Reduced Computed Tomography for Appendicitis in Children after Implementation of Next-day Surgery Clinic Follow-up.

The use of computed tomography (CT) in the emergency department (ED) evaluation of pediatric patients for suspected appendicitis can be safely reduced. However, published examples of reduced CT use also report increased MRI utilization, ED length of stay, hospitalization rates, and in-ED surgical consultation. In addition, previous studies recommended follow-up for undifferentiated abdominal pain, yet none with pediatric surgeons. Therefore, we implemented a diagnostic algorithm that includes an option for next-day surgery clinic follow-up in cases where uncertainty remains after appendix ultrasound (US) to reduce CT utilization without increasing hospital-based resources. Methods: We implemented a diagnostic algorithm in January 2014. We retrospectively identified 4,577 patients who underwent an evaluation for suspected appendicitis from January 2012 to September 2015. CT utilization was compared before and after implementation using Statistical Process Control. In addition, we evaluated secondary outcomes, including US utilization, hospital admission, surgery clinic follow-up, ED surgery consultation, ED return visits within 7 days, and ED length of stay. Results: Following the implementation of the algorithm, CT utilization decreased significantly from 13.8% to 6%. Forty-eight patients were evaluated the next day in the optional pediatric surgery clinic for 21 months after implementation. There was no significant change in US utilization, hospital admission, ED surgery consultation, ED return visits within 7 days, or ED length of stay. Conclusion: We achieved decreased CT utilization without an increase in the utilization of other hospital-based resources after implementing a pediatric appendicitis evaluation algorithm that includes the option for next-day pediatric surgery clinic follow-up.

An Unusual Cause for Intermittent Stridor and Dysphagia in an Infant.

Stridor is a common presenting symptom in young children and is produced by turbulent flow through the upper airway or trachea. In children under 12 months of age, stridor is commonly caused by laryngomalacia, tracheomalacia, croup, airway foreign body, and/or retropharyngeal abscess. In atypical presentations of stridor, soft tissue neck radiographs can be helpful to determine the underlying etiology. Occasionally, children will require bronchoscopy to determine the etiology and treatment.

Altered Mental Status at High Altitude.

Intrathecal baclofen pumps are commonly used in pediatric patients with spastic cerebral palsy. Baclofen binds to γ-aminobutyric acid receptors to inhibit both monosynaptic and polysynaptic reflexes at the spinal cord level. The blockade stops the release of excitatory transmitters and thereby decreases muscle contraction. It is commonly used for lower limb spasticity and has been shown to improve postural ability and functional status. The US Food and Drug Administration has approved baclofen for the treatment of spasticity of cerebral or spinal origin in adult and pediatric patients 4 years or older. Various complications of baclofen pumps are described in the literature. Immediately after surgery, problems from infection can arise and range from superficial skin infections to meningitis and bacteremia. Another early complication includes cerebrospinal fluid leak that can be observed by notable swelling beneath the lumbar incision. Additional problems that arise later are usually from the mechanics of the pump and catheter. Pump-related complications include failure, migration, and flipping. Catheter-related complications include disconnection, occlusion, fracture, or kink. Most of these complications typically lead to baclofen withdrawal, although there are a few case reports of overdose due to mechanical causes. Here we describe 2 cases of individuals experiencing complications of excessive baclofen exposure after significant changes in the atmospheric pressure due to travel involving ambient altitude change. These cases reflect the need to discuss this potential complication with families and patients with baclofen pumps before travel to high elevations.