256 The Journal of Emergency Medune

0 CHILDHOOD FEVER: CORRELATION OF DIAG- NOSIS WITH TEMPERATURE RESPONSE TO ACE- TAMINOPHEN. Baker MD, Fosarelli PD, Carpenter RO. Pediatrics. 1987; 80:315-319.

It is commonly believed that the temperature response to acetaminophen varies according to diagnosis. This hypoth- esis was prospectively studied in febrile patients who pre- sented to an urban pediatric emergency and walk-in facility. The study group consisted of 1,559 patients between the ages of 8 weeks and 6 years whose rectal temperatures on arrival were greater than 38.4 “C and who had not received antipyretic therapy within the previous four hours. Patients received 15 mgikg of acetaminophen and temperatures were recorded at one and two hours. The recorded decrease in temperature was slightly greater among children who had positive cultures or radiographically documented pneumo- nia; although this difference was statistically significant, it was not great enough to be clinically useful. Thus, no etio- logic inference can be made on the basis of the temperature response to acetaminophen. [Daniel A. Zak, MD]

Editor’s Note: This study will be welcomed by emergen- cy physicians who must deal with parents and nurses who demand a child be normothermic before discharge, al- though I doubt it will convince them.

0 EXPOSURE To IONIZING RADIATION IN THE EMERGENCY DEPARTMENT FROM COMMONLY PERFORMED PORTABLE RADIOGRAPHS. Grazer RE, Meislin HW, Westerman BR, et al. Ann Emerg Med. 1987; 16:417-420.

To assess the potential hazard of exposure to ionizing radiation from portable radiographs in the emergency de- partment, this study measured radiation at different dis- tances from the edge of an irradiated field during portable cervical spine, chest, and pelvis radiographs. The radiation levels were highest for pelvic films and decreased dramati- cally with distance. At 40 cm (15 inches) from the beam for a chest or cervical spine film, and at 160 cm (60 inches) for a pelvic film, radiation exposure was minimal. At these distances, one would need to be exposed to more than 1,200 such radiographs to equal background radiation. Medical personnel should not have to leave a patient care area for fear of undue acute and chronic radiation exposure during portable radiographic examinations. [Alan F. Chou, MD]

Editor’s Note: This is very useful information. In the confused, struggling patient, it is helpful to hold the desired position during the exposure of the portable film. We would still recommend wearing a lead apron.

0 SELECTIVE MANAGEMENT OF BLUNT ABDOMI- NAL TRAUMA IN CHILDREN: THE TRIAGE ROLE OF PERITONEAL LAVAGE. Rothenberg S, Moore EE, Marx JA, et al. J Trauma. 1987; 27:1101-l 106.

This report describes the results of a protocol developed after retrospective review of emergency laparotomies in 52 children sustaining blunt abdominal trauma with positive

diagnostic peritoneal lavages (DPL) by traditional criteria revealed a high incidence of injuries that could have been managed nonoperatively. The protocol consisted of (1) rou- tine DPL in children at high risk for abdominal injury; (2) laparotomy for DPL positive for blood in the face of hemo- dynamic instability; (3) mandatory laparotomy for DPL positive by criteria other than blood; (4) selective laparoto- my for DPL positive for blood in a stable child following additional evaluation by abdominal computed tomography (CT) scan (major mechanism) or liver/spleen scan (minor mechanism). This policy reduced the number of unnecessary laparotomies to 18% (2/l 1). Five children with low-energy trauma were managed nonoperatively after liver/spleen scan- ning showed minor visceral injury despite aspiration of gross blood by DPL. The authors conclude that this experience supports continued use of DPL as the initial triage point in evaluation, with CT scanning and scintigraphy providing fur- ther information for selective management.

[R. Scott Israel, MD]

Editor’s Note: Further evidence that children are not just miniature adults; but this article should not be expanded to a less aggressive approach in the adult trauma victim.

0 POOR PREDICTION OF POSITIVE COMPUTED TOMOGRAPHIC SCANS BY CLINICAL CRITERIA IN SYMPTOMATIC PEDIATRIC HEAD TRAUMA. Rivara F, Tanaguchi D, Parish RA, et al. Pediatrics. 1987; 80:579- 584.

Delayed diagnosis of intracranial injury in children with head trauma can result in death or significant morbidity. This retrospective record review analyzed children with head injury who had received a computed tomography (CT) scan of the head to attempt to discover clinical signs that would accurately identify those who would have abnormal CT findings.

Half the CT scans showed abnormalities; the most fre- quent findings were subdural hematoma (32%), linear (25%) and depressed (25%) skull fractures, and cerebral contusion (22%). Patients were more likely to have abnor- mal CT findings if any of the following were present: loss of consciousness greater than five minutes, Glasgow coma scale of 12 or less, unequal pupils, posturing, focal neuro- logic abnormalities, or hemotympanum. However, each finding had low sensitivity for predicting brain injury.

The ability to predict normal CT results was also unsat- isfactory. Six patients without the above findings had ab- normal scan results. The authors conclude that the clinical findings studied did not adequately predict brain injury.

[Douglas A. Schneider, MD]

Editor’s Note: Prohibitively large studies would be need- ed to identify safe selection criteria for CT use in head injury.

0 AORTIC DISSECTION. DeSanctis RW, Dorghazi RM, Austen WG, et al. NEngI JMed. 1987; 317:1060-1067.

Aortic dissection results from a tear in the tunica intima,