Imaging for Pediatric Blunt Abdominal Trauma With Different Prediction Rules: Is the Outcome the Same?

BACKGROUND: Computerized tomography (CT) of the abdomen and pelvis is the standard imaging modality to diagnose intra-abdominal injury (IAI). Clinicians must weigh the risk-benefit of CT compared with the degree of clinical suspicion for an IAI. Pediatric Emergency Care Applied Research Network (PECARN), Streck, and blunt abdominal trauma in children (BATiC) prediction rules have been published to help guide evaluation of these patients. Pediatric Emergency Care Applied Research Network uses history and physical examination findings, whereas Streck and BATiC use examination plus laboratory and imaging findings. At the time of the study, there was not a protocol that was more routinely sited. Our goal was to compare these different prediction rules. METHODS: This was a retrospective electronic chart review of all children younger than 18 years presenting for either level 1 or 2 trauma activations at our pediatric emergency department (ED) between June 1, 2015, to June 30, 2017. Charts were manually reviewed for a mechanism concerning for abdominal trauma, and demographic data, history and physical examination findings, laboratory and imaging results per prediction rules, and revisits in 7 days were collected.The prediction rules were applied to all charts that had all data necessary. For study purposes, a score of zero for PECARN and Streck, and score of ≤5 for modified BATiC (mBATiC) were defined as "low risk." Patients with no CT, negative CT, and no new injury found on revisit were classified as "no IAI identified," and patients with positive CT or revisit with injury found as "IAI identified." The results were compared via Fisher exact test. RESULTS: A total of 249 patients met the inclusion criteria with a median age of 12 years. Of the low-risk patients, 119 (98.7%) of 121 in PECARN group, 21 (100%) of 21 in Streck, and 48 (85.7%) of 56 in mBATiC group had no IAI identified. None of the low-risk patients required any intra-abdominal intervention. No missed IAI was identified during revisit review. Negative predictive values of all 3 rules were significant for PECARN, Streck, and mBATiC (98.35%, 100%, and 85.71%, respectively). Overall, 27 patients had positive CT results for IAI. CONCLUSIONS: The PECARN and Streck rules have high negative predictive values to predict low-risk patients who do not require CT. When laboratory studies are not obtained, PECARN is an effective means of excluding IAI for low-risk patients. When laboratory tests were obtained, the Streck rule performed well. Overall, the results are similar to the past individual studies done on each individual rule. History and physical examination findings are of high importance in pediatric trauma. This study supports limited imaging when no abnormal findings are present in children with blunt torso trauma. This is the only study found in the literature that has compared 3 different prediction rules.

Anaphyl-Crisis: Rising Rates of Pediatric Anaphylaxis.

OBJECTIVES: Anaphylaxis is a serious allergic reaction that has the potential to be life-threatening if not recognized and managed rapidly. Several regional studies have shown increased incidence of anaphylaxis over the past decade. The objectives of this study were to determine rates of pediatric anaphylaxis in southeast Michigan between January 1, 2010, and December 31, 2019, and to describe the epidemiology of pediatric patients presenting to emergency centers in southeast Michigan with anaphylaxis. METHODS: We performed a retrospective chart review of all pediatric patients aged 0 to 17 years presenting to 2 large emergency centers from 2010 to 2019 with a diagnosis of anaphylaxis using International Classification of Diseases , Ninth and Tenth Revision , Clinical Modification codes. Epidemiological and visit data, including length of stay, use of intravenous medication, and emergency severity index, were extracted and analyzed. Pediatric anaphylaxis rates were calculated based on detected anaphylaxis cases divided by total pediatric emergency department visits to the 2 emergency centers. A Poisson regression model was used to predict rates of anaphylaxis per 100,000 emergency department visits. RESULTS: One thousand three hundred ninety-one pediatric visits for anaphylaxis were identified during a period between January 1, 2010, and December 31, 2019. There was a significant rate of increase in pediatric anaphylaxis cases over the 10-year study period at both suburban emergency centers, with an annual increase of 21% and 13%. There was no significant change in trends in demographic factors. Most anaphylaxis cases were young, White males with private insurance. Most children did not receive intravenous medications (77%). The median length of stay increased by 1.5 hours over the study period and 92% of patients were discharged home. CONCLUSIONS: Pediatric emergency center visits and length of stay for anaphylaxis in southeast Michigan have markedly increased over the past 10 years.

Imaging for Suspected Appendicitis: Variation Between Academic and Private Practice Models.

BACKGROUND: Little is known regarding the effect of different emergency department (ED) practice models on computed tomography (CT) and ultrasound (US) utilization for suspected appendicitis in the ED and through the potential inpatient hospital stay. OBJECTIVES: Examination rates of CT and US for suspected appendicitis at 2 different pediatric EDs (PEDs) through hospital admission: an academic affiliated tertiary PED (site A) compared with a private practice tertiary care PED (site B). METHODS: All visits with the ICD-9 (International Classification of Diseases, Ninth Revision) chief complaint of abdominal pain were retrospectively examined from May 1, 2009, to February 21, 2012. Suspected appendicitis visits were defined as any visit with the chief complaint of abdominal pain where a complete blood cell count was obtained. Abdominal CT and US in the PED and during hospital admission were compared across the 2 sites. Return visits within 72 hours were evaluated for any missed appendicitis. RESULTS: Overall appendicitis rates were similar at both sites: site A, 4.7%; site B, 4.0%. The odds of having a CT scan performed during visits to the PED for abdominal pain were significantly higher at site B (odds ratio [OR], 3.19; 95% confidence interval [95% CI], 2.74-3.71), whereas the odds of having an US at site B were the opposite (OR, 0.34; 95% CI, 0.28-0.40). When evaluating only the admitted visits, the odds of having a CT were also greater at site B (OR, 2.32; 95% CI, 1.86-2.94) and having an US were less (OR, 0.57; 95% CI, 0.44-0.73). CONCLUSIONS: In this study of 2 PEDs with differing practice models, we identified a dramatic difference in imaging utilization among patients with suspected appendicitis.

Pediatric trauma smackdown: PTS vs SIPA.

BACKGROUND: Different scoring tools aid prediction of pediatric trauma patients' prognosis but there's no consensus on when to apply each. Pediatric Trauma Score (PTS) was one of the first tools developed. Shock Index Pediatric Adjusted (SIPA) adapts Shock Index (SI) in predicting outcomes adjusted for age. It is unclear if either scoring tool is better at predicting outcomes. OBJECTIVE: To compare SIPA and PTS for level I and II pediatric traumas to determine if both are equally effective in predicting outcomes for pediatric trauma patients. DESIGN/METHODS: This is a retrospective review of patients 1-17 years with level 1 and 2 activated trauma (1/2013 - 11/2019). OUTCOMES OF INTEREST: disposition, length of stay, ventilator use, moderate/major spleen/liver lacerations, and Index Severity Score (ISS). Patient visits were scored using both scores and placed into high/low risk category as predefined by the individual scoring tools: High risk SIPA, low risk SIPA, high risk PTS, low risk PTS. RESULTS: There were 750 patients who met inclusion criteria, 35 visits scored high with both tools and 543 visits scored low. The odds ratio (OR) for each tool showed high risk scores were more likely to be associated with increased likelihood of outcomes. When both high-risk groups were compared, PTS had an increased OR for most outcomes. SIPA had an increased OR for receiving fluid bolus. CONCLUSION: This study externally validates both scoring tools for the same cohort. Both tools were reliable predictors, but PTS identifies more "high risk" visits. PTS requires more variables to calculate than SIPA. SIPA may be an effective way to triage when resources are scarce. However, there's still a need for a pediatric trauma triage score that can encompass the accuracy of PTS and the convenience of SIPA.

Child abuse education: an objective evaluation of resident and attending physician knowledge.

OBJECTIVE: The objective of the study was to evaluate residents' and practicing physicians' medical knowledge of child abuse and maltreatment. METHODS: In a freestanding pediatric hospital and community hospital, a 30-question survey was administered to pediatric residents, general pediatricians (GPs), and pediatric emergency medicine (PEM) physicians. The institution's child protection team developed the questions, which were pilot tested for validity. Question content covered major concepts in child abuse and neglect. Information on previous training of child abuse was also collected. RESULTS: There were 95 respondents, 64.2% (n = 61) were residents, 19% (n = 18) were GPs, and 16.8% (n = 16) were PEM physicians. Overall, the average score was 63.3% (SD, 13.8%). There was a statistically significant difference in the knowledge of child abuse and neglect across physician categories (P < 0.001). Pediatric emergency medicine physicians scored the highest (76.9 [SD, 9.1]) compared with GPs (66.7 [SD, 12.4]; P = 0.018) and pediatric residents (60.4 [SD, 12.9]; P < 0.001). There was no difference in the level of knowledge across residency training years (P = 0.076). CONCLUSIONS: With a mean score in our study of 63.3%, there appears to be an overall lack of knowledge in child abuse. These findings highlight the need for increased education in child maltreatment.

I am blue: a toddler's Raynaud's phenomenon.

Raynaud's phenomenon (RP) is a well-known disorder of self-limiting paroxysmal vasospasms occurring in small arteries of the digits, in the order of skin pallor (white), followed by cyanosis (blue), ending with hyperemia (red). These designative triphasic colour changes with exposure to cold, or emotional response is diagnostic in adults. RP is a very rare phenomenon in the young paediatric population as noted by Nigrovic et al with 123 patients <19 year old in a large children's centre over 10 years and only 4 patients being <2 years old, with 69% of these being primary RP. To our knowledge, this is the youngest documented case of Raynaud's disease that has not required treatment.

Screening Pediatric Patients in New-Onset Syncope (SPINS) Study.

Objectives. The primary objective is to determine the frequency of history findings associated with cardiac syncope. Second, to determine the frequency of abnormal electrocardiograms (EKG) in patients presenting with typical vasovagal syncope. Methods. Retrospective chart review from January 2006 to April 2017 of children aged 5 to 18 years presenting to the emergency department with a chief complaint of syncope. Target population was all patients with first episode of syncope and a documented EKG. Excluded patients were those with head trauma, drug intoxication, current pregnancy, seizure, and any endocrine problem. Patients with cardiac causes of syncope were identified by an abnormal EKG or echocardiogram. Specific history findings (past cardiac history, chest pain, palpitations, syncope with exercise, absence of prodrome with syncope) were compared with those with and without cardiac etiology of syncope. The possibility of missing a patient with cardiac cause of syncope based on specific history findings was identified. Results. Of the total 4115 visits of patients with chief complaints of syncope, 2293 patients (55.7%) met the inclusion criteria. Nine patients (0.39%) were identified with cardiac etiology of syncope. The remaining were determined to be of vasovagal origin. All patients with cardiac etiology of syncope were found to have one positive specific history findings. A total of 1972 patients were identified with absence of specific history findings; no patient had a cardiac etiology of syncope. Conclusions. This study identifies screening questions to identify cardiac syncope. Implementing these standard questions could potentially decrease resource utilization and time for evaluation as well as guide follow-up.

Changing incidence of methicillin-resistant staphylococcus aureus skin abscesses in a pediatric emergency department.

OBJECTIVES: The primary objective of this study was to determine the etiology of skin abscesses in a pediatric emergency department (ED) during a 4-year period and to determine whether the incidence of methicillin-resistant Staphylococcus aureus (MRSA) skin abscesses has increased. The secondary objective was to characterize MRSA infections by antibiotic susceptibility during the same period. METHODS: A retrospective chart review examining all cases of skin abscess requiring an incision and drainage seen in a free-standing children's hospital ED from January 1, 2003, to December 30, 2006, was performed. Demographic and clinical data were abstracted from the medical records. Culture results, including sensitivities to antibiotics, were obtained to identify how many of these patients had MRSA. RESULTS: The charts of 442 children were analyzed, and 274 (62%) had MRSA isolated during the entire study period. In 2003, 36.2% of all drained abscesses were caused by MRSA, and by 2006, this increased to 66.5% (P < 0.001). Methicillin-resistant S. aureus isolates were sensitive to trimethoprim-sulfamethoxazole in 99% of the cases, but the sensitivity of MRSA to clindamycin decreased from 96% in 2003 to 87% by 2006. All isolates remain sensitive to rifampin, vancomycin, and gentamicin. CONCLUSIONS: The incidence of MRSA skin abscesses has increased in the pediatric ED population and now accounts for greater than 50% of all abscesses. If antimicrobial therapy is indicated for the treatment of these abscesses, cultures should be obtained, and antibiotics should be chosen to provide MRSA coverage.

Opportunistic Screening for Exposure to Bullying in the Pediatric Emergency Department.

To assess opportunistic screening for exposure to bullying in the pediatric emergency department (ED), an anonymous survey inquiring about exposure to physical, verbal, social, and cyber bullying behaviors was given to ED patients 5 to 18 years old. The survey asked about being the recipient, perpetrator, and/or witness of bullying; the frequency of exposure; liking school; missing school; and presenting complaint. Either the child or parent could complete the survey. A total of 909 surveys were analyzed. Exposure was 78.7%. A greater proportion of females reported being victims and witnesses. Youth who reported being both victims and witnesses represented the largest group, with witness-only the second largest. Parents reported less cyber-bullying and witness status to all types of bullying. For children who did not like school, there was a significant difference in exposure versus nonexposure. There was no association with presenting complaint. Opportunistic screening for bullying exposure in pediatric ED patients warrants consideration as it may increase detection of preclinical status and clinical sequelae.

Supraventricular tachycardia in the pediatric trauma patient: a case report.

Any injured patient who is cool and tachycardic is considered to be in shock until proven otherwise.(1) We describe the diagnostic challenge when evaluating persistent tachycardia in the setting of multiple system trauma with hemorrhagic shock. This is a unique case of a 17-year-old patient with the secondary condition of cardiogenic shock due to supraventricular tachycardia (SVT) complicating ongoing hemorrhagic shock from a facial laceration. She had sustained tachycardia despite aggressive resuscitation and required medical cardioversion 30 minutes after arrival to the emergency department. After successful conversion, she maintained normal sinus rhythm for the rest of her hospitalization. During her follow-up cardiac catheterization, she was found to have a left-sided accessory pathway, consistent with atrioventricular reciprocating tachycardia. This is a unique and rare case of SVT in the traumatic patient. We review causes of tachycardia in the setting of pediatric multisystem trauma, as well as discuss acute SVT evaluation and management in the pediatric emergency department.

Trends in computed tomography utilization in the pediatric emergency department.

OBJECTIVE: The purpose of this study was to determine the overall trend of computed tomography (CT) utilization in the pediatric emergency department (PED) from 2003 to 2010 and to determine trends categorized by common chief complaints. METHODS: Electronic chart records at 2 tertiary care PEDs within a large pediatric health care system were reviewed from January 2003 through December 2010. The annual CT utilization rate, by anatomic location, was determined. Annual CT utilization rates were compared with alternative imaging trends for visits with chief complaints of head injury, seizure, and abdominal pain. Analysis was performed with linear regression. RESULTS: There was no change in overall CT utilization from 2003 to 2010 (ß 0.25, 95% confidence interval [CI] [-1.61 to 2.73]) or within anatomic subgroups. Head CT utilization for the chief complaints of seizure (ß -0.97, 95% CI [-1.44 to -0.90]) and head injury (ß -0.93, 95% CI [-1.71 to -0.73]) showed significant declines. Although there was no change in the abdominal CT utilization rate for abdominal pain, abdominal ultrasound utilization for abdominal pain significantly increased (ß 0.89, 95% CI [0.25-0.79]). CONCLUSIONS: Our data showed no overall increase in CT utilization through 2010. In areas where alternative non-radiation-based modalities were options, there were decreased CT trends and increased use of potential alternative non-radiation-based modalities. This is the first large PED cohort study to show a decrease in CT utilization in recent years in a regional pediatric referral center and may correlate with increased awareness of radiation risk in children.