Children With Elbow Injuries and Sonographic Elevated Posterior Fat Pad but No Identifiable Posterior Fat Pad on Lateral Radiographs: A Case Series.

Point of Care Ultrasound (POCUS) is used to evaluate the injured pediatric elbow. Standard of care, however, remains radiography. POCUS performed in the setting of normal radiographs have been obtained may demonstrate radiologic occult lipohemarthrosis indicative of occult fracture. We reviewed our pediatric emergency department (PED) POCUS archive for lipohemarthrosis, and then isolated those cases with normal elbow radiography. Radiography was deemed to be normal per the interpretation of the treating PED physician, and was reviewed for this series by an experienced ABR board certified pediatric radiologist. Fracture on POCUS was defined as fracture line or lipohemarthrosis in a posterior sagittal or transverse view of the distal humerus. Fracture was confirmed by signs of cortical healing on follow-up radiography, or clinical course consistent with fracture as documented by an orthopedist. We identified four children with elbow fractures who had no fracture line or elevated posterior fat pad on radiography but demonstrated lipohemarthrosis on POCUS. POCUS may elicit evidence of fracture even after normal radiography, and POCUS findings suggesting occult fracture may allow for more effective guidance on discharge.

The Medical Somatic Dissociation Questionnaire Assessment For Childhood Sexual Abuse: A Brief Report.

Child sexual abuse is a prevalent phenomenon worldwide. However, a gap exists between its incidence and its disclosure rate. Furthermore, assessment tools and techniques capable to identify the source of symptoms are lacking. This study investigates the extent to which the validated Medical Somatic Dissociation Questionnaire (MSDQ) can differentiate between sexually and non-sexually abused children. A total of 794 children and youth between the ages of 8 and 18 (mean age: 12.2 (SD = 2.3); 42% female, 58% male) were recruited from the general population; other participants were residents of boarding schools and children who were referred to medical treatment. The anonymous online questionnaire included queries about demographics, a condensed version of the Traumatic Life Events Questionnaire, and the MSDQ. Findings indicate strong internal consistency, reliability, incremental validity, and predictive validity of the instrument, indicating the superiority of the MSDQ's ability to predict sexual abuse compared to physical abuse or the loss of a family member. It is concluded that the MSDQ can be integrated into the evaluation process performed by healthcare professionals in the diagnosis of minors with unexplained symptomatology.

Point-of-Care Ultrasound-Guided Drainage of Joint Effusions in the Pediatric Emergency Setting: A Case Series.

Literature supporting the use of point-of-care ultrasound (POCUS) for both identification and aspiration of effusions in large joints in the pediatric emergency department (PED) is sparse. We collected a case series of five patients who presented to the PED from August 2020 to December 2020 with an effusion in the hip, shoulder, knee, or elbow identified and aspirated under POCUS performed by pediatric emergency medicine (PEM) physicians. POCUS confirms effusion location and size and visualization of a completely evacuated effusion. POCUS can also guide the decision to start antibiotics earlier in the course of illness, can prevent unnecessary transfers for formal sonographic imaging or for potentially unnecessary radiographic imaging. This series supports the role of a PEM physician and POCUS guidance in the identification and aspiration of large-joint effusions.

Use of Point-of-Care Ultrasound to Identify Occult Fractures of the Tibia in the Pediatric Emergency Department: A Case Series.

BACKGROUND: Although point-of-care ultrasound (POCUS) has been shown to be useful in the identification of both pediatric and adult long-bone fractures in the emergency setting, radiography remains the standard of care. Emergency physicians are often faced with the dilemma of how to evaluate and treat the child with lower leg injury and physical examination concerning for fracture but no readily identifiable fracture line on radiography. CASE REPORTS: We present four cases in which POCUS was used to diagnose a radiographically occult fracture of the proximal tibia in young children. This is the first case series of occult fracture of the tibia diagnosed with POCUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS can demonstrate evidence of fracture even after unremarkable radiography is obtained, and POCUS findings consistent with fracture might allow for more effective guidance on discharge.

Ultrasound-Guided Distal Forearm Fracture Reduction by Pediatric Emergency Physicians: A Single Center Retrospective Study.

INTRODUCTION: Fracture reduction under point-of-care ultrasound (POCUS) guidance facilitates measurement of residual angulation or displacement that may not be apparent on examination. Point-of-care ultrasound is without patient or staff exposure to ionizing radiation and enlists no additional staffing resources or patient transfer. METHODS: We conducted a chart review of all children who underwent reduction of a distal forearm fracture in the pediatric emergency department over a 2-year period, from September 2018 to September 2020. We compared length of stay (LOS) with that for orthopedist-performed distal forearm reductions during the study period. We allowed a 6-week lag period to ensure no missed rereduction before analyzing the data. After reduction, children were instructed to follow up with an orthopedist within 1 week. Children with loss of reduction on orthopedic follow-up are referred back through our emergency department for operative reduction. RESULTS: A total of 74 children with 75 distal forearm fractures were identified. Average LOS was 179 minutes for the pediatric emergency medicine physician reductions and 215 minutes for the orthopedist reductions (P < 0.001). Ninety-six percent of reductions were completed with POCUS assistance, and 61% had less than 5 degrees of angulation on postreduction radiography. Only 2.7% of children underwent rereduction. CONCLUSIONS: Distal forearm fracture reductions by a pediatric emergency medicine physician under POCUS guidance have a high rate of excellent alignment, low rate of failed reduction, and significantly shorter LOS (P < 0.001) than reductions performed by orthopedists.

Contamination rates of different methods of urine culture collection in children: A retrospective cohort study.

AIM: Urinary tract infection is a common cause of paediatric morbidity. However, there is no consensus on the default method for urine culture collection in children. This study aimed to examine the contamination rates of different urine collection methods. METHODS: This was a retrospective cohort study in a paediatric emergency department. Data were collected from electronic health records on all children whose urine culture samples were obtained in the paediatric emergency department between March 2018 and March 2019. Different methods of urine collection included the midstream (MS) method, clean catch (CC), transurethral bladder catheterisation and suprapubic aspiration. Contamination rates and positive urine culture rates were calculated and compared for sex, age, and collection method. RESULTS: Urine culture samples were collected from 1507 children. There were 284 (18.8%) cultures that were positive with significant growth and 52 (3.5%) that were defined as 'contaminated'. The contamination rates for the midstream method in toilet-trained children were 1.6% (10/609), 4.9% (17/348) for CC in pre-continent children, 4.9% (25/515) for transurethral bladder catheterisation and 0% (0/35) (P = 0.006) for suprapubic aspiration. There was no significant difference in contamination rates of urine cultures collected by CC and catheterisation in the compared groups. The rates of positive cultures in the subgroup of children with high suspicion for Urinary tract infection were also found to be similar. CONCLUSIONS: Our study shows that CC is non-inferior to catheterisation for collecting urine cultures in young children.

The Child With a Painful Arm: A POCUS Screening Protocol to Identify Fracture in Children With Upper Extremity Injury.

BACKGROUND: Young children present frequently to the emergency department with an immobile, painful arm. It is often difficult to discern a point of tenderness in a frightened, injured child. Common approaches included sending the child for x-ray studies of the extremity or empirically attempting reduction of radial head subluxation. We created a step-by-step point-of-care ultrasound screening protocol of the upper extremity to increase or decrease the probability of fracture before x-ray study or reduction. CASE REPORT: We present the cases of 6 children younger than 4 years without a clear history of pulled elbow and without swelling or deformity on examination, for whom this protocol revealed fracture or lowered the probability of fracture, thereby increasing the safety of radial head reduction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In most cases, identification of a single fracture on ultrasound allows for focused x-ray study on the area of fracture. Children with a normal ultrasound screen can undergo reduction of radial head subluxation safely.

Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic.

AIM: To present seven paediatric patients with appendicitis, all with late diagnosis resulting from different aspects of the fear from the current global COVID-19 pandemic. METHODS: Cases were collected from three paediatric surgical wards. Comparison between complicated appendicitis rates in the COVID-19 era and similar period in previous year was performed. RESULTS: All seven children presented with complicated appendicitis. Main reasons for the delayed diagnosis during the COVID-19 era were parental concern, telemedicine use and insufficient evaluation. Higher complication rates were found during the COVID-19 era compared to similar period in previous year (22% vs 11%, P-value .06). CONCLUSION: The fear from COVID-19 pandemic may result in delayed diagnosis and higher complication rates in common paediatric medical conditions. We believe caregivers and healthcare providers should not withhold necessary medical care since delay in diagnosis and treatment in these routinely seen medical emergencies may become as big of a threat as COVID-19 itself.

Identifying Retrocecal Appendicitis on Point-of-Care Ultrasound (POCUS).

BACKGROUND: Retrocecal appendicitis may be challenging to find. We present the first case series in which retrocecal appendicitis was found on point-of-care ultrasound (POCUS). CASE REPORTS: In each of the five cases, appendicitis was found by a pediatric emergency physician in the right periumbilical region or right upper quadrant. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The POCUS practitioner should scan both the right upper and right lower quadrant of the abdomen in search of appendicitis, as well as in search of signs of perforation.

Beyond Point-of-Care Ultrasound: Bedside Ultrasound in the Diagnosis of Soft Tissue Mass.

Cancer is diagnosed in 1 in 7000 children annually. Here, we report 6 cases of a mass identified by the author, a novice sonographer in a pediatric emergency medicine fellowship, using point-of-care ultrasound, from January of 2017 to May of 2018. Identification of these cases early in presentation allowed for earlier involvement of the relevant specialist and shorter time to diagnosis and treatment, and might be expected to increase parent satisfaction as well.

Childhood Drowning: Review of Patients Presenting to the Emergency Departments of 2 Large Tertiary Care Pediatric Hospitals Near and Distant From the Sea Coast.

OBJECTIVE: Drowning is a leading cause of death among infants and toddlers. Unique physiological and behavioral factors contribute to high mortality rates. Drowning incidents predominantly occur during warmer months and holidays. The aim of this study was to describe the characteristics of pediatric drowning victims who attended 2 different emergency departments (EDs), 1 near and 1 distant from the sea coast, to recognize risk factors, complications, causes of death, and the educational needs of families and caregivers. METHODS: Retrospective cohort analysis of incident history, clinical presentation, treatments, and outcomes of drowning victims was performed. Data were analyzed both by age group and proximity of institution to the sea coast. RESULTS: From 2005 to 2015, 70 drowning patients presented to the 2 institutions; there was no difference in incident history or outcomes based on proximity to the sea coast. Fifty-six percent of patients were younger than 6 years, the majority drowning in pools. More of the older children drowned in the sea (48% vs 23%). Half of all patients were treated and followed in the ED or ward, and the other half were treated in the pediatric intensive care unit; 12 suffered severe complications, including 5 diagnosed with brain death. Cardiopulmonary resuscitation was performed in 80% of the fatal group and 23% of the nonfatal group (P = 0.006). Seven children who experienced a cardiac arrest with hypothermia were treated before arrival in the ED, and 5 had ongoing cardiac arrest upon arrival in the ED (these were the 5 suffering brain death). DISCUSSION: Most of patients younger than 6 years drowned in swimming pools, suggesting that parents are perhaps less vigilant in these circumstances, even though they may remain in close proximity. Active adult supervision entails attention, proximity, and continuity. Educational efforts should be aimed at reminding parents of this, especially in the summer months.

Subgaleal haematoma due to hair pulling: Review of the literature.

AIM: To identify all cases of subgaleal haematoma (SGH) as a result of non-abusive hair straightening or pulling without evidence of blunt trauma or coagulopathy. METHODS: We conducted a search in the English-language literature of all cases of SGH in children. We excluded those in neonates, those in which the child was abused by a caregiver, those in which blunt trauma was not excluded, and those in which a coagulopathy or other blood dyscrasia was found. RESULTS: Sixteen cases were identified in children from a range of ages. Time to presentation ranged from several days to a week and a half. In most cases, management is conservative, though SGH can cause fever, symptomatic anaemia and can threaten vision. CONCLUSION: Subgaleal haematoma can occur in otherwise healthy children, can accumulate slowly and can result in sequelae. However, most cases of SGH are managed conservatively.

A Novel Screening Tool for Assessing Child Abuse: The Medical Somatic Dissociation Questionnaire-MSDQ.

Somatic dissociation is known to be associated with childhood abuse, particularly with childhood sexual abuse (CSA). Currently, the diagnosis of CSA is hampered by the lack of a validated questionnaire. While some questionnaires are excellent research tools, there is no suitable applied measure for the assessment of distress due to CSA. The current study's objective was to validate a novel questionnaire, designated the Medical Somatic Dissociation Questionnaire-MSDQ, for evaluating somatic dissociation in the healthcare system setting. A total of 541 adults, 160 (30%) male and 381 (70%) female, of average age 35 years were recruited from the general population via the Internet. The Life Events Checklist for DSM-5 (LEC-5) was used for screening subjects for reporting a history of CSA. Our examination of the MSDQ indicated powerful internal consistency, reliability, and convergent validity of the instrument, with high correlations between the MSDQ and the SDQ-20 and also between the MSDQ and psychological symptomatology. In addition, there was known-groups validity when differences between adults who experienced CSA and those who did not were compared. Importantly, the MSDQ can be easily integrated into the evaluation process performed by medical professionals in the diagnosis of adult patients with apparently unexplained symptomatology.

Success rate of pneumatic reduction of intussusception with and without sedation.

BACKGROUND: Pneumatic reduction of ileocolic intussusception is often performed without sedation. The aim of this study was to evaluate the success rate of pneumatic reduction of intussusception with and without sedation. METHODS: We conducted a retrospective cohort study in Israel in two tertiary care centers using a similar protocol for pneumatic reduction of intussusception. In one center, patients had pneumatic reduction of intussusception under propofol-based sedation, while in the other, patients had pneumatic reduction of intussusception without any sedation. Children aged 3 months to 8 years who were diagnosed with ileocolic intussusception between January 1, 2008 and July 31, 2015 were included in the study. Multivariable regression was used to adjust for the possible confounders of age, gender, number of cases of intussusception prior to the study period, time period from the beginning of symptoms to emergency department admission (<12 h, >12 h), and time period from emergency department admission to the beginning of pneumatic reduction of intussusception. Secondary outcomes of the study included the proportion of bowel perforations during the procedure, and the proportion of early (within 48 h) recurrence of intussusception. RESULTS: The sedation and nonsedation cohorts included 124 and 90 patients, respectively. The cohorts were comparable with regard to demographic characteristics, hemodynamic vital signs on admission to the emergency department, blood gases tests during emergency department stay, and time variables prior to reduction of intussusception. Multivariable regression revealed reduction of intussusception success rates of 89.5% and 83.3% for the sedation group and nonsedation group, respectively, with an adjusted odds ratio of 1.2, 95% CI 1.1-5.3. Three sedated patients and 0 nonsedated patients developed bowel perforations during the procedure. Rates of early recurrence of intussusception of sedated patients and nonsedated patients were 5.1% (6/117) and 1.3% (1/79), respectively (P = 0.15, RR = 3.9, 95% CI: 0.47 to 31.81). CONCLUSION: The findings suggest that the pneumatic reduction of intussusception under propofol-based sedation had a slightly higher success rate than the pneumatic reduction of intussusception without sedation; however, the safety of this practice is yet to be determined.

Ultrasound-Assisted Reduction of Displaced and Shortened Fractures by Pediatric Emergency Physicians.

Pediatric emergency physicians at Kaplan Medical Center regularly reduce forearm fractures under point-of-care ultrasound guidance in the pediatric emergency department. We present 3 children who arrived at our department with shortened, angulated forearm fractures within the span of a single week. We report on the successful reduction of these fractures under point-of-care ultrasound and on the maintenance of anatomic alignment at follow-up 1 week postreduction.