Clinical Characteristics, Outcomes, and Interobserver Agreement of Point-of-Care Ultrasound Detected Mesenteric Adenitis in Nonsurgical Pediatric Abdominal Pain: A Retrospective Cohort Study.

OBJECTIVES: Point-of-care ultrasound (PoCUS) in the emergency department (ED) may facilitate the diagnosis of nonsurgical sources of abdominal pain after surgical causes are excluded. Identifying mesenteric adenitis is a feasible PoCUS application due to its ease of use and speed. However, there are scant data regarding the diagnosis of mesenteric adenitis by PoCUS. The objective of this study was to describe the clinical characteristics, outcomes, and interobserver agreement of mesenteric adenitis identified on PoCUS in pediatric patients with nonsurgical abdominal pain. METHODS: This was a retrospective review at a tertiary-care, urban pediatric ED. All cases of mesenteric adenitis diagnosed on PoCUS from January 2018 to August 2022 were reviewed. Demographics and clinical data, including relevant outcomes, were recorded. All PoCUS videos were reviewed by a senior sonologist-physician for determination of mesenteric adenitis in children 21 years and younger with nonsurgical abdominal pain. Interobserver agreement by Cohen κ was calculated between experienced and novice physician sonologists blinded to diagnosis, who reviewed 77 six-second video clips for presence or absence of mesenteric adenitis. RESULTS: Thirty-three subjects were identified by PoCUS to have mesenteric adenitis in the setting of nonsurgical abdominal pain presenting to our ED. Most common indications for PoCUS were for suspected appendicitis, suspected intussusception, or undifferentiated abdominal pain. Forty-six percent of patients were male; median age was 9 years (interquartile range, 4-14 years). On 4-week clinical follow-up, 1 patient returned to our ED with a surgical abdomen. Cohen κ values were 0.83 (95% confidence interval, 0.70-0.97) between experienced sonologist-physicians and 0.76 (95% confidence interval, 0.61-.90) between novice and experienced sonologist-physicians. CONCLUSIONS: PoCUS can identify mesenteric adenitis, typically a diagnosis of exclusion, in pediatric patients with nonsurgical abdominal pain, both by novice and experienced physician-sonologists. Use of PoCUS may help ED clinicians identify a common cause of nonsurgical abdominal pain in children.

Point-of-Care Ultrasound on Management of Cellulitis Versus Local Angioedema in the Pediatric Emergency Department.

OBJECTIVES: To evaluate whether ultrasound can differentiate between cellulitis and angioedema from insect bites in pediatric patients. METHODS: A prospective, pre-post study in an urban pediatric emergency department of patients younger than 21 years with soft tissue swelling from insect bites without abscesses were enrolled. Treating physician's pretest opinions regarding the diagnosis and need for antibiotics were determined. Ultrasound of the affected areas was performed, and effects on management were recorded. Further imaging, medications, and disposition were at the discretion of the enrolling physician. Phone call follow-ups were made within a week of presentation. RESULTS: Among 103 patients enrolled with soft tissue swelling secondary to insect bites, ultrasound changed the management in 27 (26%) patients (95% confidence interval [CI], 18-35%). Of the patients who were indeterminate or believed to require antibiotics, ultrasound changed management in 6 (23%) of 26 patients (95% CI, 6%-40%). In those patients who were believed not to require antibiotics, ultrasound changed management in 12 (16%) 77 patients (95% CI, 7%-24%). Patients with diagnosis of local angioedema achieved symptom resolution 1.4 days sooner than patients diagnosed with cellulitis (mean, -1.389; 95% CI, -2.087 to -0.690; P < 0.001). No patient who was initially diagnosed as local angioedema received antibiotics upon patient follow-up. CONCLUSIONS: Point-of-care ultrasound changed physician management in 1 of 4 patients in the pediatric emergency department with soft tissue swelling secondary to insect bites. Ultrasound may guide the management in these patients and lead to improved antibiotic stewardship in conjunction with history and physical examination.

Supraglottic airway devices for pediatric airway management in the emergency department.

Endotracheal intubation can be difficult in the emergent situation, and it is important to have an appropriate backup strategy. Supraglottic airway devices have provided an alternative method for pediatric airway management that is relatively easy to learn, with a high success rate. This issue reviews the use of supraglottic airway devices in pediatric patients including common devices, indications and techniques for placement, and complications associated with their use. The use of supraglottic airway devices in the patient with a difficult airway is also discussed.

Features of COVID-19 post-infectious cytokine release syndrome in children presenting to the emergency department.

The 2019 coronavirus disease (COVID-19) has not appeared to affect children as severely as adults. However, approximately 1 month after the COVID-19 peak in New York City in April 2020, cases of children with prolonged fevers abruptly developing inflammatory shock-like states have been reported in Western Europe and the United States. This case series describes four previously healthy children with COVID-19 infection confirmed by serologic antibody testing, but negative by nasopharyngeal RT-PCR swab, presenting to the Pediatric Emergency Department (PED) with prolonged fever (5 or more days) and abrupt onset of hemodynamic instability with elevated serologic inflammatory markers and cytokine levels (IL-6, IL-8 and TNF-α). Emergency physicians must maintain a high clinical suspicion for this COVID-19 associated post-infectious cytokine release syndrome, with features that overlap with Kawasaki Disease (KD) and Toxic Shock Syndrome (TSS) in children with recent or current COVID-19 infection, as patients can decompensate quickly.

Emergency department management of pediatric septic arthritis and osteomyelitis

Septic arthritis and osteomyelitis in pediatric patients represent true emergencies, and can quickly threaten life and limb. A high index of suspicion should be maintained, as these conditions often present with a subacute course of illness and vague signs and symptoms. Septic arthritis and osteomyelitis can occur concurrently, so suspicion for one should also prompt investigation for the other. The diagnostic evaluation should include blood work as well as samples from the infected joint or bone for culture. Management with antibiotics is a standard approach, but the duration of antibiotic therapy is controversial. This issue reviews the current literature and provides an evidence-based approach for the evaluation and management of pediatric patients with septic arthritis and osteomyelitis.

Diagnosis and management of group A streptococcal pharyngitis and associated complications

Although group A Streptococcus (GAS) pharyngitis is the most common cause of bacterial pharyngitis in children and adolescents, many viral and bacterial infections mimic the symptoms of GAS pharyngitis. Emergency clinicians must recognize the symptomatology of GAS pharyngitis and use appropriate means of diagnosis and treatment to promote good antibiotic stewardship. This issue reviews the signs and symptoms of GAS pharyngitis, as well as associated complications, and provides recommendations for appropriate treatment that focuses on reducing the severity and duration of symptoms, reducing the incidence of nonsuppurative complications, and reducing transmission.

Pediatric wound care and management in the emergency department

Traumatic wounds and lacerations are common pediatric presenting complaints to emergency departments. Although there is a large body of literature on wound care, many emergency clinicians base management of wounds on theories and techniques that have been passed down, so controversial, conflicting, and unfounded recommendations are prevalent. This issue reviews evidence-based recommendations for wound care and management, including wound cleansing and irrigation, anxiolysis/sedation techniques, closure methods, and post-repair wound care.

Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial.

BACKGROUND: Chest radiography (CXR) is the test of choice for diagnosing pneumonia. Lung ultrasonography (LUS) has been shown to be accurate for diagnosing pneumonia in children and may be an alternative to CXR. Our objective was to determine the feasibility and safety of substituting LUS for CXR when evaluating children suspected of having pneumonia. METHODS: We conducted a randomized control trial comparing LUS with CXR in 191 children from birth to 21 years of age suspected of having pneumonia in an ED. Patients in the investigational arm underwent LUS. If there was clinical uncertainty after ultrasonography, physicians had the option to perform CXR. Patients in the control arm underwent sequential imaging with CXR followed by LUS. The primary outcome was the rate of CXR reduction; secondary outcomes were missed pneumonia, subsequent unscheduled health-care visits, and adverse events between the investigational and control arms. RESULTS: There was a 38.8% reduction (95% CI, 30.0%-48.9%) in CXR among investigational subjects compared with no reduction (95% CI, 0.0%-3.6%) in the control group. Novice and experienced physician-sonologists achieved 30.0% and 60.6% reduction in CXR use, respectively. There were no cases of missed pneumonia among all study participants (investigational arm, 0.0%: 95% CI, 0.0%-2.9%; control arm, 0.0%: 95% CI, 0.0%-3.0%), or differences in adverse events, or subsequent unscheduled health-care visits between arms. CONCLUSIONS: It may be feasible and safe to substitute LUS for CXR when evaluating children suspected of having pneumonia with no missed cases of pneumonia or increase in rates of adverse events. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01654887; URL: www.clinicaltrials.gov.

Evidence-based management of skin and soft-tissue infections in pediatric patients in the emergency department.

Skin and soft-tissue infections are among the most common conditions seen in children in the emergency department. Emergency department visits for these infections more than doubled between 1993 and 2005, and they currently account for approximately 2% of all emergency department visits in the United States. This rapid increase in patient visits can be attributed largely to the pervasiveness of community-acquired methicillin-resistant Staphylococcus aureus. The emergence of this disease entity has created a great deal of controver- sy regarding treatment regimens for skin and soft-tissue infections. This issue of Pediatric Emergency Medicine Practice will focus on the management of children with skin and soft-tissue infections, based on the current literature.

Pediatric herpes simplex virus infections: an evidence-based approach to treatment.

Herpes simplex virus is a common virus that causes a variety of clinical presentations ranging from mild to life-threatening. Orolabial and genital herpes are common disorders that can often be managed in an outpatient setting; however, some patients do present to the emergency department with those conditions, and emergency clinicians should be aware of possible complications in the pediatric population. Neonatal herpes is a rare disorder, but prompt recognition and initiation of antiviral therapy is imperative, as the morbidity and mortality of the disease is high. Herpes encephalitis is an emergency that also requires a high index of suspicion to diagnose. Herpes simplex virus is also responsible for a variety of other clinical presentations, including herpes gladiatorum, herpetic whitlow, eczema herpeticum, and ocular herpes. This issue reviews the common clinical presentations of the herpes simplex virus, the life-threatening infections that require expedient identification and management, and recommended treatment regimens.

Manifestations of pediatric appendicopathia oxyurica.

Enterobius vermicularis is a parasite that inhabits the human digestive tract. We present two pediatric patients with symptoms mimicking acute appendicitis who were found to have E. vermicularis infection. The first case is a 5-year-old female who presented with flank and abdominal pain associated with low-grade fever and anorexia. She had localized tenderness in the right lower quadrant and a leukocytosis with left shift. Intraoperative findings included a normal-appearing appendix, but ex vivo examination revealed Enterobius vermicularis. The second case is a 7-year-old female who presented with periumbilical abdominal pain, anorexia, and emesis. She had tenderness at McBurney's point, and ultrasound revealed a small echogenic focus within the appendix. Intraoperatively, the distal tip of the appendix appeared inflamed. Again, ex vivo examination revealed E. vermicularis. Enterobius vermicularis infection of the appendix can present with a clinical picture similar to acute appendicitis. In at-risk populations, it should be included in the differential diagnosis for children with right lower quadrant abdominal pain. Complete therapy requires treatment with mebendazole.