Evaluation and Management of Elevated BP in Children in the ED.

PURPOSE OF REVIEW: Pediatric hypertension has been on the rise over the past four decades. While most cases are evaluated and managed in the primary healthcare setting, some children may be referred to the emergency department (ED) for an expedited workup of elevated blood pressure or for management of hypertensive crisis. RECENT FINDINGS: Acute severe hypertension without end-organ damage and hypertensive emergency are life-threatening conditions that healthcare providers must be prepared to accurately recognize and treat as pediatric hypertension increases in prevalence. In this article, we review the most recent definitions of elevated blood pressure and hypertension and discuss the updated literature on the evaluation and management of hypertension and hypertensive crisis of children in the ED.

Comparison of anaphylaxis epidemiology between urban and suburban pediatric emergency departments.

BACKGROUND: Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. To date, there are no published data on epidemiology of pediatric anaphylaxis in Michigan. Our objective was to describe and compare the time trends in incidence of anaphylaxis in urban and suburban populations of Metro Detroit. METHODS: We performed a retrospective study of Pediatric Emergency Department (ED) anaphylaxis visits from January 1, 2010, to December 1, 2017. The study was conducted at 1 suburban ED (SED) and 1 urban ED (UED). We identified cases using an International Classification of Diseases (ICD) 9 and 10 query of the electronic medical record. Patients were included if they aged 0-17 years and met the 2006 National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network diagnostic criteria for anaphylaxis. The anaphylaxis rate was calculated as the number of detected cases divided by the total number of pediatric emergency room visits for that month. Anaphylaxis rates were compared between the two EDs using Poisson regression. RESULTS: A total of 8,627 patient encounters had ICD codes for anaphylaxis, of which 703 visits fulfilled the inclusion criteria and were used in subsequent analyses. Overall, the incidence of anaphylaxis was more common in males and in children < 4 years of age in both centers. Although the total number of anaphylaxis related visits was higher at UED over the eight-year time frame for this study, the anaphylaxis rate (cases per 100,000 ED visits) throughout the study was higher at the SED. While the observed anaphylaxis rate at UED was 10.47 - 162.05 cases per 100,000 ED visits, the observed anaphylaxis rate at SED was 0 - 556.24 cases per 100,000 ED visits. CONCLUSION: Pediatric anaphylaxis rates differ significantly between urban and suburban populations in metro Detroit EDs. The rate of anaphylaxis related visits to the ED has significantly increased over the past 8 years in the metro Detroit area, with significantly higher rise in suburban compared to urban ED. More studies are needed to explore the reasons for this observed difference in increase rates.

Saliva microRNA Profile in Children with and without Severe SARS-CoV-2 Infection.

Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) may impair immune modulating host microRNAs, causing severe disease. Our objectives were to determine the salivary miRNA profile in children with SARS-CoV-2 infection at presentation and compare the expression in those with and without severe outcomes. Children <18 years with SARS-CoV-2 infection evaluated at two hospitals between March 2021 and February 2022 were prospectively enrolled. Severe outcomes included respiratory failure, shock or death. Saliva microRNAs were quantified with RNA sequencing. Data on 197 infected children (severe = 45) were analyzed. Of the known human miRNAs, 1606 (60%) were measured and compared across saliva samples. There were 43 miRNAs with ≥2-fold difference between severe and non-severe cases (adjusted p-value < 0.05). The majority (31/43) were downregulated in severe cases. The largest between-group differences involved miR-4495, miR-296-5p, miR-548ao-3p and miR-1273c. These microRNAs displayed enrichment for 32 gene ontology pathways including viral processing and transforming growth factor beta and Fc-gamma receptor signaling. In conclusion, salivary miRNA levels are perturbed in children with severe COVID-19, with the majority of miRNAs being down regulated. Further studies are required to validate and determine the utility of salivary miRNAs as biomarkers of severe COVID-19.

Pediatric Melatonin Ingestions - United States, 2012-2021.

Melatonin is an endogenous neurohormone that regulates the sleep-wake cycle (1). It is used therapeutically for insomnia in adults and for primary sleep disorders in children (2). Melatonin is regulated by the Food and Drug Administration (FDA) as a dietary supplement. Various synthetic melatonin preparations are widely available over the counter (OTC) in the United States with sales increasing from $285 million in 2016 to $821 million in 2020 (3). Children are at increased risk for melatonin exposure because of the supplement's widespread use and growing popularity as a sleep aid. In 2020, melatonin became the most frequently ingested substance among children reported to national poison control centers (4); however, more research is needed to describe the toxicity and outcomes associated with melatonin ingestions in children. This study assessed isolated melatonin ingestions among the pediatric population (defined here as children, adolescents, and young adults aged ≤19 years) during January 1, 2012-December 31, 2021, using the American Association of Poison Control Centers' National Poison Data System (NPDS). During the 10-year study period, 260,435 pediatric melatonin ingestions were reported to NPDS, and the annual number of ingestions increased 530%. In addition, pediatric melatonin ingestions accounted for 4.9% of all pediatric ingestions reported to poison control centers in 2021 compared with 0.6% in 2012. Pediatric hospitalizations and more serious outcomes due to melatonin ingestions increased during the study period, primarily related to an increase in unintentional ingestions among children aged ≤5 years. Five children required mechanical ventilation, and two died. Consumers and health care professionals should be encouraged to report any melatonin product-related adverse events to MedWatch, the FDA's medical product safety reporting program. Public health initiatives should focus on raising awareness of increasing numbers of melatonin ingestions among children and on the development of preventive measures to eliminate this risk.

Association between respiratory rate oxygenation index and need for positive pressure ventilation in children on high flow nasal cannula for bronchiolitis.

Our objective was to evaluate the association of respiratory rate oxygenation index (ROX) with the need for positive pressure ventilation in children < 2 years of age with bronchiolitis on high flow nasal cannula (HFNC) therapy. We performed a single-center prospective observational study of a convenience sample of children < 2 years of age with bronchiolitis who had HFNC initiated in the pediatric emergency department between November and March, 2018-2020. ROX was calculated as pulse oximetry/FiO2/respiratory rate at HFNC initiation. Demographics, need for positive pressure ventilation (PPV), disposition, and hospital length of stay were collected. Logistic regression model was used to determine the odds ratio for PPV need relative to the highest ROX quartile. Of the 373 patients included, 49 (13.1%) required PPV. ROX was lower in patients who required PPV compared with those who did not (5.86 [4.71-7.42] vs. 6.74 [5.46-8.25]; p = 0.01). Logistic regression revealed that those patients whose ROX was in the lowest quartile (< 5.39) were three times more likely to require PPV compared to those in the highest quartile (> 8.21). These results held true after adjusting for confounders (odds ratio 3.1; 95% CI [1.3 to 7.5]; p = 0.02). The model's AUROC (0.701) indicated acceptable discrimination between cases and controls. CONCLUSION: Low ROX index was associated with the need for PPV in children with bronchiolitis on HFNC. The risk stratification provided and ROX threshold for risk stratification require confirmation in other populations with a larger sample size. WHAT IS KNOWN: • Demographic and clinical factors associated with high flow nasal cannula (HFNC) therapy in children with bronchiolitis has been studied. WHAT IS NEW: • This is the first study to  report the utility of association of Respiratory Rate Oxygenation (ROX) index for need for positive pressure ventilation (PPV) in children < 2 years of age with bronchiolitis on HFNC therapy. • ROX was lower in children who required PPV and children whose ROX was in the lowest quartile (< 5.39) were three times more likely to require PPV compared to those in the highest quartile (> 8.21).

Bicycle handlebar injuries - a systematic review of pediatric chest and abdominal injuries.

OBJECTIVE: The severity of handlebar injuries can be overlooked due to subtle signs and wide range of associated internal injuries. Our objective was to describe thoracoabdominal injuries due to bicycle handlebars and their outcomes in children. METHODS: Articles that reported thoracoabdominal injuries were identified from database conception to March 3, 2019 using PubMed, EMBASE, Cochrane Library, CINHAHL Complete, Web of Science and Scopus. A systematic review of studies of thoracoabdominal handlebar injuries in children ≤21 years on human-powered bicycles in English was performed. Information on demographics, clinical features, injuries, interventions and outcomes was noted. RESULTS: A total of 138 articles were identified from 1952 to 2019. There were 1072 children (males, 85.1%) and 1255 thoracoabdominal injuries. Mean age was 9.7 ± 3.3 years old. Common clinical features included abdominal pain and guarding, vomiting, fever and a handlebar imprint. The liver was the most frequently injured organ. Surgery was performed in 338 children with a mean age of 10.0 ± 3.3 years. Twenty-seven children (2.5%) were discharged and returned due to worsening symptoms, of whom 23 (85.2%) required surgery. Thirty-one children (2.9%) transferred to a higher level of care due to injury severity. Two deaths were reported. CONCLUSION: Bicycle handlebars can cause significant thoracoabdominal injuries. Presence of abdominal pain, vomiting, fever or a circular imprint on the chest or abdomen should prompt further workup. Future studies on diagnostic modalities and best practices are needed to lower the chance of missed injuries.

MIS-C among return visits for fever in a pediatric emergency department during the COVID-19 pandemic.

Return visits (RV) to a pediatric emergency department (PED) can be secondary to illness progression, parental concerns, call backs or rarely due to a diagnostic error during the first visit. Fever accounts for nearly half of these RVs and is also one of the most common presenting complaints of Corona Virus Disease 2019 (COVID- 19) due to severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection in children. Although majority of children with COVID 19 have a mild illness, severe complications such as Multisystem inflammatory syndrome in children (MIS-C) can occur. These children are often critically ill with a mortality rate of 2-4%. Initial symptoms of MIS- C are non- specific and mimic other viral illness making early diagnosis challenging. We report five patients who were evaluated for fever and discharged from our PED and were subsequently diagnosed with MIS-C (n = 3) or Kawasaki Disease (n = 2) during their RV within 7 days. All patients presented with fever during the initial visit and three of the five children had gastrointestinal symptoms. They were all noted have persistent tachycardia during the index visit. Three patients presented in cardiogenic shock and echocardiographic abnormalities were noted in four patients during the RV. Significant interventions were required in majority of these children (PICU admission: 4, inotropes: 3, mechanical ventilation:2). Clinicians need to maintain a high index of suspicion for diagnosis of MIS-C especially in those who present with persistent fever and have abnormal vital signs during the COVID-19 pandemic.

Emergency Department Utilization and Serious Bacterial Infection Rates in Children With Renal Transplants.

OBJECTIVES: Emergency department (ED) visits by children with solid organ transplants have increased significantly. Our objectives were to describe the common complaints, diagnosis, types, and rates of serious bacterial infection (SBI) in children with renal transplant (RT) who present to the hospital. METHODS: We conducted a retrospective study from 2012 to 2016 of RT children up to 18 years who presented to the ED or were directly admitted. We excluded patients who presented for a procedure. We collected demographics, transplant type, immunosuppressive data, chief complaints, diagnostic testing with results, interventions performed, and final diagnosis. RESULTS: We analyzed 131 visits in 29 patients during the study period. Most common chief complaints were infectious (34.4%) and gastrointestinal (26%). Infection was proven in 42.0% of visits with only 3.1% being organ rejection. Serious bacterial infection was diagnosed in 34 visits (26.0%) with urinary tract infection (UTI) being the most common (20.6%). Of the 33 visits for fever, SBI occurred in 16 (48.5%) patients with the most common SBI being UTI 10 (30.3%). Bacteremia occurred in 1 patient and hypotension in 4 patients. Antibiotic administration was the most common intervention performed (78; 59.5%). Significant interventions were uncommon (2 patients). Logistic regression revealed no factors to be associated with SBI. CONCLUSIONS: Our cohort of children with RT presented most commonly with infections to the hospital with UTI being the most common SBI. Bacteremia and significant interventions were rare. Future studies are needed to identify subgroups of low-risk pediatric RT patients who can possibly be safely discharged home from the ED.

SARS-CoV-2-associated multisystem inflammatory syndrome in children: clinical manifestations and the role of infliximab treatment.

This study was conducted to assess the clinical spectrum, management, and outcome of SARS-CoV-2-related multisystem inflammatory syndrome in children (MIS-C). We reviewed medical records of children with MIS-C diagnosis seen at the Children's Hospital of Michigan in Detroit between April and June 2020. Thirty-three children were identified including 22 who required critical care (group 1) and 11 with less intense inflammation (group 2). Children in group 1 were older (median 7.0 years) than those in group 2 (median 2.0 years). Abdominal pain was present in 68% of patients in group 1. Hypotension or shock was present in 17/22 patients in group 1. Thirteen (39.4%) had Kawasaki disease (KD)-like manifestations. Five developed coronary artery dilatation; All resolved on follow-up. Intravenous immunoglobulin (IVIG) was given to all patients in group 1 and 7/11 in group 2. Second-line therapy was needed in 13/22 (group 1) for persisting inflammation or myocardial dysfunction; 12 received infliximab. All patients recovered.Conclusion: MIS-C clinical manifestations may overlap with KD; however, MIS-C is likely a distinct inflammatory process characterized by reversible myocardial dysfunction and rarely coronary artery dilatation. Supportive care, IVIG, and second-line therapy with infliximab were associated with a favorable outcome. What is Known: • Multisystem inflammatory syndrome in children (MIS-C) manifestations include fever, gastrointestinal symptoms, shock, and occasional features of Kawasaki disease (KD). • Treatment includes immunomodulatory agents, most commonly IVIG and corticosteroids. What is New: • Spectrum of MIS-C varies from mild to severe inflammation and coronary artery dilatation occurred in 5/22 (23%) critically ill patients. • IVIG and infliximab therapy were associated with a favorable outcome including resolution of coronary dilatation; only 2/33 received corticosteroids.

Thrombosis of external iliac and common femoral arteries secondary to blunt trauma due to handlebar injury.

BACKGROUND: Vascular injuries are uncommon following a bicycle handlebar injury in children. However, they are associated with an extremely high morbidity including limb loss and asymmetric limb growth. CASE PRESENTATION: 11 year old previously healthy female who presented to a pediatric emergency department immediately after sustaining blunt trauma to her abdomen by a bicycle handlebar. She complained of pain in her right lower extremity without paresthesia and was noted to have a painful superficial laceration to the right lower abdomen with tenderness on palpation. The extremity was noted to be mottled, cool to touch, with decreased sensations and delayed capillary refill but intact motor function. The peripheral pulses in the extremity were noted to be absent on exam, which was confirmed by a bedside Doppler. A Computed Tomography Angiography (CTA) of the abdomen and pelvis revealed an occluding thrombus in the external iliac and right common femoral arteries which required surgical repair. She subsequently developed occlusion secondary to traumatic dissection and compartment syndrome in the same extremity requiring repeat surgical intervention. CONCLUSION: In managing patients with blunt force trauma to the abdomen from handlebars, clinicians should have a high index of suspicion for vascular injuries even with low-risk mechanism of injury and superficial injuries noted on exam. Their assessment should include immediate examination of bilateral peripheral pulses of the lower extremities to evaluate for clinical findings associated with acute lower limb ischemia as well as bedside Doppler exams and early consideration of CTA to assess for occult vascular injury.

Pediatric minor head injury related return visits to the emergency department and their outcome.

BACKGROUND: Minor head injury (MHI) in children is a common emergency department (ED) presentation. It is well established that majority of these patients don't require imaging and can be safely discharged. What is less known is how often these children come back to the ED and the outcome of their revisits? The objective of this study was to describe the frequency and outcome of unscheduled return visits (RVs) for MHI in a pediatric ED. METHODS: A retrospective chart review of emergency department RV's database was conducted from August 2016 to July 2019. MHI patients <18 years of age who came back to the ED within 72 h of their index visit - for head injury related complaints - were eligible for inclusion. RESULTS: Return visit rate for MHI was around 1% (61/6225). Of these, 55.7% (34/61) were female and 85.5% (53/61) were in the age group 2-17 years. Three-fourths of the revisits were for concussion-related symptoms. Nearly two-thirds of the patients required one or more interventions upon revisit. Missed clinically important traumatic brain injury was rare. Only one patient required operative intervention upon revisit. Though largely unpreventable, 5% (3/61) of the revisits were deemed potentially avoidable. CONCLUSION(S): RVs secondary to MHI in children remain low and are associated with good outcomes.

Multisystem inflammatory syndrome in children associated with novel coronavirus SARS-CoV-2: Presentations to a pediatric emergency department in Michigan.

The SARS-CoV-2 is a respiratory virus of the coronavirus family responsible for a global pandemic since December 2019. More than 35 million people have been affected with the novel coronavirus disease (COVID-19), with more than one million deaths worldwide. Michigan was one of the top three states in the United States that was severely affected by the SAR-CoV-2 pandemic with more than 7000 deaths in adults and greater than 145,000 confirmed infections. However, compared to adults, the majority of children until recently were either asymptomatic or had a mild illness with SARS-CoV-2. Recently, a rare but potentially serious presentation associated with SARS-CoV-2 called multisystem inflammatory syndrome in children (MIS-C) has been recently reported and the Centers for Disease Control (CDC) released a case definition for the same. We report the clinical and laboratory presentations and outcomes of 34 children with MIS-C who were evaluated within a 12 week period at a pediatric emergency department (PED) of single institution in Michigan. These cases presented approximately three weeks after the peak of adult SAR-CoV-2 related deaths occurred in the state. While many children presented with clinical characteristics similar to incomplete Kawasaki disease (KD), they also exhibited certain unique features which differentiated MIS-C from KD. The information presented below will aid clinicians with early recognition, evaluation and management of MIS-C in the emergency department.

Antipsychiatric Medication Errors in Children Boarded in a Pediatric Emergency Department.

OBJECTIVES: Mental health visits to the pediatric emergency department (PED) have increased significantly. Our objective was to describe medication errors in children with mental health illness who were boarded in a PED for more than 6 hours. METHODS: We conducted a retrospective study from 2014 to 2015 of children 6 to 18 years with psychiatric complaints and a length of stay of more than 6 hours. Admitted patients and those not on home medications were excluded. We collected demographics, number, types, and doses of antipsychiatric medications and errors. RESULTS: A total of 676 patients (53.1% males) with a median age of 14 (interquartile range, 12, 15) years were included. The median length of stay was 11.7 (interquartile range, 8.5, 20.5) hours. A total of 974 medication errors occurred in 491 (72.7%) patients. Omission errors were noted in 376 patients (76.6%), commission in 44 patients (9.0%), and both in 71 patients (14.4%). Among commission errors, 8 (18.1%) were serious and 8 (18.1%) were significant. One third of patients (30.5%) had 1 medication error, 23.9% had 2, 11.7% had 3, and 5% had 4.Medication errors were most commonly noted in antidepressant and antipsychotic classes. One third (35.8%) of errors involved 2 medication classes. Being on 3 (odds ratio, 1.8; 95% confidence interval, 1.09-2.9) or 4 or more (odds ratio, 2.81; 95% confidence interval, 1.54-5.34) antipsychiatric medications was significantly associated with a prescription error. CONCLUSION: There is a high incidence of medication errors, particularly those of omission, among antipsychiatric prescriptions in children boarded in the PED. A refinement of current medication reconciliation and integration of psychiatric medication databases between the PED and pharmacies are urgently needed to reduce these errors.

Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department.

BACKGROUND: Practice variation exists in pain management of children with long bone fractures (LBFs). OBJECTIVE: The objectives of this study were to describe current pain management in children with LBFs and the factors associated with the undertreatment of pain. METHODS: We retrospectively studied children (aged 0-18 years) with a diagnosis of LBF in a pediatric emergency department (PED) from November 2015 through August 2016. Demographic characteristics and quality measures were noted. We determined the impact of PED crowding using the National Emergency Department Overcrowding Scale. RESULTS: A total of 905 patients (63% male, 48% African American) were enrolled. Median age was 6 years (interquartile range [IQR] 7 years), 72% had upper extremity injuries, falls were the most common mechanism (74%), and the majority were discharged (77%). Median time to pain score was 6 min (IQR 14 min). Seventy-two percent received analgesia with a median time to order of 63 min and medication receipt of 87 min. Ibuprofen was the analgesia prescribed most commonly. There were no identified factors associated with oligoanalgesia. Nonuse of narcotics was associated with African-American race, public insurance, single fractures, and arrival via private vehicle. Ambulance arrivals, lower extremity fractures, and disaster mode were associated with receiving analgesia within 60 min. CONCLUSIONS: In our study, 28% of children with LBFs did not receive pain medications, especially during normal PED volumes. Additional studies are required to explore triage as a venue for analgesia delivery for LBFs.

Parental Knowledge of Appropriate Placement of Child Restraint Systems Before and After Educational Intervention in a Pediatric Emergency Department.

OBJECTIVE: This study aimed to determine caregiver's knowledge of appropriate car restraint systems (CRSs) use and compare this with the actual use among children presenting to the pediatric emergency department (PED), and to determine the efficacy of PED-based intervention on improving knowledge. METHODS: We conducted a prospective, intervention study of children (<8 years old) during a 12-month period in the PED. Based on their height and weight, children were assigned to group 1 (rear facing), group 2 (forward facing), or group 3 (booster). Caregivers were surveyed in their baseline CRS knowledge. Certified child passenger safety technicians evaluated each CRS and gave caregivers one-on-one education. Participants were called back to answer a posttest to determine if the information given was retained. RESULTS: Of the 170 children enrolled, 64 (37.6%) were assigned to group 1, 68 (40%) to group 2, and 38 (22.3%) to group 3. Of these, 63% were not aware of the state law regarding CRS use. Among those without a CRS, 18% belonged to group 1, 36% to group 2, and 46% to group 3. Even among those who reportedly had CRS, 13% of children did not have one-on-on inspection. After inspection, 84% of group 1, 71% of group 2, and 70% of group 3 were in the appropriate one. Nearly 45% were not compliant with American Academy of Pediatrics guidelines of children riding in rear-facing CRS until 2 years of age. CONCLUSIONS: A significant proportion of children visiting the PED are not in appropriate CRS, and caretaker knowledge about correct CRS types and installation is poor. Future educational efforts should focus on rear-facing and booster seat age-group children.

Procedural sedation in children with autism spectrum disorders in the emergency department.

BACKGROUND AND OBJECTIVES: Children with autism spectrum disorder (ASD) present more frequently to the emergency department (ED) than children with normal development, and frequently have injuries requiring procedural sedation. Our objective was to describe sedation practice and outcomes in children with ASD in the ED. METHODS: We performed a retrospective chart review of children with ASD who underwent sedation at two tertiary care EDs between January 2009-December 2016. Data were collected on children 1-18 years of age with ASD who were sedated in the ED. RESULTS: There were 6020 ED visits by children with ASD, 126 (2.1%) of whom received sedation. The most frequent indications for sedation were laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%), and physical examination (11.9%). The most common sedatives used were ketamine (50.8%) and midazolam (50.8%). Ketamine was most commonly given intravenously (71.9%), while midazolam was usually given intranasally (71.9%). Procedures could not be completed in 4 (3.2%) patients, and adverse events were noted in 23 (18.3%) patients. Only four (3.2%) patients required supplemental oxygenation, and one received positive pressure ventilation. CONCLUSIONS: Children with autism in the ED commonly received sedation; one in four of which were for non-painful diagnostic procedures or physical examination. Over one-third received sedation via a non-parenteral route for intended minimal sedation. Sedative medication dosing and observed adverse events were similar to those reported previously in children without ASD. Emergency providers must be prepared to meet the unique sedation needs of children with ASD.

Distributive Shock in a Neonate with Diffuse Infantile Hepatic Hemangioma.

BACKGROUND: Hemangiomas are common cutaneous findings on healthy infants. These vascular malformations are generally benign, though in rare circumstances they can potentially be fatal. This is particularly true when the hemangiomas are large or numerous and occurring in visceral organs. Previously unrecognized visceral hemangiomas are part of the differential for any neonate presenting unexpectedly in shock. CASE REPORT: A 10-day-old neonate presented to the pediatric emergency department with difficulty breathing. On examination, he appeared to be in respiratory distress and in shock. Echocardiography showed cardiomegaly, and an abdominal ultrasound showed a massive and heterogeneous liver. Magnetic resonance imagine performed after stabilization in the pediatric intensive care unit verified the presence of diffuse infantile hepatic hemangiomas. This case demonstrates how numerous visceral hemangiomas can generate high-volume vascular steal, distributive shock, and cardiac failure. Our patient was subsequently noted to have bruits over his liver. WHY AN EMERGENCY PHYSICIAN SHOULD BE AWARE OF THIS?: Diffuse hemangiomas and arteriovenous malformations are rare causes of extrinsic cardiogenic shock in the neonate. Targeted palpation of an enlarged liver or auscultation of a right upper quadrant bruit can raise suspicion of this diagnosis.

Ischemic Stroke of the Spinal Cord: A Pediatric Emergency in an Otherwise Healthy Child.

BACKGROUND: Spinal cord infarctions in children are rare, with few cases reported in the literature. Recognition is challenging, as children's clinical presentations and underlying pathological processes differ from those of adults. Most reported cases are in children with predisposing medical conditions, but spinal cord strokes can occur in otherwise healthy individuals. CASE REPORT: A 10-year-old boy with no significant medical history presented with progressive left-sided weakness and neck pain. He was diagnosed with ischemic infarction of his inferior medulla and cervical spinal cord. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ischemic stroke of the spinal cord should be considered in children with clinical weakness, even in the absence of risk factors.