DRESS Syndrome: Drug Reaction With Eosinophilia and Systemic Symptoms.

DRESS syndrome is a cutaneous and systemic drug reaction with severe complications and a long course that can be fatal. Recognition may be difficult, and the condition is just rare enough that clinicians will eventually see it but may not be familiar with it. This review will focus on key elements to help clinicians with the challenges of recognition and differential diagnosis.

Variation in Computed Tomography Use for Evaluation of Head Injury in a Pediatric Emergency Department.

OBJECTIVES: Recent research has shown significant variation in rates of computed tomography (CT) use among pediatric hospital emergency departments (ED) for evaluation of head injured children. We examined the rates of CT use by individual ED attending physicians for evaluation of head injured children in a pediatric hospital ED. METHODS: We used an administrative database to identify children younger than 18 years evaluated for head injury from January 2011 through March 2013 at our children's hospital ED, staffed by pediatric emergency medicine (PEM) fellowship trained physicians and pediatricians. We excluded encounters with trauma team activation or previous head CT performed elsewhere. We excluded physicians whose patient volume was less than 1 standard deviation below the group mean. RESULTS: After exclusions, we evaluated 5340 encounters for head injury by 27 ED attending physicians. For individual physicians, CT rates ranged from 12.4% to 37.3%, with a mean group rate of 28.4%. Individual PEM physician CT rates ranged from 18.9% to 37.3%, versus 12.4% to 31.8% for pediatricians. Of the 1518 encounters in which CT was done, 128 (8.4%) had a traumatic brain injury on CT, and 125 (8.2%) had a simple skull fracture without traumatic brain injury on CT. Patient factors associated with CT use included age younger than 2 years, higher triage acuity, arrival time of 10:00 PM to 6:00 AM, hospital admission, and evaluation by a PEM physician. CONCLUSIONS: Physicians at our pediatric hospital ED varied in the use of CT for the evaluation of head-injured children.

Point-of-Care Ultrasound to Assess Anuria in Children.

Anuria in children may arise from a host of causes and is a frequent concern in the emergency department. This review focuses on differentiating common causes of obstructive and nonobstructive anuria and the role of point-of-care ultrasound in this evaluation. We discuss some indications and basic techniques for bedside ultrasound imaging of the urinary system.

A Randomized Controlled Trial of Positioning for Lumbar Puncture in Young Infants.

OBJECTIVE: The lateral and sitting positions are those most widely used to perform lumbar puncture (LP) in infants. This study sought to compare LP success rates by position. Secondary outcomes were successful LP on the first attempt and rates of procedural complications. METHODS: Infants aged 1 to 90 days undergoing LP in our pediatric emergency department between June 1, 2012 and October 31, 2013 were randomized to 1 position or the other. Successful LP was defined as collection of cerebrospinal fluid with a red blood cell count of less than 10,000 cells/mm on either of the first 2 attempts. Electronic medical records were reviewed for patient information, cerebrospinal fluid results, and procedural complications. Providers completed a questionnaire detailing their previous LP experience and technique. Primary results were analyzed using the intention-to-treat principle. RESULTS: We enrolled 168 infants. Of 167 with data eligible for analysis, 82 (49%) were randomized to the lateral position. There was no statistically significant difference in LP success rate between the lateral (77%, 63/82) and sitting (72%, 61/85) positions (difference, 5.1%; 95% confidence interval, -8.2%-18.3%). There were no significant differences in success on the first LP attempt or the rates of procedural complications. CONCLUSIONS: Among infants 1 to 90 days of age, this study found no difference in LP success between the lateral and sitting positions.

Accidental hypothermia.

Accidental hypothermia has produced many cases of intact survival even after prolonged cardiac arrest, but it is also often fatal. In recent years, alterations in resuscitation care that sometimes confused or discouraged resuscitation teams have largely been supplanted by an emphasis on safe, rapid, effective rewarming. Rewarming decisions and even the simple recognition of hypothermia remain challenging. This review seeks to update and demystify some of these challenges.

Bronchiolitis: clinical characteristics associated with hospitalization and length of stay.

OBJECTIVES: Bronchiolitis is a leading cause of infant hospitalization in the United States; the mean length of stay (LOS) is 3.3 days. We sought to identify the initial clinical characteristics of bronchiolitis associated with admission and with longer LOS in a large multicenter clinical trial. METHODS: This study was a secondary analysis of a randomized trial conducted in 20 emergency departments in the Pediatric Emergency Care Applied Research Network. We examined age, sex, days of illness, Respiratory Distress Assessment Instrument score, vital signs, and oxygen saturation by pulse oximetry (SpO(2)) at presentation in 598 infants aged 2 to 12 months with moderate to severe bronchiolitis. We used classification and regression tree and logistic regression analyses to identify associations with admission and longer LOS (defined as LOS > 1 night). RESULTS: Of the 598 infants, 240 (40%) were hospitalized; two thirds underwent longer LOS. The best predictor of hospitalization was initial SpO(2) value of less than 94%, followed by Respiratory Distress Assessment Instrument score of greater than 11 and respiratory rate of greater than 60. For this model, the sensitivity was 56% (95% confidence interval, 50%-62%) and the specificity was 74% (95% confidence interval, 70%-79%). Among admitted patients, the only decision point for prediction of longer LOS was initial SpO(2) value of 97% or less. CONCLUSIONS: A model using objective findings had limited accuracy for predicting hospitalization after emergency department evaluation for bronchiolitis. In these infants with moderate to severe bronchiolitis, however, initial SpO(2) was the best predictor of hospital admission and of longer LOS. Efforts to better define and manage hypoxemia in bronchiolitis may be helpful.

Abusive head trauma.

Abusive head trauma is a leading cause of morbidity and mortality in infants and young children. These patients will often first present to the emergency department. They may present with dramatic or subtle findings. It is important that pediatric emergency physicians be aware of the possible presentations of abusive head trauma. This article will review the epidemiology, the clinical findings, the diagnosis, the differential diagnosis, and the management of abusive head trauma.

A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis.

BACKGROUND: Bronchiolitis, the most common infection of the lower respiratory tract in infants, is a leading cause of hospitalization in childhood. Corticosteroids are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited. METHODS: We conducted a double-blind, randomized trial comparing a single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis (defined by a Respiratory Distress Assessment Instrument score > or =6). We enrolled patients at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was hospital admission after 4 hours of emergency department observation. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events. RESULTS: Baseline characteristics were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, -1.3%; 95% confidence interval [CI], -9.2 to 6.5). Both groups had respiratory improvement during observation; the mean 4-hour RACS was -5.3 for dexamethasone, as compared with -4.8 for placebo (absolute difference, -0.5; 95% CI, -1.3 to 0.3). Multivariate adjustment did not significantly alter the results, nor were differences detected in later outcomes. CONCLUSIONS: In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes. (ClinicalTrials.gov number, NCT00119002 [ClinicalTrials.gov].).

Barriers to discharge from a 24-hour observation unit for children with bronchiolitis.

OBJECTIVES: The aim of this study was to determine physician-identified barriers to discharge of patients with bronchiolitis from a 24-hour emergency department-based observation unit. METHODS: Patients 3 to 24 months of age with a diagnosis of bronchiolitis were prospectively enrolled from January through April 2008. Patients were treated according to a standard hospital-wide bronchiolitis pathway that included an option for discharge on home oxygen. Treating physicians recorded barriers to discharge in those not sent home within 24 hours. The primary outcome was successful discharge within 24 hours; we analyzed barriers to such discharges. RESULTS: Fifty-five patients were enrolled in the study. Discharge within 24 hours failed in 30 patients (55%; 95% confidence interval [CI], 42%-67%). Among the 25 discharged patients, 6 (24%) went home on supplemental oxygen without adverse outcomes or readmission. Hypoxia was the most commonly identified barrier to discharge (n = 22, 73%). Of the 22 cases where hypoxia was a barrier, 18 (82%) also noted the need for deep nasal suctioning; 12 (55%), parental discomfort; 12 (55%), respiratory distress; 10 (46%), poor feeding; and 4 (18%), MD discomfort. CONCLUSIONS: Hypoxia was the most common barrier to discharge within 24 hours for patients with bronchiolitis, and a common cofactor when other barriers were identified. Research on home oxygen, the use of deep nasal suctioning, and parental discomfort with early discharge may be useful in reducing the need for inpatient care for bronchiolitis.

Variation in diethylenetriamine pentaacetic acid and mercaptoacetyltriglycine renal scans: clinical implications of interobserver and intraobserver differences.

PURPOSE: Diethylenetriamine pentaacetic acid and mercaptoacetyltriglycine renal scans are commonly used to evaluate infants and children with hydronephrosis to assess for changes in kidney function and drainage. We evaluate the certified nuclear medicine technologist intraobserver and interobserver variability of data processing in diuretic renal scan interpretation of the percent differential function of the right kidney so that true physiological changes can be understood by the clinician. MATERIALS AND METHODS: A total of 30 renal scans (diethylenetriamine pentaacetic acid in 20 patients and mercaptoacetyltriglycine in 10) were randomly selected for evaluation by 3 technologists who processed the scan data for each patient on 5 different occasions at least 1 week apart. Regions of interest were drawn and background areas were subtracted, and percent differential function of the right kidney was calculated. Technologists were blinded to patient identification and previous interpretation results. The data were then statistically analyzed. RESULTS: The data focused on percent differential function of the right kidney. Confidence limits for the single scan interpretation at the 95% level showed +/-5.8% differential function variation, although this scan was the same renal scan processed 1 week later. CONCLUSIONS: For differential function determined on diethylenetriamine pentaacetic acid or mercaptoacetyltriglycine diuretic renal scan the single scan 95% confidence limits were +/-5.8% differential function. From one renal scan to the next the differential percent of kidney function must change +/-11.6% differential function for a clinician to be 95% confident that a real change in kidney function has occurred. This uncertainty is substantial and is likely larger than is currently allowed for in clinical practice.

A practical approach to warts in the emergency department.

Although cutaneous warts are one of the most common skin conditions affecting children, their management can be challenging, especially in complex cases and even more so during a single emergency department encounter. Anogenital warts require particular attention because of their possible but nonspecific association with sexual abuse. This review will focus on cutaneous warts and anogenital warts, with a discussion of their recognition and treatment, especially in the emergency department. The medicolegal implications of anogenital warts in children are also reviewed.

Inhaled Nitric Oxide as a Preoperative Test (INOP Test I): the INOP Test Study Group.

BACKGROUND: This study was performed to determine whether a preoperative hemodynamic evaluation with oxygen and inhaled nitric oxide identifies patients with pulmonary hypertension who are appropriate candidates for corrective cardiac surgery or transplantation more accurately than an evaluation with oxygen alone. METHODS AND RESULTS: At 10 institutions, 124 patients with heart disease and severe pulmonary hypertension underwent cardiac catheterization to determine operability. The ratio of pulmonary and systemic vascular resistance (Rp:Rs) was determined at baseline while breathing approximately 21% to 30% oxygen, and in approximately 100% oxygen and approximately 100% oxygen with 10 to 80 parts per million nitric oxide to evaluate pulmonary vascular reactivity. Surgery was performed in 74 patients. Twelve patients died or developed right heart failure secondary to pulmonary hypertension following surgery. Rp:Rs<0.33 and a 20% decrease in Rp:Rs from baseline were chosen as 2 criteria for operability to determine, in retrospect, the efficacy of preoperative testing in patient selection. In comparison to an evaluation with oxygen alone, sensitivity (64% versus 97%) and accuracy (68% versus 90%) were increased by an evaluation with oxygen and nitric oxide when Rp:Rs<0.33 was used as the criterion for operability. Specificity was only 8% when a 20% decrease in Rp:Rs from baseline was used as the criterion for operability. CONCLUSION: By using a combination of oxygen and inhaled nitric oxide, a greater number of appropriate candidates for corrective cardiac surgery or transplantation can be identified during preoperative testing when a specific value of Rp:Rs is used as a criterion for operability.

Nucleic acid amplification tests (polymerase chain reaction, ligase chain reaction) for the diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in pediatric emergency medicine.

Nucleic acid amplification tests, such as ligase chain reaction and polymerase chain reaction, offer potential advantages of speed, simplicity, and accuracy in the detection of genitourinary tract infection with Neisseria gonorrhoeae and Chlamydia trachomatis. Their appropriate use in pediatric emergency medicine depends on an understanding of their strengths and weaknesses. Problems arise in defining the sensitivity and, especially, specificity of these tests. The clinical scenario, the site of infection, the age and sex of the patient, and especially the presence or absence of medicolegal concerns strongly affect the applicability of these tests. The risk of false positives may be significant even when legal concerns do not arise and even if a highly specific test is used. This article reviews the uses and limitations of such tests in pediatric emergency medicine. Discussion is directed to both technical and practical considerations.

Treatment of skin and soft tissue infections in a pediatric observation unit.

OBJECTIVES: To report the success rate of observation unit (OU) treatment of pediatric skin and soft tissue infections (SSTIs) and to see if we could identify variables at the time of initial evaluation that predicted successful OU treatment. METHODS: A retrospective review of children less than 18 years of age admitted for SSTI treatment to our OU from the emergency department between January 2003 and June 2009. RESULTS: On records review, 853 patients matched eligibility criteria; median age was 5.2 years (interquartile range = 2.5-9 years). Of the 853 patients, 597 (70.0%) met the primary outcome criteria of successful OU discharge within 26 hours. Secondary analysis revealed that 82% of the patients achieved successful discharge from the OU within 48 hours. Although some laboratory variables demonstrated statistical association with success, none achieved a combination of high sensitivity and specificity to predict OU failure. OU success rates varied by location. Dental and face infections and those of the extremities or multiple sites demonstrated OU success rates higher than 65%, while infection of the groin, buttocks, trunk, or neck had success rates between 24% (neck) and 60% (groin). In multivariate analysis, only 3 variables remained significant. Unfavorable location was most strongly associated with OU failure, followed by C-reactive protein > 4 and then by erythrocyte sedimentation rate > 20. CONCLUSIONS: Our findings suggest that successful OU treatment is possible in a large group of patients needing hospitalization for SSTIs. Consideration of infection location may assist the emergency department clinician in determining the most appropriate unit for admission.

Has the growth and development of subspecialization in pediatric urology affected scholarly activity?

PURPOSE: How has academic productivity changed in a decade in the American Academy of Pediatrics Section on Urology? Do academic pursuits slow as section members become older? What is the average number of publications yearly by section members? What percent of research is funded in pediatric urology? Has change occurred with multiple authorships? MATERIALS AND METHODS: American Academy of Pediatrics Urology Section active memberships for 1993 and 2003 were obtained. A PubMed study was performed by reviewing all manuscripts published by American Academy of Pediatrics Section on Urology active members for 1991 to 1993 and 2001 to 2003. The data recorded were author, year, PubMed identification number, the number of authors, financial support and journal. Parametric and nonparametric statistics were used for analysis. RESULTS: In the 1991 to 1993 era there were 245 active members, of whom 145 published a total of 972 manuscripts. There were 604 clinical authorships, 161 basic science articles, 42 reviews and 186 case reports, of which 154 manuscripts received funding. In the 2001 to 2003 era there were 252 members, of whom 177 published a total of 1,152 manuscripts. There were 773 clinical authorships, 140 basic science articles, 107 reviews and 124 case reports, of which 151 manuscripts receiving funding. For members in the 2 periods the mean number of articles decreased by 1.0 from 1 decade to the next (p = 0.002). CONCLUSIONS: Scholarly pursuit of pediatric urology as a subspecialty has remained remarkably steady, averaging about 2 authorships per author yearly in the recent decade. The percent of authorships with funding in pediatric urology has decreased. The number of funded authorships has remained steady. A higher percent of American Academy of Pediatrics members have published manuscripts in the last decade. More manuscripts were published during the last decade study period than during the prior decade. The mix of manuscript types has changed with more reviews, and fewer case reports and basic science authorships in the most recent decade. New members are more likely to publish with a low unpublished percent.

Rapid Detection and Diagnosis of Group A Streptococcal Pharyngitis.

This article reviews techniques of rapid testing and the effective diagnosis of streptococcal pharyngitis. Despite 50 years' study of streptococcal pharyngitis and 20 years' experience with rapid tests for its diagnosis, the subject continues to evolve. Rapid diagnostic tests have become more sensitive. Experts now consider not if but when they may replace throat cultures. Highly accurate rapid tests will still challenge clinicians to screen the right patients. The improvement of clinical diagnosis will require an understanding of the clinical spectrum of pharyngitis and questions relating to disease prevalence, test performance, and medical decision making. Implications for diagnostic strategies are discussed.

Against all advice: an analysis of out-of-hospital refusals of care.

STUDY OBJECTIVE: We examine the characteristics of patients involved in out-of-hospital emergency medical services (EMS) incidents that result in refusal of care and determine the rates of subsequent EMS, emergency department (ED), and inpatient care, as well as death within 7 days. METHODS: Utah statewide EMS data identifying refusals of care were probabilistically linked to Utah statewide ED, inpatient, and death certificate data within 7 days of the initial EMS refusals for 1996 to 1998. Refusals were defined as incidents in which field treatment or transport was refused and did not include incidents in which EMS providers deemed care or transport unnecessary. RESULTS: Of 277244 EMS incidents, 14109 (5.1%) resulted in refusals of care. For all age groups, motor vehicle crash dispatches resulted in the highest rate of refusal of care, ranging from 8.0% to 11.7%. Slightly more than 3% of patients involved in a refusal of care incident had a subsequent EMS dispatch within a week. One fifth of the patients involved in EMS refusals of care had a subsequent ED visit. Less than 2% of the EMS refusal patients were hospitalized; hospitalization was highest among children younger than 3 years and adults older than 64 years. Twenty-five adults died within a week of refusing EMS care, of whom 19 (76.0%) were older than 64 years. CONCLUSION: Refusal of care incidents are a small segment of all EMS incidents. They arise from a variety of situations, and the risk for missed intervention may be minimal.