Correspondence (reply): In Reply

We would like to thank our colleagues for the detailed discussion and for the valuable input from numerous letters. This has shown us that we have succeeded in waking the interest of many readers.

We have read the current review article referred to by Dr. Lukowski, but do not share his reservations about the administration of antipyretics. In most of the studies cited there, the fever could not be adequately reduced under the study medication (1). In one study, higher temperatures were even measured in children with recurrent febrile seizures than in the control group (2). We therefore do not regard it as justified to make a clear statement about the lack of reduction in the frequency of seizures. As Dr. Lukowski himself admits, the antipyretics help to control the fever and to safeguard the child’s well-being. If weight-adjusted doses are used and the contraindications respected, we see no evidence that the treatment is useless or even dangerous.

Genzwürker, Gernoth and Hinkelbein emphasize that the procedure of percutaneous coniotomy, as described by us, is not a standard procedure, for many reasons. They correctly point out that there is a DIN norm for first aid material. It is, however, common knowledge that, even for adult emergencies, desirable materials—or even material prescribed by the DIN norm—are often omitted. If medically approved products are not available in an emergency, the technique with simple materials which we describe (and use ourselves) can be employed to prevent potentially fatal hypoxia in the child, till the respiratory tract can be adequately safeguarded.

Drs. Müller-Lobeck and Spies refer to the Pediatric Assessment Triangle for the clinical assessment of pediatric emergencies. We have found that this practical aid is of great value in many emergency situations. We nevertheless think that it is unsuitable for assessing fluid loss, as two of the three parameters it records (respiratory work and skin perfusion) only change in the final stage of dehydration, during the transition to hypovolemic shock. For this reason, we prefer the classification shown in Table 3, which is widely used in pediatrics. We use the term “diabetic ketoacidosis” in the colloquial sense of the clinical picture of ketoacidotic coma, rather than as a description of the biochemical findings. We urgently advise against infusing uncontrolled potassium as a component of balanced electrolyte solutions, as there is often initial hyperkalemia in these patients, due to impaired renal function. For this reason, the current guidelines recommend initial fluid replacement with 0.9% NaCl (3).

We are grateful for the comments from Strauß and Becke about the possibilities and restrictions for preclinical management of the respiratory tract. However, we do not share their view about the preferability of small cuffed tubes. On the one hand, current studies call the dogma into doubt that it is less traumatic to use uncuffed tubes in children (4). On the other hand, the use of a cuffed tube which is too narrow can cause serious problems. This can considerably increase the resistance on expiration, particularly at high respiratory rates and/or with obstructive lung diseases (both of which are frequent in children).

We also wish to thank Dr. Mader for his suggestions and questions, although we unfortunately do not have enough space to answer them fully here. We hope that the emergency physician will manage to arrive within less than 15 min, as specified as the appropriate time limit in the individual federal states. In our opinion, the method of choice is rectal administration of diazepam, followed by escalating doses of antiepileptics. Because of the potential for side effects, we think it is at least debatable whether propofol can be recommended to all emergency physicians without specific training in pediatric anesthetics. In addition, propofol is not one of the drugs of first choice for epileptic seizures in children (5). Our article apparently left the impression that a narrow venous access with a 26G in-dwelling cannula is adequate for shock therapy. This is of course not the case. On the other hand, an access of this sort can, for example, be valuable to permit analgesic sedation when making an intra-osseous access or when applying lifesaving emergency drugs.