Trends in CT Request and Related Outcomes in a Pediatric Emergency Department.

OBJECTIVES: To study and to establish the overall trends of computed tomography (CT) use and associated outcomes in the pediatric emergency department (PED) at Royal Hospital, Oman, from 2010 to 2014. METHODS: The hospital electronic medical record was retrospectively searched to find children (from birth to 12 years old) who had visited the PED and the number of CT requests between 1 January 2010 and 31 December 2014. The types of CT examinations ordered were analyzed according to anatomical location and were as follows; head, abdomen/pelvis, chest, cervical spine/neck, and others. RESULTS: There were a total of 67 244 PED visits during the study period, 569 of which received 642 CT scans. There was a remarkable rise in CT uses per 1000 visits from 7 in 2010 to 12 in 2014. There was a 56% hike in CT requests from 87 in 2010 to 175 in 2014 while the number of pediatric emergency visits rose by about 28% from 11 721 to 15 052. Although head CT scans were the most common, cervical spine CT scans had the highest rate of increase (600%) followed by the chest (112%), head (54%) and abdomen (13%). There were no significant changes in other CT scan requests. The cost of CT scans increased from $18 096 to $36 400 during the study period, which increased the average PED cost by about $2 per visit. The average time between a CT being requested and then performed was 1.24 hours. CONCLUSIONS: CT use in the pediatric emergency department has risen significantly at a rate that markedly exceeds the growth of emergency visits. This is associated with an increase in PED costs and longer waiting times.

Resuscitation volume in paediatric non-haemorrhagic blunt trauma.

INTRODUCTION: Trauma is a major cause of paediatric morbidity and mortality, yet knowledge of fluid resuscitation is limited. Our objectives were to determine current practises in resuscitation volume (RV) administered to paediatric non-haemorrhagic (NH) blunt trauma patients and to identify fluid related complications. METHODS: We examined data from 139 trauma patients 1-17 years of age with an injury severity score ≥ 12 resuscitated at a Trauma-designated Children's Hospital. Patients were separated into discreet groups based on ATLS age-dependent vital functions: toddler/preschooler (1-5 years), school age (6-12 years) and adolescent (13-17 years). RESULTS: The median RV (total fluid intake-maintenance fluid intake) in ml/kg over the first 24h from the time of trauma by age was: 24 (IQR=19-47; 1-5 years); 26 (IQR=15-36; 6-12 years); and 22 (IQR=14-42; 13-17 years). The differences in RV/kg/24h following NH trauma was not significantly different between age groups (p=0.41). Urine output over the 24h ranged from 2.5 (IQR=1.9-3.3; lower age group) to 1.8 (IQR=1.2-2.4; upper age group) ml/kg/h; greater than the ATLS recommended age-dependent targets. Haematocrit was the only significant independent predictor of RV/kg/24h (p<0.001). Fluid-related complications attributable to RV were identified in 12% (n=17/139) of patients, and included ascites (8%; n=11/139) and/or pleural effusion(s) (9%; n=13/139). Patients with fluid-related complications received significantly more RV in ml/kg/24h (42, IQR=27-76) than those without complications (22, IQR=14-36; p=0.001). CONCLUSIONS: The range of median RV administered to paediatric NH blunt trauma patients with ISS ≥ 12 was 22-26 ml/kg/24h. The RV administered was excessive based on high urine outputs and the presence of fluid-related complications. Further evaluation of RV triggers and endpoints used by paediatric traumatologists is required.

Periurethral cleaning prior to urinary catheterization in children: sterile water versus 10% povidone-iodine.

OBJECTIVE: To compare urinary infection rate in children cleaned with sterile water versus a 10% povidone-iodine before bladder catheterization. METHODS: Prospective randomized controlled study of children requiring bladder catheterization in the emergency department whose parents consented to the study were randomly assigned to either of 2 groups, in which sterile water (the "sterile water" group) or 10% povidone-iodine (the "10% povidone-iodine" group) was to be used for peri-urethral cleansing prior to catheterization. RESULTS: The sterile water group had 92 patients and the povidone-iodine group had 94. Most children (87%) were under 12 months of age. Urine cultures were positive in 16% of children in the povidone-iodine group and in 18% in the water group. There was no significant difference in signs and symptoms between the 2 groups. There was no significant association between solution preparation and cultures on univariate regression analysis. CONCLUSIONS: Cleaning the periurethral area of children with sterile water prior to catheterization is not inferior to cleaning with povidone-iodine.

Test characteristics of neuroimaging in the emergency department evaluation of children for cerebrospinal fluid shunt malfunction.

OBJECTIVE: Cerebrospinal fluid (CSF) shunt malfunction is one of the most common life-threatening neurosurgical conditions. In the emergency department (ED), imaging techniques to identify shunt malfunction include the shunt series (SS) and CT scanning of the head. We sought to determine the test characteristics of the SS and CT scan for identifying children with shunt malfunction. METHODS: We retrospectively reviewed the medical records of children with a CSF shunt who presented to our tertiary care pediatric emergency department and received an SS during a 2-year period from Jan. 1, 2001, to Dec. 31, 2002. A pediatric neuroradiologist reviewed all SS and CT scans. We defined shunt malfunction as present if the child underwent operative shunt revision. RESULTS: We identified 437 ED visits by 280 children. Forty-seven SS were read as abnormal. A CT scan was performed in 386 (88.3%) cases and 80 were abnormal. Shunt malfunction was identified in 131 (30.0%) children. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of the SS for identifying cases of shunt malfunction were 30.0%, 95.8%, 72.3%, 75.1%, 7.1 and 0.7, respectively; for the CT scan, they were 61.0%, 82.7%, 64.5%, 80.5%, 3.5 and 0.5, respectively. CONCLUSION: Neuroimaging has a low sensitivity for identifying shunt malfunction. Neurosurgical consultation should be sought if shunt malfunction is clinically suspected, despite normal imaging.