Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region.

OBJECTIVES: Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock. METHODS: We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors. RESULTS: Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]). CONCLUSIONS: Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

Pediatric emergency care in New York City during the COVID-19 pandemic shutdown and reopening periods.

OBJECTIVE: New York City (NYC) is home to the largest public healthcare system in the United States and was an early epicenter of coronavirus disease 2019 (COVID-19) infections. This system serves as the safety net for underserved and marginalized communities disproportionately affected by the pandemic. Prior studies reported substantial declines in pediatric emergency department (ED) volume during the initial pandemic surge, but few describe the ongoing impact of COVID-19 throughout the year. We evaluated the characteristics of pediatric ED visits to NYC public hospitals during the pandemic lockdown and reopening periods of 2020 compared to the prior year. METHODS: Retrospective cross-sectional analysis of pediatric ED visits from 11 NYC public hospitals from January 2019-December 2020. Visit demographics, throughput times, and diagnosis information during the early (3/7/20-6/7/20) and late (6/8/20-12/31/20) pandemic periods coinciding with the New York State of emergency declaration (3/7/20) and the first reopening date (6/7/20) were compared to similar time periods in 2019. Findings were correlated with key pandemic shutdown and reopening events. RESULTS: There was a 47% decrease in ED volume in 2020 compared to 2019 (125,649 versus 238,024 visits). After reopening orders began in June 2020, volumes increased but peaked at <60% of 2019 volumes. Admission rates, triage acuity, and risk of presenting with a serious medical illness were significantly higher in 2020 versus 2019 (P < 0.001). Time-to-provider times decreased however provider-to-disposition times increased during the pandemic (P < 0.001). Infectious and asthma diagnoses declined >70% during the pandemic in contrast to the year prior. After reopening periods began, penetrating traumatic injuries significantly increased compared to 2019 [+34%, Relative Risk: 3.2 (2.6, 3.8)]. CONCLUSIONS: NYC public hospitals experienced a sharp decrease in pediatric volume but an increase in patient acuity during both the initial pandemic surge and through the reopening periods. As COVID-19 variants emerge, the threat of the current pandemic expanding remains. Understanding its influence on pediatric ED utilization can optimize resource allocation and ensure equitable care for future surge events.

A Comparison of Temperature Thresholds to Begin Laboratory Evaluation of Well-Appearing Febrile Infants.

OBJECTIVE: Young infants who develop fever are at an increased risk for serious infection. It is unclear, however, what temperature cutoff would be optimal to begin evaluating these infants because some criteria use different thresholds. We sought to determine the percentage of infants presenting to the Emergency Department (ED) with a temperature less than 38.2°C who develop serious infection compared with those with higher temperatures. METHODS: We used a publicly available dataset from the Pediatric Emergency Care Applied Research Network. Patients were included if they were aged 60 days or younger, had a documented rectal temperature of 38.0°C or higher in the ED or a history of fever within 24 hours before presentation to the ED, and were being evaluated for serious infection. We used the same exclusion criteria as the original Pediatric Emergency Care Applied Research Network study but further excluded those who were ill-appearing (Yale Observation Score > 10). Serious infections included any of the following: urinary tract infection, bacteremia, bacterial or herpes meningitis, bacterial pneumonia, or bacterial enteritis. Data were described using frequencies (percentages) and compared between groups using χ 2 test. RESULTS: Of the 4619 eligible infants, 1311 (28.4%) had a temperature lower than 38.2°C. Infants with temperatures lower than 38.2°C were significantly less likely to have a serious infection compared with those with higher temperatures (97 [7.5%] vs 365 [11.2%], P < 0.001). Of the infants with temperatures lower than 38.2°C who were tested, 67 (5.8%) had a urinary tract infection, 10 (0.8%) had bacteremia, 3 (0.4%) had bacterial meningitis, 3 (2.9%) had herpes meningitis, 17 (4.5%) had bacterial pneumonia, and 2 (4.8%) had bacterial enteritis. CONCLUSIONS: In this study, we found that infants with temperatures lower than 38.2°C were significantly less likely to have a serious infection than those with higher temperatures. Using an evaluation cutoff of 38.2°C, however, would likely miss a clinically important number of well-appearing infants with serious infections.

An Unusual Cause of Persistent Crying in a Toddler.

BACKGROUND: Excessive or persistent crying is a common presentation to the pediatric emergency department, and often poses a diagnostic dilemma to emergency physicians. There are several reasons for excessive or persistent crying in children, ranging from benign causes like hunger, to life-threatening causes such as intussusception. CASE REPORT: We report an interesting case of a toddler whose cause of excess crying, with no detectable clinical clues, was eventually attributed to a foreign body in the esophagus. A brief review of diagnostic approach to excess crying and management of ingested foreign bodies is presented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ingested foreign body is a potential cause of persistent crying, and early recognition can result in definitive treatment and prevention of potential mortality and morbidity.

Visual Diagnosis: Pinpoint, Nonfollicular, Sterile Pustules on Edematous Erythema in a 15-year-old.

AGEP is a rare skin reaction that causes the formation of numerous aseptic pustules on an erythematous base. In most cases, it presents after exposure to drugs, more often antibiotics. Fever and leukocytosis are common. The history, clinical appearance, and histology of the pustules confirm the diagnosis of AGEP. Pustular psoriasis, SJM, and EM must be ruled out. The lesions heal spontaneously within 2 weeks after discontinuation of the offending agent, an occurrence that further supports the diagnosis. Immediate withdrawal of the causative agent and supportive therapy is the mainstay of treatment for AGEP.

Cardiopulmonary resuscitation skill training and retention in teens (CPR START): A randomized control trial in high school students.

AIM: High school students are currently the largest group of individuals in the US receiving CPR training every year. This study examines the effect of adding a real-time visual feedback device to a standard instructor-led CPR course on skill acquisition and retention in high school students. METHODS: All study participants underwent baseline CPR skill testing and received a standard instructor-led compression-only CPR course. We then randomized students to a 'Feedback Group', consisting of 2 min of CPR training using a real-time visual feedback device, or 'Standard Group' that continued to practice on the inflatable manikin. CPR skills for all students were tested afterwards using the feedback device and reported as a compression score (CS) derived from their chest compression depth, rate, hand position, and full chest recoil. We compared the CS at baseline, week-0 (immediately post-intervention), week-10, week-28, and week-52 between groups. RESULTS: A total of 220 students were included in the analyses (Feedback Group = 110, Standard Group = 110). Both groups showed similar CPR performance at baseline. At week-0, the Feedback Group had a significantly higher CS compared to the Standard Group (adjusted difference: 20% [95% CI: 11%-29%; p < 0.001]). This difference attenuated over time but remained significant at the week-10 and week-28 follow-up; however, by the week-52 follow-up, there was no significant difference between groups. CONCLUSIONS: Using a real-time visual feedback device during CPR training significantly improves skill acquisition and retention in high school students and should be integrated into the high school CPR curriculum.