Efficacy of two oral premedicants: midazolam or a low‐dose combination of midazolam–ketamine for reducing stress during intravenous cannulation in children undergoing CT imaging

Background: Pain, anxiety and fear of needles make intravenous cannulation extremely difficult in children. We assessed the efficacy and safety of oral midazolam and a low‐dose combination of midazolam and ketamine to reduce the stress and anxiety during intravenous cannulation in children undergoing computed tomography (CT) imaging when compared to placebo. Methods: Ninety‐two ASA I or II children (1–5 years) scheduled for CT imaging under sedation were studied. Children were randomized to one of the three groups. Group M received 0.5 mg·kg^?1 midazolam in 5 ml of honey, group MK received 0.25 mg·kg^?1 midazolam mixed with 1 mg·kg^?1 ketamine in 5‐ml honey and group P received 5‐ml honey alone, orally. In 20–30 min after premedication, venipuncture was attempted at the site of eutectic mixture of local anesthetics cream. Sedation scores and venipuncture scores were recorded. Primary outcome of the study was incidence of children crying at venipuncture (venipuncture score of 4). Results: Significantly more children cried during venipuncture in placebo group compared to the other two groups (19/32 (59%) in group P vs 1 each in groups M and MK, (P < 0.001) (RR 2.37, 95% CI 1.55‐3.63). In 20–30 min after premedication, group P had more children in sedation score 1 or 2 (crying or anxious) compared to the other two groups (P < 0.05). At this time, group MK showed more children in calm and awake compared to group M (P = 0.02). At venipuncture, group P had more children in venipuncture score 3 or 4 (crying or withdrawing) compared to group M or MK (P < 0.05), while groups M and MK were comparable. Conclusion: A low‐dose combination of oral midazolam and ketamine or oral midazolam alone effectively reduces the stress during intravenous cannulation in children undergoing CT imaging without any adverse effects. However, the combination provides more children in calm and quiet state when compared to midazolam alone at venipuncture.     

Evaluation of results of intertrochanteric valgus osteotomy in ununited fracture neck femur

The aim of this study was to evaluate the results of valgus osteotomy in patients with neglected or failed internal fixation of intracapsular fracture neck femur.Thirty patients in the age group from 17 years to 55 years were treated with valgus osteotomy and fixation with double angled blade plate. One additional 6.5 mm cannulated cancellous screw was also used.The average duration between injury and surgery was 11.3 weeks. The union at fracture site was achieved in 26 patients at an average period of 22 weeks. The union at osteotomy site was achieved at 8.6 weeks. The osteotomy site united in all cases. The complications of surgical procedure included 2 cases of blade cut through, 2 cases of joint penetration, 4 cases of avascular necrosis and 2 cases of nonunion. There was one case of superficial infection which was controlled by antibiotics. The results were clinically graded using and Harris hip score which was good to excellent in 80% of cases, fair in 7%, and poor in 13% of cases.Valgus intertrochanteric osteotomy for neglected or ununited intracapsular fracture of neck of femur and its fixation with double angled blade plate gives satisfactory results in most cases.     

Catapult splint: A foot dorsiflexion assist splint

Background

Loss of dorsiflexion is a common problem in cases where an external fixator or Ilizarov assembly is applied. It results in functional impairment of the foot by affecting the swing phase of gait cycle. We devised a simple dynamic dorsiflexion assist splint for prevention, correction of equinus/cavus deformity and maintenance of normal dorsiflexion of foot.

Methods

This prospective study used a rubber splint styled in the shape of a catapult, made of discarded car rubber tubes attached to the frame of fixator in 50 patients.

Results

In 17 patients there was varying amount of loss of dorsiflexion at the time of application of splint while in 22 patients it was applied soon after the application of the fixator. In the rest of patients it was applied for cavus deformity. Out of 17 patients 10 had complete recovery of dorsiflexion. 22 patients in whom it was applied at the outset had normal range of movement at ankle. Correction was achieved in all 6 cases of cavus deformity and prevented its occurrence in the rest of 5 cases.

Conclusion

Catapult splint is a low cost foot dorsiflexion assist splint.     

Fatal unintentional injuries among young children – A hospital based retrospective analysis

Unintentional (accidental) injuries in childhood constitute a significant public health problem. Young children are extremely vulnerable to unintentional injuries that are vastly preventable. All cases of fatal unintentional injuries in children aged 10 years and below autopsied during 1994–2007 were retrospectively reviewed. Seventy five such cases were identified during the 14 year study period. Males accounted for 68% of cases with a male–female ratio of 2.1:1. Mean age of male and female victims was 5.3 and 4.9 years, respectively. Road traffic fatalities accounted for majority of the cases in this age group (52%), followed by those due to thermal injuries (22.7%). Flame was the cause of thermal injuries in 52.9% cases and scalds were observed in 47.1% cases. Traffic fatalities, fall and drowning were more common in school age children while toddlers and pre-school age children were relatively at a greater risk from domestic accidents (thermal injuries and poisoning). The most frequent victims of road traffic incidents were pedestrians (64.1%). Head injuries alone were the cause of fatalities in the majority of road traffic incidents (82.1%). The study highlights on the pattern of fatalities due to unintentional injuries among young children. To reduce the burden of unintentional childhood mortalities in this region, priorities for school age children are traffic injuries and for toddlers and pre-school children, thermal injuries.