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    <recommendedItem id="20100101_19_116"
                     title="SCCM: Toddler Found Frozen in Creek Revives (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17927?impressionId=1265715292194"
                     
      &lt;p&gt;MIAMI BEACH  --  When Scott Magley, MD, of Conemaugh Memorial Medical Center in Johnstown, Pa., arrived at the scene in December 2008, the 23-month old toddler was literally a block of ice.&lt;/p&gt;
&lt;p&gt;After going missing for at least three hours, she had been found face down in a creek. She had no heartbeat, no response. Her initial core temperature was below the reading limits of Magley&apos;s field thermometer. Ice crystals had formed in her mouth.&lt;/p&gt;
&lt;p&gt;&quot;We have learned that we can&apos;t just give up on these patients,&quot; said Ricardo Patton Po, MD, chief trauma and surgical resident at Conemaugh, who presented the girl&apos;s remarkable case study at the annual meeting of the Society of Critical Care Medicine here. &quot;We believe this was the youngest child to be revived without extracorporeal warming.&quot;&lt;/p&gt;
&lt;p&gt;Magley, another critical care specialist who lives in the countryside near the spot where the Amish child was found, managed to perform endotracheal intubation. He began advanced life support and transported her to the hospital, with multiple doses of epinephrine and atropine administered en route.&lt;/p&gt;
&lt;p&gt;&quot;On arrival the girl was unresponsive, with fixed and dilated pupils, no palpable pulse and no appreciable cardiac wall movement on ultrasound,&quot; Po recalled. &quot;Cardiac rhythm showed asystole.&quot;&lt;/p&gt;
&lt;p&gt;Over the course of the next two hours, the cardiopulmonary resuscitation Magley had begun in the field continued at the hospital. Passive warming was initiated, but the staff could not do an extracorporeal bypass because the appropriate-sized catheters weren&apos;t available. Active warming was performed using the Arctic Sun Management System.&lt;/p&gt;
&lt;p&gt;&quot;We continued working because we were encouraged that her body temperature appeared to be rising  --  from a low of 19 degrees Celsius (66.8 degrees F),&quot; Po said.&lt;/p&gt;
&lt;p&gt;The girl occasionally opened her eyes and made nonpurposeful arm movements during cardiac compressions.&lt;/p&gt;
&lt;p&gt;When her core temperature rose to 26 degrees C (79 degrees F), doctors detected ventricular fibrillation. They administered one electric shock, and regular sinus rhythm returned. That resulted in a palpable pulse and eventually a discernible blood pressure.&lt;/p&gt;
&lt;p&gt;&quot;She then began to exhibit purposeful movements and appeared to recognize her parents, who had since arrived at the hospital,&quot; Po told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;She was transferred to Children&apos;s Hospital of Pittsburgh when her internal temperature rose to 31-33 degrees C (88-91 degrees F).&lt;/p&gt;
&lt;p&gt;Po said the transfer created a problem because her parents insisted that she not be transported by powered vehicles  --  and most certainly not by an aircraft, as doctors first proposed.&lt;/p&gt;
&lt;p&gt;He said they finally compromised on an ambulance transfer.&lt;/p&gt;
&lt;p&gt;She was extubated on day one at the hospital and was discharged home on day five, with apparently normal neurological status.&lt;/p&gt;
&lt;p&gt;Po said that on follow-up, her parents thought she was having some difficulty in picking up items with either hand, but otherwise did not appear to have any lasting ill-effects.&lt;/p&gt;
&lt;p&gt;&quot;This case serves as an opportunity to review important concepts in the resuscitation of the profoundly hypothermic patient and to emphasize the resiliency of quickly cooled tissue, deprived of perfusion but before hypoxia damages cellular mechanisms involved in recovery,&quot; Po said.&lt;/p&gt;
&lt;p&gt;&quot;The abundant case reports in the literature, both children and adults, speak to the ability of prolonged and vigorous resuscitation to achieve favorable outcomes,&quot; he said.&lt;/p&gt;
&lt;p&gt;Dominic Cave, MD, a fellow in pediatric intensive care at Stollery Children&apos;s Hospital/University of Alberta in Edmonton, said he&apos;s seen similar episodes.&lt;/p&gt;
&lt;p&gt;&quot;This is another one of those amazing cases that seem to follow the rule that a person isn&apos;t dead until he or she is warm and dead,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;The survival of this child without apparent brain damage is also gratifying,&quot; he added. &quot;You never know if the person you are reviving is going to make such an amazing recovery.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;None of the doctors disclosed any relevant financial relationships.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3868"
                     title="Doctors Overlook Signs of Child Abuse (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Pediatrics/DomesticViolence/tb/17213?impressionId=1265715292194"
                     
      &lt;p&gt;Physicians often misdiagnose bone fractures caused by child abuse as accidental breaks, particularly if the child is male and the doctor is not a pediatrician, a new study found.&lt;/p&gt;
&lt;p&gt;Of children who suffered fractures from abuse, about 20% had at least one previous medical visit during which a doctor missed signs of the problem (95% CI 15.8 to 26.0), according to a report published online Nov. 30 in &lt;em&gt;Pediatrics&lt;/em&gt;. It took a median of eight days after the initial visit before doctors correctly assessed abuse during a subsequent examination.&lt;/p&gt;
&lt;p&gt;Doctors were most likely to misdiagnose abusive fractures if the patients were boys, had breaks in the limbs, or were seen in a primary care setting or general emergency room, as opposed to a pediatric emergency department.&lt;/p&gt;
&lt;p&gt;&quot;This study is the first to report the frequency of delayed recognition of abusive fractures in children,&quot; Kathy Boutis, MD, MSc, of the Hospital for Sick Children, University of Toronto, and colleagues wrote. &quot;One-fifth of children with abusive fractures were missed at initial physician visits, which is comparable to that reported for other types of abuse; however, we do not know how many cases of abusive fractures are never detected.&quot;&lt;/p&gt;
&lt;p&gt;While fractures are common signs of child abuse and repeat injuries occur in 35% of child abuse cases, previous research suggested that doctors have difficulty distinguishing breaks caused by accidents from those resulting from abuse  --  and thus miss a chance to prevent further abuse.&lt;/p&gt;
&lt;p&gt;However, the frequency at which cases of abuse are overlooked was unknown.&lt;/p&gt;
&lt;p&gt;The authors assessed 258 cases of children younger than 3 years treated for abusive fractures at Toronto Hospital for Sick Children between January 1993 and December 2007. The children had seen physicians previously for treatment of fractures. Of the children, 54 had a least one previous visit with a physician at which abuse was missed, the study found.&lt;/p&gt;
&lt;p&gt;Abuse-related fractures were nearly twice as likely to be missed in boys as in girls. &quot;Although the reason for this is unclear, injuries in general occur more often in boys, which may bias a clinician in assuming that the cause of a fracture is accidental,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Of the 145 children with breaks to an extremity, 28% (95% CI 20.8 to 35.8) were cases of abuse that were overlooked. About a third of the cases of abuse that were missed on the initial visit were the result of physicians not diagnosing fractures from radiographs.&lt;/p&gt;
&lt;p&gt;&quot;This study suggests that front-line physicians should strongly consider consulting a radiologist when the presence of a fracture may lead to increased suspicion of abuse,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;They also suggested that physicians carefully check for other risk factors of abuse in children with fractures and that they err on the side of performing skeletal surveys for children who are at higher risk.&lt;/p&gt;
&lt;p&gt;They cautioned that the study was retrospective, and that some cases of abuse may have been overlooked by the researchers because they were never referred to the child protection team at the hospital.&lt;/p&gt;
&lt;p&gt;On the other hand, complex cases may not have been referred to the child abuse team, which may have elevated the estimate of the percentage of abuse cases that are overlooked on a child&apos;s initial physician visit for a fracture.&lt;/p&gt;
&lt;p&gt;&quot;However,&quot; the authors wrote, &quot;child abuse is under-recognized, and there is also the possibility that we are underestimating the proportion of cases missed.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Canadian Hospitals Injury Reporting and Prevention Program.&lt;/p&gt;&lt;p&gt;The authors reported no financial conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_242"
                     title="Injuries to Cheerleaders Are Not Out of Bounds"
                     score="-0.006"
                     href="