Risk factors of pediatric ocular trauma related to ophthalmic complications.

BACKGROUND: Ocular injury is a leading cause of monocular blindness in children. However, data on the association of injury type with ophthalmological complications are lacking. This study aimed to investigate the risk factors of pediatric ocular injuries related to ophthalmological complications. METHODS: This retrospective, observational study was conducted in a pediatric emergency department (ED) in Japan from March 2010 to March 2021. Patients aged less than 16 years presenting with ocular trauma, diagnosed on the basis of the International Classification of Diseases 10: S05, 0-9, were enrolled. Emergency department follow-up visits for the same complaint were excluded. The patients' sex, age, arrival time, injury mechanism, symptoms, examinations, diagnosis, history of urgent ophthalmological consultation, outcomes, and ophthalmological complications were investigated. The primary endpoints were the odds ratio (OR) and 95% confidence interval (CI) of the incidence of ophthalmological complications, defined as any new acute complaint or worsening/persistence of an initial complaint following or resulting from ocular trauma. RESULTS: In total, 469 patients were analyzed. The median age was 7.3 years; the interquartile range (IQR) was 3.1-11.5 years. The most common diagnosis was contusion (79.3%), followed by lamellar laceration (11.7%). Seven patients (1.5%) had ophthalmological complications during follow up. Bivariate analysis demonstrated that daytime ED visit, impact with a sharp object, animal-related injury, visual impairment, decreased visual acuity, and open globe injury were factors significantly associated with ophthalmological complications. CONCLUSION: Daytime ED visit, impact with a sharp object, animal-related injury, visual impairment, decreased visual acuity, and open globe injury were independent factors of ophthalmological complications.

Characteristics of pediatric ocular trauma in a pediatric emergency department in Japan.

INTRODUCTION: Pediatric ocular trauma is a common complaint in pediatric emergency departments (ED) and is a major cause of acquired monocular blindness. However, data on its epidemiology and management in the ED are lacking. The objective of this study was to describe the characteristics and management of pediatric ocular trauma patients who visited a Japanese pediatric emergency department (ED). METHODS: The present, retrospective, observational study was conducted in a pediatric ED in Japan between March 2010 and March 2021. Children younger than 16 years who visited our pediatric ED and received the diagnosis of ocular trauma were included. ED visits for follow-up examinations for the same complaint were excluded. The patients' sex, age, arrival time, mechanism of injury, signs and symptoms, examinations, diagnosis, history of urgent ophthalmological consultation, outcomes, and ophthalmological complications were extracted from electronic medical records. RESULTS: In total, 469 patients were included; of these, 318 (68%) were male, and the median age was 7.3 years. The incident leading to trauma occurred most frequently at home (26%) and most often involved being struck in the eye (34%). In 20% of the cases, the eye was struck by some body part. Tests performed in the ED included visual acuity testing (44%), fluorescein staining (27%), and computed tomography (19%). Thirty-seven (8%) patients underwent a procedure in the ED. Most patients had a closed globe injury (CGI), with only two (0.4%) having an open globe injury (OGI). Eighty-five (18%) patients required an urgent ophthalmological referral, and 12 (3%) required emergency surgery. Ophthalmological complications occurred in only seven patients (2%). CONCLUSION: Most cases of pediatric ocular trauma seen in the pediatric ED were CGI, with only a few cases leading to emergency surgery or ophthalmological complications. Pediatric ocular trauma can be safely managed by pediatric emergency physicians.

Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis.

BACKGROUND: Previous studies have examined the utility of ultrasonography performed by radiologists for diagnosing paediatric testicular torsion. While point-of-care ultrasound (POCUS) is used in paediatric emergency medicine, its diagnostic accuracy is still unknown. OBJECTIVES: The present systematic review and meta-analysis aimed to clarify the accuracy of POCUS in diagnosing testicular torsion in children. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-analysis of Diagnostic Test Accuracy guidelines, a systematic review was performed using the indices of MEDLINE, EMBASE plus EMBASE classics, PubMed and the Cochrane database from inception to November 2020. Any study investigating the diagnostic accuracy of POCUS for paediatric testicular torsion was extracted. The primary outcome was the assessment of the diagnostic accuracy of POCUS for paediatric testicular torsion. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: Four studies enrolling 784 patients in total were included. The pooled sensitivity, specificity, and positive and negative likelihood ratios of POCUS were 98.4% (95% CI: 88.5% to 99.8%), 97.2% (95% CI: 87.2% to 99.4%), 34.7 (95% CI: 7.4 to 164.4) and 0.017 (95% CI: 0.002 to 0.12), respectively. Risk-of-bias assessment using QUADAS-2 revealed that two of the studies had a high risk of bias in patient selection. CONCLUSION: The present systematic review and meta-analysis showed that POCUS had high sensitivity and specificity for identifying testicular torsion in paediatric patients although the risk of bias was high in the studies analysed.

Avulsion Fracture of the Anterior Superior Iliac Spine in a Young Athlete Detected by Point-Of-Care Ultrasound.

Pelvic avulsion fractures (PAFs) are common in adolescents. X-ray is commonly used to diagnose PAF, but the use of point-of-care ultrasound (POCUS) for this purpose in pediatric emergency departments has yet to be published. We reported herein a pediatric case of anterior superior iliac spine (ASIS) avulsion fracture detected by POCUS. A 14-year-old male patient visited our emergency department for groin pain he experienced during a game of baseball. POCUS of the right ilium demonstrated a hyperechoic structure anterolaterally displaced towards the ASIS, suggesting an ASIS avulsion fracture. X-ray of the pelvis confirmed the findings and led to the diagnosis of ASIS avulsion fracture.

Creating Clinical Reasoning Assessment Tools in Different Languages: Adaptation of the Pediatric Emergency Medicine Script Concordance Test to Japanese.

Introduction: Clinical reasoning is a crucial skill in the practice of pediatric emergency medicine and a vital element of the various competencies achieved during the clinical training of resident doctors. Pediatric emergency physicians are often required to stabilize patients and make correct diagnoses with limited clinical information, time and resources. The Pediatric Emergency Medicine Script Concordance Test (PEM-SCT) has been developed specifically for assessing physician's reasoning skills in the context of the uncertainties in pediatric emergency practice. In this study, we developed the Japanese version of the PEM-SCT (Jpem-SCT) and confirmed its validity by collecting relevant evidence. Methods: The Jpem-SCT was developed by translating the PEM-SCT into Japanese using the Translation, Review, Adjudication, Pretest, Documentation team translation model, which follows cross-cultural survey guidelines for proper translation and cross-cultural and linguistic equivalences between the English and Japanese version of the survey. First, 15 experienced pediatricians participated in the pre-test session, serving as a reference panel for modifying the test descriptions, incorporating Japanese context, and establishing the basis for the scoring process. Then, a 1-h test containing 60 questions was administered to 75 trainees from three academic institutions. Following data collection, we calculated the item-total correlations of the scores to optimize selection of the best items in the final version of the Jpem-SCT. The reliability of the finalized Jpem-SCT was calculated using Cronbach's α coefficient for ensuring generalizability of the evidence. We also conducted multiple regression analysis of the test score to collect evidence on validity of the extrapolation. Results: The final version of the test, based on item-total correlation data analysis, contained 45 questions. The participant's specialties were as follows: Transitional interns 12.0%, pediatric residents 56.0%, emergency medicine residents 25.3%, and PEM fellows 6.7%. The mean score of the final version of the Jpem-SCT was 68.6 (SD 9.8). The reliability of the optimized test (Cronbach's α) was 0.70. Multiple regression analysis showed that being a transitional intern was a negative predictor of test scores, indicating that clinical experience relates to performance on the Jpem-SCT. Conclusion: This pediatric emergency medicine Script Concordance Test was reliable and valid for assessing the development of clinical reasoning by trainee doctors during residency training.

Predictor of Early Administration of Antibiotics and a Volume Resuscitation for Young Infants with Septic Shock.

(1) Background: It is critical to administer antibiotics and fluid bolus within 1 h of recognizing sepsis in pediatric patients. This study aimed to identify the predictor of the successful completion of a 1-h sepsis bundle for infants with suspected sepsis. (2) Methods: This is an observational study using a prospective registry including febrile young infants (aged < 90 days) who visited a pediatric emergency department with a core body temperature of 38.0 °C or higher and 36.0 °C or lower. Univariate and logistic regression analyses were conducted to determine the predictor (s) of successful sepsis bundle completion. (3) Results: Of the 323 registered patients, 118 patients with suspected sepsis were analyzed, and 38 patients (32.2%) received a bundle-compliant treatment. Among potential variables, such as age, sex, and vital sign parameters, the logistic regression analysis showed that heart rate (odds ratio: OR 1.02; 95% confidence interval: 1.00-1.04) is a significant predictor of the completion of a 1-h sepsis bundle. (4) Conclusions: We found that tachycardia facilitated the sepsis recognition and promoted the successful completion of a 1-h sepsis bundle for young infants with suspected septic shock and a possible indicator for improving the quality of the team-based sepsis management.

Detection of a Urethral Foreign Body in a Pediatric Patient: Another Useful Application of Point-of-Care Ultrasound.

BACKGROUND: Urethral foreign bodies (UFBs) are rare in pediatric emergency care, but require immediate diagnosis and intervention when they occur. Although radiography, computed tomography, and cystography are available for diagnosing UFBs, these modalities are undesirable because they involve radiation exposure. Point-of-care ultrasound (POCUS) is used as an alternative imaging modality for UFB detection in adult patients, but reports of its use in pediatric emergency departments are still scarce. We report a pediatric case of a UFB detected by POCUS. CASE REPORT: A 10-year-old boy with a history of a learning disorder presented to our pediatric emergency department with a paper clip in his penis, which he had intentionally inserted during play. He denied any symptoms, such as abdominal pain, vomiting, and hematuria. Physical examination failed to reveal the tip of the FB, but showed a palpable mass in the penile urethra accompanied by mild tenderness in the area. POCUS demonstrated a hyperechoic structure with reverberation artifact extending to the bulbar urethra. Endoscopic removal was planned, but the tip of the FB emerged from the external urethral meatus with postural change. Manual removal was successfully performed, after which the hyperechoic structure in the urethra was no longer visible on ultrasonography. The patient was discharged on the same day of the procedure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS is a noninvasive procedure that can be useful for detecting UFBs in children.

Prognosis of ultrasonographic low-grade pediatric appendicitis treated with supportive care.

BACKGROUND: A previous report proposed ultrasonography-based classification as a promising means of predicting pediatric spontaneously resolving appendicitis. The present study investigated the long-term prognosis of supportive care for low-grade appendicitis identified by ultrasonography, defined as an appendix with a smooth submucosal layer irrespective of blood flow or an appendix with an irregular layer and increased blood flow. METHODS: The present, retrospective cohort study enrolled patients under 16 years of age with acute appendicitis at a children's hospital between October 2010 and September 2016. The inclusion criteria were ultrasonography findings showing an appendix with (1) full visualization, (2) a diameter ≥6 mm, (3) a smooth submucosal layer or an irregular layer with increased blood flow, and (4) no appendiceal mass, abscess, or perforation. The exclusion criteria were: (1) a history of acute appendicitis, (2) antibiotic administration within 72 hours before diagnosis, and (3) antibiotic administration or surgery before supportive care. The primary outcome was the event-free duration, defined as a period of supportive care alone with no additional intervention or recurrence of appendicitis. RESULTS: One hundred and eighty-two patients were enrolled. The median Alvarado score was 7 (interquartile range, 6-8), and the median follow-up duration in event-free cases was 1,922 days (interquartile range, 1,347-2,614 days). The event-free rate was 75.0%, 67.0%, and 62.5%, at 1, 2, and 5 years, respectively. CONCLUSION: The long-term, event-free rate exceeded 60% in patients with low-grade appendicitis defined by ultrasonography who received neither surgery nor antibiotic treatment. Most recurrences occurred within 2 years of the initial diagnosis.

Intracranial bruits in meningitis.

Intracranial bruits (ICB) are faint, high-pitched, and mostly heard on the orbit in the systolic phase of the cardiovascular cycle. This report discusses a case of Listeria monocytogenes meningitis in a 17-month-old male patient in whom ICB were auscultated. ICB is thought to be caused by compression of blood vessels due to increased intracranial pressure and may serve as an additional sign supporting the diagnosis of meningitis. The present report contains video data on the ICB.

Ultrasound-guided nasogastric tube placement in a pediatric emergency department.

Nasogastric tube (NGT) insertion is commonly performed in pediatric emergency care. Point-of-care ultrasound is used for confirming NGT insertion, but reports of its use in the pediatric emergency department (ED) are scarce. We describe our experience of ultrasound-guided NGT placement in a pediatric ED. The study pool consisted of twelve patients and the NGT tip was successfully visualized in the esophagus and gastric cardia in all cases, demonstrating that ultrasound has the potential to be a useful alternative to conventional methods of NGT insertion in the pediatric ED.

Semi-automatic intraosseous device (EZ-IO) in a paediatric emergency department.

AIM: Intraosseous access is an alternative to conventional intravenous access. A number of studies have demonstrated the utility and safety of EZ-IO, a recently introduced semi-automatic intraosseous device. However, few studies have investigated the use of EZ-IO in the paediatric emergency setting. The aim of this study was to describe the epidemiological characteristics EZ-IO use including complications among paediatric patients in a paediatric emergency department. METHODS: We conducted a retrospective descriptive study enrolling children younger than 16 years who visited our emergency department between January 2013 and August 2018. Data on age, gender, diagnosis, insertion success rate and complications were collected and analysed. RESULTS: Seventy-two patients were enrolled; of these 38 (52.8%) were male. The median age was 9 months (interquartile range: 3-34.5 months). Of the total, 22 (30.6%) received more than one IO insertion. Ninety-seven consecutive IO insertions were identified. The rate of successful insertions was achieved at 92.7% (90 insertions). There were 21 complications (21.6%), including 17 extravasations (17.5%) of fluid and four dermal abrasions (4.1%). We found no cases of complications that may have compromised patient safety. CONCLUSIONS: The success rate of the EZ-IO insertion was high in paediatric patients. However, we found a higher incidence of dermal abrasions, which might be a complication specific to children.

Pediatric Case of Successful Point-of-Care Ultrasound-Guided Nasogastric Tube Placement.

BACKGROUND: Nasogastric tube (NGT) placement is commonly performed in pediatric emergency care and is classically confirmed by any one of several methods, among which auscultation or aspiration and radiography comprise the currently recognized as the reference standard. Point-of-care ultrasound (POCUS) is used to confirm NGT insertion, especially in adults or prehospital patients, but reports of its use in the pediatric emergency department (ED) are still scarce. We report a case of successful POCUS-guided NGT placement in a pediatric ED. CASE REPORT: A 3-year-old male undergoing remission therapy for acute lymphocytic leukemia presented to our ED with fever and decreased appetite. Tumor lysis syndrome was diagnosed, and endotracheal intubation was required because of the need for emergency hemodialysis for hypercalcemia. Because of difficulty in guiding the tube through the nose, ultrasound-guided placement was attempted. In the transverse view over the neck below the level of the cricoid cartilage, the 10-Fr NGT was visualized under ultrasound guidance as it passed through the esophagus. Subsequently, the entry of the NGT tip into the gastric cardia was confirmed on the subxiphoid longitudinal view. A chest radiograph confirmed the presence of the NGT in the stomach. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the utility of POCUS for NGT placement was reported in adult patients, reports of its use in pediatric cases are still few. POCUS is a real-time, noninvasive, time-saving procedure that can be a useful alternative to radiography for confirming correct NGT placement.

Early Diagnosis of a Pediatric Pancreatic Tumor by Abdominal Physical Examination: A Case Report.

BACKGROUND: Detecting a neoplasm in pediatric patients with acute abdominal pain is difficult, especially when there is no palpable mass. Ihara's maneuver, which allows the physician to apply manual pressure directly on the pancreatic body, is a useful palpation method of diagnosing acute pancreatitis in children. We report a case of solid pseudopapillary neoplasm of the pancreas (SPNP) detected by Ihara's maneuver. CASE REPORT: An otherwise healthy, 15-year-old male visited our emergency department with acute abdominal pain and nausea. His vital signs were appropriate for his age. A physical examination denied peritoneal signs, but Ihara's maneuver induced strong tenderness. His serum amylase and lipase were normal. A contrast-enhanced computed tomography scan revealed a well-defined, 2.2-cm, nonenhanced mass in the pancreatic tail. Laparoscopic distal pancreatectomy was performed, and the diagnosis of SPNP was confirmed. The patient was well postoperatively without any metastasis. SPNP is a rare neoplasm with low malignant potential. Although it typically occurs in young females, it has also been reported in children. The early diagnosis of SPNP is usually challenging because most patients do not have specific symptoms or laboratory findings. In the present case, the SPNP was difficult to detect by palpation because of its size, but Ihara's maneuver induced strong tenderness of the pancreas and led to a diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ihara's maneuver has the potential to enable early diagnosis not only of pancreatitis but also of pancreatic tumors, such as SPNP.

Metered-dose inhaler ipratropium bromide for children with acute asthma exacerbation: A prospective, non-randomized, observational study.

BACKGROUND: Ipratropium bromide (IB), when administered with ß2-agonists, is effective in reducing hospital admissions of children presenting to the emergency department (ED) with severe asthma. While IB is commonly delivered in its nebulized form, using a metered-dose inhaler (MDI), can, reportedly, shorten patients' length of stay in the ED. However, the effectiveness and safety of IB administration using an MDI with a spacer have not been established. This study aimed to investigate the effectiveness and safety of MDI-delivered IB in pediatric patients with acute asthma exacerbation. METHODS: This prospective, non-randomized, observational study included patients aged ≥4 years with a history of severe asthma exacerbation. Patients received IB via MDI with a spacer three times at 20-min intervals. IB use was determined by the physicians' treatment policy. Propensity score matching was used to adjust the confounding factors related to IB administration. RESULTS: Of the 158 patients, 88 were treated with IB and 70 were treated without IB. A propensity score-matching analysis extracted 54 patients from each group. We found no statistical difference in the admission rate of the two groups (IB group: 25.9% vs non-IB group: 31.5%; P = 0.67). The post-treatment modified pulmonary index scores (mean ± SD) were also similar (IB: 6.6 ± 2.0 vs non-IB: 6.3 ± 2.5; P = 0.53). Only one patient (1.0%) treated with IB experienced vomiting, which resolved spontaneously. CONCLUSION: The metered-dose inhaler IB was ineffective in reducing the admission rate possibly because it was less effective than a nebulizer for IB inhalation.