RC, Peters, MJ, Nadel, S. Emergency management of children with severe sepsis in the United Kingdom: the results of the Paediatric Intensive Care Society sepsis audit. Arch Dis Child 2009; 94:348.

للأمانة العلمية هذا المقال جيد وحديث جدا ً ولكني أتمنى منك في المرات المقبلة أن تقوم مشكورا ً بترجمة هذا المقال ؟إلى اللغة العربية حتى يستطيع الأعضاء العاديون من فهمه مباشرة والله يعطيك العافية !!