Loma Linda University

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Lance Brown, MD, MPH
Head, Emergency Medicine, Pediatric Emergency Medicine
School of Medicine
Professor, Emergency Medicine
School of Medicine
Professor, Pediatrics
School of Medicine
Publications    Scholarly Journals--Published
  • Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD; For the Emergency Department Ketamine Meta-Analysis Study Group. Predictors of Emesis and Recovery Agitation with Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children. Ann Emerg Med 2009 June 4. [Epub ahead of print] PMID: 19501426. ( 6/2009 )
  • Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia Pena BM, Gerber AC, Losek JD; For the Emergency Department Ketamine Meta-Analysis Study Group. Predictors of Airway and Respiratory Adverse Events with Ketamine SEdation in the Emergency Department: An Individual-Patient Data Meta-Analysis of 8,282 Children. Ann Emerg Med 2009 Feb 5. [Epub ahead of print] PMID: 19201064 ( 2/2009 )
  • Thorp AW, Brown L, Green SM. Ketamine-associated vomiting: is it dose-related? Pediatr Emerg Care 2009 Jan;25(1):15-8. PMID: 19116497 ( 1/2009 )
  • Brown L, Christian-Kopp S, Sherwin TS, Khan A, Barcega B, Denmark TK, Moynihan JA, Kim GJ, Stewart G, Green SM. Adjunctive atropine is unnecessary during ketamine sedation in children. Acad Emerg Med 2008 Apr;15(4):314-8. PMID: 18370983 ( 4/2008 )
  • Hasty, MB, Klasner A, Kness S, Denmark TK, Ellis D, Herman MI, Brown L.. "Cutaneous community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among all skin and soft tissue infections in two geographically distant pediatric emergency departments." Academic Emergency Medicine 23.8 (2007): 549-552. ( 8/2007 )
    OBJECTIVES: To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California. METHODS: Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0-686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities. RESULTS: Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA-positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensativities at both institutions were similar. CONCLUSIONS: The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings.
  • Babl FE, Lewena S, Brown L. "Vaccination related adverse events." Pediatr Emerg Care 2006;22:514-21. PMID: 16871116 ( 7/2007 )
  • Thorp A, Brown L. "An assessment of the inaccessibility of internet references in the Annals of Emergency Medicine: Is it time to require archiving?." Annals of Emergency Medicine 50.2 (2007): 188-192, 192.e1-33. ( 1/2007 )
    Study objective: We seek to evaluate the accessibility of all Internet references appearing in Annals of Emergency Medicine from 2000, 2003, and 2005. Secondary objectives are to determine whether the number of Internet references is increasing and to describe how Internet references are inaccessible. Methods: We visually scanned all articles for references made in the printed version of Annals of Emergency Medicine for 2000, 2003, and 2005. We identified the Internet references and grouped them into 11 categories according to the results of entering the uniform resource locator (URL) into the Internet browser. Results: We identified 15,745 references published in Annals of Emergency Medicine. The proportion of Internet references increased from 1% of the total references in 2000 to 5.4% in 2005. Internet references were not readily accessible for 40 of 51 Internet references in 2000 (78%; 95% confidence interval [CI] 65% to 88%), 161 of 286 Internet references in 2003 (56%; 95% CI 50% to 62%), and 111 of 249 Internet references in 2005 (45%; 95% CI 39% to 51%). Inaccessibility was most commmonly manifested by URLs that no longer link to active Web sites (172 of 312 inaccessible Internet referneces [55%; 95% CI 50% to 61% and URLs that linnked to generic home pages where the authors' references material could not be found (115 of 312 inaccessible Internet references [37%]; 95% CI 32% to 42%). Conclusion: In Annals of Emergency Medicine, older Internet references appear to be less accessible than newer references. Internet reference archiving is one solution to preserving this information for future readers.
  • Kim TY, Brown L, Stewart G. "Test Characteristics of Parent's Visual Analog Scale Score in Predicting Ventricuoperieoneal Shunt Malfunction in the Pediatric Emergency Department." Pediatric Emergency Care 23.8 (2007): 549-552. ( 1/2007 )
    Objectives: Many parents of children with ventriculoperitoneal shunts present to the emergency deparment for evaluation of a possible shunt malfunction. No study to date has evaluated their ability to predict a shunt malfunction. Our study objective was to evaluate parents' accuracy for predicting a shunt malfunction in their child. We hypothesize that parents more experienced with prior shunt malfuctions are better able to predict subsequent malfunctions in their child. Methods: We conducted a prospective, descriptive study on children younger than 18 years presenting to our tertiary care pediatric emergency department with a possible ventriculoperitoneal shunt malfunction. Parents rated the likelihood of a shunt malfunction using an unmarked 100-mm visual analog scale marked definitely malfunctioning at the high end. An experienced parent was defined as one who had previously experienced at least 3 shunt malfunctions in their child. Results: We enrolled 85 parent-child dyads in our study. Twenty-four children were diagnosed with a malfunction. The predictive ability of parents to determine a shunt malfunction was found at a threshold visual analog scale score of 66 (sensitivity, 88.9%, and specificity 62.2%). At a determined threshold value of 85 or more, experienced parents had a high specificity of 89.2% with a positive likelihood ratio of 5.1. Experienced parents showed an area under the curve of 0.7928 (95% confidence interval, 0.6037-0.9819); and inexperienced parents, 0.5611 (95% confidence interval, 0.3646-0.7576) (P = 0.096). Conclusions: Experienced parents are better able to predict a shunt malfunction in their child.
  • Kim TY, Stewart G, Moynihan JA, Voth M, Brown L. "Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department." Pediatric Emergency Care 22.1 (2006): 28-34. ( 1/2006 )
    OBJECTIVES: Pediatric patients with cerebrospinal fluid shunts frequently present to the emergency department for evaluation of possible shunt malfunction. Most shunt studies appear in the neurosurgical literature. To our knowledge, none have reviewed presenting signs and symptoms of shunt malfunction in patients who present to the pediatric emergency department. The study objective was to evaluate the medical record of children with cerebrospinal fluid shunts who presented to a pediatric emergency department to determine if any signs and/or symptoms were predictive of shunt malfunction. METHODS: A retrospective chart review was conducted on 352 pediatric patients aged 0 to 18 years, who presented to the pediatric emergency department between January 1, 1998, and December 31, 2002, with signs and/or symptoms that prompted an evaluation for possible shunt malfunction. RESULTS: Univariate analysis of all signs and symptoms revealed lethargy (odds ratio, 1.99; 95% confidence interval, 1.15-3.42; P = 0.02) and shunt site swelling (odds ratio, 2.56, 95% confidence interval, 1.08-6.07, P = 0.03) to be significantly predictive of shunt malfunction. Logistic regression analysis continued to show significance for lethargy (odds ratio, 2.20; bias-corrected 95% confidence interval, 1.11-3.63) and shunt site swelling (odds ratio, 3.10; bias-corrected 95% confidence interval, 1.38-9.05), but found no other study variable to be significant. Bootstrap resampling validated the importance of the significant variables identified in the regression analysis. CONCLUSIONS: In this study, lethargy and shunt site swelling were predictive of shunt malfunction. Other signs and symptoms studied did not reach statistical significance; however, one must maintain a high index of suspicion when evaluating children with an intracranial shunt because the presentation of malfunction is widely varied. A missed diagnosis can result in permanent neurological sequelae or even death.
  • Checchia PA, Moynihan JA, Brown L. "Cardiac troponin I as a predictor of mortality for pediatric submersion injuries requiring out of hospital cardiopulomonary resuscitation." Pediatric Emergency Care 22.4 (2006): 222-225. ( 1/2006 )
    BACKGROUND: It is difficult to predict ultimate survivors to hospital discharge in children who are successfully resuscitated after a cardiorespiratory arrest associated with a submersion injury. Serum measurements of organ injury or dysfunction may serve as a surrogate marker of the degree of hypoxic injury. We designed a prospective study whose purpose was to assess the predictive value for outcome of serum cardiac troponin I measurements after submersion injury and cardiorespiratory arrest. METHODS: This is a prospective, observational study of children admitted to a postintensive care unit after experiencing an out-of-hospital cardiorespiratory arrest associated with a submersion event. Cardiac troponin I measurements were examined upon admission to the postoperative intensive care unit after successful emergency department resuscitation. RESULTS: Nine patients were admitted, and 2 patients (22%) survived to hospital discharge. The area under the receiver operating characteristic curve is 0.786 (95% confidence interval, 0.481-1.0). This suggests that cardiac troponin I has a moderate degree of discriminatory power in selecting children who did not survive to hospital discharge.
  • Rivera ML, Kim TY, Stewart GM, Minasyan L, Brown L.. "Albuterol nebulized in heliox in the initial ED treatment of pediatric asthma: A blinded, randomized controlled trial ." American Journal of Emergency Medicine 24.1 (2006): 38-42. ( 1/2006 )
    OBJECTIVE: A prospective blinded, randomized controlled trial was undertaken to compare the initial response of albuterol nebulized in heliox or control in the treatment of moderately severe asthma in children presenting to a pediatric ED. METHODS: Patients were randomized to receive heliox (n = 20) or control (n = 21). The primary outcome was to compare a modified dyspnea index score at 10 and 20 minutes after randomization. Secondary outcomes were to determine if heliox decreased admission rates or endotracheal intubation. RESULTS: There was no statistically significant difference found at 10 or 20 minutes after randomization with heliox (P = .169 and P = .062, respectively). No statistical difference in admission rate was found, and no patients required endotracheal intubation in either group. CONCLUSIONS: Our results demonstrate that albuterol nebulized with heliox offered no clinical benefit over standard therapy in the initial treatment of moderately severe asthma in the ED.
  • Denmark TK, Crane HA, Brown L. "Ketamine to avoid mechanical ventilation in severe pediatric asthma." Journal of Emergency Medicine 30.2 (2006): 163-166. ( 1/2006 )
    Children experiencing severe asthma exacerbations may deteriorate to respiratory failure requiring endotracheal intubation and mechanical ventilation. Mechanical ventilation is often life saving in this setting, but also exposes the asthmatic child to substantial iatrogenic risk. We present two cases of severe asthma exacerbations in prepubertal children for whom the administration of a bolus of intravenous ketamine followed by a continuous infusion of a relatively large dose of ketamine led to prompt improvement, obviating the need for mechanical ventilation. These cases suggest that for children experiencing severe asthma exacerbations, intravenous ketamine may be an effective temporizing measure to avoid exposing these children to the risks associated with mechanical ventilation.
  • Thorp A, Hurt T, Kim TY, Brown L. "Tracheoinnominate artery fistula: A rare and often fatal complication of indwelling tracheostomy tubes." Pediatric Emergency Care 21.11 (2005): 763-766. ( 1/2005 )
    Fistula formation between the innominate artery and the trachea is a rare but potentially catastrophic complication after tracheostomy. Although surgery is the definitive treatment of tracheoinnominate artery fistula, the responsibility for making the proper diagnosis and stabilizing the patient before surgery often falls on the personnel in the emergency department. We describe the emergency department management of a 14-year-old girl with a tracheoinnominate artery fistula. A discussion of the risk factors, diagnostic considerations, and emergency department management strategies of tracheoinnominate artery fistula is presented.
  • Brown L, Shaw T, Wittlake WA. "Does leukocytosis identify bacterial infections in febrile neonates presenting to the emergency department?." Emergency Medicine Journal 22. (2005): 256-259. ( 1/2005 )
  • Brown L. "Mandating automated external defibrillators in schools: Fire, ready, aim!." Canadian Journal of Emergency Medicine 6.6 (2004): 431-433. ( 11/2004 ) Link...
  • Vargas EJ, Mody AP, Kim TY, Denmark TK, Moynihan JA, Barcega BB, Khan A, Clark RT, Brown L. "Pediatric upper esophageal coin removal by emergency physicians: A pilot study." Canadian Journal of Emergency Medicine 6.6 (2004): 434-440. ( 11/2004 ) Link...
    ABSTRACT Objective: There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure. Methods: This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004. Results: Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems. Conclusions: This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.
  • Brown L, Shaw T, Moynihan JA, Denmark TK, Mody A, Wittlake WA. "Investigation of afebrile neonates with a history of fever." Canadian Journal of Emergency Medicine 6.5 (2004): 343-348. ( 9/2004 ) Link...
    ABSTRACT Objective: Our objective was to describe clinically significant infections in a cohort of afebrile neonates who underwent an emergency department (ED) septic workup because of the history of a measured fever at home. Methods: Retrospective medical record review of all infants 28 days of age who presented to our tertiary care pediatric ED between Jan. 1, 1999, and Aug. 22, 2002, underwent lumbar puncture in the ED, had a reported temperature at home of >=38C, and an ED triage temperature of
  • Denmark TK, Hargrove JR, Brown L. "Intramuscular ketamine to facilitate pediatric central vascular access." Canadian Journal of Emergency Medicine 6.4 (2004): 259-262. ( 7/2004 ) Link...
    ABSTRACT Objectives: Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. The objective of our study was to describe our experience using intramuscular (IM) ketamine to facilitate the placement of central venous catheters in children presenting to our ED needing vascular access in a timely fashion. Methods: We performed a retrospective medical record review of all pediatric patients
  • Brown L, Denmark TK, Wittlake WA, Vargas EJ, Watson T, Crabb JW. "Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies." American Journal of Emergency Medicine 22.4 (2004): 310-314. ( 7/2004 )
    This is the first report of which we are aware that describes the use of procedural sedation for the emergency department management of ear and nose foreign bodies in children < 18 years of age. During a 5.5-year period, we identified 312 cases of children with a foreign body in a single orifice (174 ear, 138 nose). Procedural sedation was performed in 23% of cases (43 ear, 28 nose) and ketamine was used most commonly (92%). Emergency physicians had a high rate of success in removing foreign bodies (84% ear, 95% nose) and a low complication rate. Procedural sedation had a positive effect on the success rate as more than half of the sedation cases had undergone failed attempts without sedation by the same physician. Emergency physicians should have familiarity with this indication for procedural sedation.
  • Vargas EJ, Mody AP, Kim TY, Denmark TK, Moynihan JA, Barcega BB, Khan A, Clark RT, Brown L. "Pediatric upper esophageal coin removal by emergency physicians: A pilot study." Canadian Journal of Emergency Medicine 6. (2004): 434-440. ( 1/2004 )
  • Denmark TK, Hargrove JR, Brown L. "Intramuscular ketamine to facilitate pediatric central vascular access." Canadian Journal of Emergency Medicine 6. (2004): 259-262. ( 1/2004 )
  • Brown L, Moynihan J, Denmark TK. "Blunt pediatric head trauma requiring neurosurgical intervention: How subtle can it be?." American Journal of Emergency Medicine 21. (2003): 467-472. ( 1/2003 )
  • Moynihan JA, Brown L, Sehra R, Checchia PA. "Cardiac troponin I as a predictor of respiratory failure in children hospitalized with respiratory syncytial virus (RSV) infections: A pilot study." American Journal of Emergency Medicine 21. (2003): 479-482. ( 1/2003 )
  • Brown L, Reiley DG, Jeng A, Green SM. "Objective criteria fail to predict which children with bronchiolitis are eligible for brief hospitalization." 5. (2003): 239-244. ( 1/2003 )
  • Brown L, Tomasi A, Salcedo G. "An attractive approach to magnets adherent across the nasal septum." Canadian Journal of Emergency Medicine 5. (2003): 356-358. ( 1/2003 )
  • Brown L, Dannenberg B. "Pulse oximetry in discharge decision making: A survey of emergency physicians." 4. (2002): 388-393. ( 1/2002 )
  • Brown L, Takeuchi D, Challoner K. "Corneal abrasions associated with pepper spray exposure." American Journal of Emergency Medicine 18. (2000): 271-272. ( 1/2000 )
  Books and Chapters
  • Brown L. Approach to Multisystem Trauma. In Baren, Brennan, Brown, Rothrock (eds). Pediatric Emergency Medicine.. Phildelphia: Saunder/Elsevier 2008: 123-131. ISBN 978-1-4160-0087-7 ( 0/2008 )
  • Kim GJ, Brown L. Pediatric Trauma. In Schaider, Hayden, Wolfe, et al (eds). Rosen & Barkin''s 5-Minute Emergency Medicine Consult, 3rd edition.. Philadelphia: Lippincott, Williams & Wilkins, 2007: 288-90. ISBN 0781771722 ( 0/2008 )
  • Hicks M, Brown L. Excessive Crying. In Baren JM, Rothrock SG, Brennan JA, Brown L (eds). Pediatric Emergency Medicine. Philadelphia, Saunders/Elsevier 2008: 121-131. ISBN 978-1-4160-0087-7 ( 0/2008 )
  • Brown L, Minasyan L. Nonpharmacologic Interventions: Psychologic Techniques. In Mace SE, DuCharme J, Murphy MF (eds). Pain Management and Procedural Sedation in the Emergency Department.. New York: McGraw Hill Publishers, 2006. 398 - 403 ( 1/2006 )
  • Kim GJ, Brown L. Case 8 - 10 year old male with eye pain In Weinstock M (ed). Bouncebacks! Emergency Department Cases: ED Returns. Columbus, Ohio: Anadem Publishing, 2006: 261-8. ISBN-13: 9781890018610 ( 1/2006 )
  • Brown L, Green SM. Shortness of Breath in Children. In Mahadevan SV, Garmel GM (eds). An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department.. New York: Cambridge University Press, 2005. 503 - 516 ( 1/2005 )