"Parenteral" Diarrhea Associated With Pediatric Urinary Tract Infections: A Retrospective Chart Review.

OBJECTIVES: The association of noninfectious diarrhea with extraintestinal infections such as otitis media, pneumonia, or febrile urinary tract infections (UTIs) is commonly known as parenteral diarrhea. Although this association has been described for over a century and parenteral diarrhea is mentioned in current reference literature, available evidence for this association seems to be limited. The primary research question was to determine if there is an association between UTIs and reports of diarrhea. METHODS: A retrospective chart review was performed using the medical records from October 1, 2017, to March 29, 2019 at our tertiary pediatric medical center. We searched for all cases of afebrile and febrile UTIs evaluated in the pediatric emergency department or admitted directly to the hospital for treatment. All children younger than 5 years were eligible for inclusion. Exclusion criteria included children with recent urological procedures, known urinary tract disease, immune suppression, sepsis, or known gastrointestinal diseases. The medical records of each of the pediatric patients with culture-positive UTIs were reviewed for reports of concurrent diarrhea or diarrhea-like illness. In addition, using a comparative quantitative design, we performed a retrospective chart review of all children younger than 5 years with 1 of 2 noninfectious chief complaints, head trauma, and extremity fractures, presenting during the same period to assess the background rate of reported diarrhea.This research project received the approval of the University of South Alabama's Institutional Review Board. RESULTS: A total of 236 children with a culture-positive UTI presented to our pediatric medical center from October 1, 2017 to March 29, 2019. Reports of diarrhea were documented in the medical record for 44 of the 236 UTIs (18.6%). Escherichia coli was the predominant infectious agent in 32 of the 44 children (72.7%) with culture-positive UTIs and diarrhea. Of the 368 comparison group patients who visited the pediatric emergency department for a noninfectious complaint, diarrhea was reported in 2 patients (0.01%). CONCLUSIONS: Our retrospective review of pediatric patients younger than 5 years with culture-proven UTIs found an association of reported diarrhea. It is our opinion based on our single-center retrospective chart review that the current available evidence suggests an association between UTIs and extraintestinal diarrhea. Future prospective studies are recommended to confirm this association.

The Problematic 2014 American Academy of Pediatrics Bronchiolitis Guidelines.

The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.

Testicular Torsion Pain Honeymoons.

A subset of testicular torsion patients report resolution of their initial severe pain that is followed by variable periods of hours to days of reduced or absent pain. Other patients report only mild pain that is described as gradual in onset. Because of delayed initial presentations or less than timely returns for secondary evaluation, these pain honeymoons may be partially responsible for poor clinical outcomes of the torsed spermatic cords and ischemic testicles.

A Systematic Review of Testicle Survival Time After a Torsion Event.

BACKGROUND: The time window for possible salvage and survival of a torsed testicle is commonly thought to be 6 to 8 hours. However, survival of torsed testicles with or without subsequent atrophy is known to occur outside that critical time window. In this article, we performed a systematic review of the English literature to provide a more accurate understanding of reported time frames of testicle survival after a torsion event. OBJECTIVES: The primary research question was to determine the relationship between time to treatment and the rate of survival for testicles of male patients presenting with testicular torsion (TT). METHODS: A systematic review of the literature was performed and structured according to PRISMA guidelines. An exhaustive library search was performed after search strategies were developed for multiple databases that included PubMed, Cochrane library, Ovid MEDLINE, Web of Science, and ProQuest Theses and Dissertations. Two different searches were developed including "testicular torsion" and TT with the search term "time" added. Articles specifically reporting TT case series, testicle outcomes, and time to surgical or manual treatment were selected for review. In addition to and preceding the systematic review, an exhaustive manual search of the literature was also performed by the authors. As a result of these searches, a total of 30 studies with data considered relevant to the research question were included. The information extracted from the articles was tabulated with regard to time intervals to treatment and survival outcome. RESULTS: The systematic review process and protocol are reported in this article. A total of 30 studies were found that reported case series of TT patients and their outcomes as well as time to treatment reported in useful time frames. From these reports, a total of 2116 TT patients were culled, and their outcomes and time to treatment are reported. Because the time to treatment was reported variously in different case series, the 3 most common formats for reporting time to treatment and outcome were used. When overlap between the tables existed, the data were tallied and reported cumulatively. When reported in 6-hour intervals (1,283 patients), survival at 0 to 6 hours was 97.2%; 7 to 12 hours, 79.3%; 13 to 18 hours, 61.3%; 19 to 24 hours, 42.5%; 25 to 48 hours, 24.4%; and greater than 48 hours, 7.4%. Moreover, we reported cumulative survival data based on reporting for all 3 groups of patients. Testicular salvage in the first 12 hours is 90.4%, from 13 to 24 hours survival is 54.0%, and beyond 24 hours survival is 18.1%. Testicle survival after TT was significant beyond the commonly held 6 to 8 hour time frame and even after more than 24 hours of ischemia. CONCLUSIONS: Survival of the testicle irrespective of subsequent atrophy, decreased spermatogenesis or impaired endocrine function after TT can be much longer than the 6 to 8 hours that is commonly taught. Our systematic review of the literature demonstrates that survival percentages are significant even past 24 hours of torsion. This information should encourage aggressive management of patients presenting with TT pain that has been ongoing for many hours.

Torsion of the testicle: it is time to stop tossing the dice.

In this review, long-held myths and misperceptions about the evaluation and management of testicular torsion are discussed, and recommendations for the management of patients who present with acute scrotal pain are presented.

A case of penetrating neck trauma in a child.

Penetrating injuries to the neck are potentially devastating, and recommendations concerning their evaluation have generated extensive discussion over the years. In this article, we present the case of a 9-year-old girl who narrowly missed a serious vascular injury when she fell on a pencil. We also discuss the most current recommendations concerning management of zone II injuries to the neck of a pediatric patient.

Do pediatric headaches respond to bilateral lower cervical paraspinous bupivacaine injections?

OBJECTIVE: Bilateral lower cervical paraspinous intramuscular bupivacaine injections have recently been reported as a therapeutic modality for headache pain in adult patients presenting to an emergency department. In this study, we accomplished a retrospective review of all pediatric patients with headaches who were treated with this technique in an emergency department setting over a 16-month period. The therapeutic response of all pediatric patients who received bilateral lower cervical paraspinous intramuscular bupivacaine injections for headache pain is described in this article. METHODS: Three separate databases were reviewed to capture all patients younger than 18 years with a diagnosis of headache who received bilateral cervical injections between June 30, 2003, and December 1, 2004, in the Medical College of Georgia and Children's Medical Center emergency departments. Their medical records were retrospectively reviewed to determine their response to this procedure. RESULTS: The headaches of 13 patients younger than 18 years were treated with this procedure. The mean headache severity was 9.15, and the mean duration of headache was 3.16 days. Six (46.2%) of 13 patients had complete relief of their headaches, whereas 5 (38.4%) of 13 patients had partial relief. No significant relief was documented in 2 (15.4%) of 13 patients. A therapeutic response was documented in 11 (84.6%) of 13 of the patients. CONCLUSIONS: These retrospective observations suggest that bilateral lower cervical paraspinous intramuscular injections with small amounts of bupivacaine may have a therapeutic role in the management of headache pain in children, and their rate of therapeutic response may be similar to that recently reported for adult headache patients.

Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 114 patients.

AIMS: To describe 1 year's experience in treating orofacial pain with intramuscular injections of 0.5% bupivacaine bilateral to the spinous processes of the lower cervical vertebrae. METHODS: A retrospective review of 2,517 emergency department patients with discharge diagnoses of a variety of orofacial pain conditions and 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004 was performed. The records of all adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of an orofacial pain condition were extracted from these 2 databases and included in this retrospective review. Pain relief was reported in 2 different ways: (1) patients (n = 114) were placed in 1 of 4 orofacial pain relief categories based on common clinical experience and face validity and (2) pain relief was calculated based on patients' (n = 71) ratings of their pain on a numerical descriptor scale before and after treatment. RESULTS: Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 118 adult patients. Four charts were excluded from review because of missing or inadequate documentation. Pain relief (complete or clinical) occurred in 75 patients (66%), and partial orofacial pain relief in 32 patients (28%). No significant relief was reported in 7 patients (6%). Overall, some therapeutic response was reported in 107 of 114 patients (94%). Orofacial pain relief was rapid, with many patients reporting complete relief within 5 to 15 minutes. CONCLUSION: This is the first report of a large case series of emergency department patients whose orofacial pain conditions were treated with intramuscular injections of bupivacaine in the paraspinous muscles of the lower neck. The findings suggest that lower cervical paraspinous intramuscular injections with bupivacaine may prove to be a new therapeutic option for acute orofacial pain in the emergency department setting.

Effective Educational Videos in Emergency Medicine.

Video is a popular format for teaching and learning online. Emergency medicine (EM) has been a leader in online learning and EM educators may wish to use video to teach. The creation of online video content is fraught with pitfalls that may make videos less effective. We review notable theory and evidence regarding effective use of video for education in EM with international considerations.

Normokalemic Thyrotoxic Periodic Paralysis with Acute Resolution in the Emergency Department.

Thyrotoxic periodic paralysis is a rare cause of acute paralysis in the emergency department (ED). The disorder is generally thought to be due to acute hypokalemia leading to paralysis. Treatment is generally targeted at correcting the thyrotoxic state with careful potassium repletion. We present a rare case of normokalemic, thyrotoxic periodic paralysis with acute resolution while in the ED.

Pediatric laryngoscope blade size selection using facial landmarks.

OBJECTIVES: The study evaluates whether facial landmarks can be used to estimate an appropriate laryngoscope blade length for oral endotracheal intubation in children. We tested the hypothesis that the laryngoscope blade measuring 10 mm or less distal or proximal to the angle of the mandible (when the flat portion of the blade follows the facial contour from the upper incisor teeth to the angle of the mandible) will demonstrate greater success and ease of oral tracheal intubation. METHODS: We performed an observational study that prospectively evaluated a convenience sample of children 8 years old or younger and who were undergoing direct laryngoscopy for oral endotracheal intubation in the operating room, outpatient surgery center, emergency department, or pediatric intensive care unit of a tertiary referral medical center. Ease and success of oral tracheal intubation were compared with distance measurements from the angle of the mandible to the tip of the laryngoscope blade. RESULTS: Blade lengths considered too short (blade lengths >10 mm proximal to the angle of the mandible) were more likely to be associated with more than 1 attempt at intubation. Only 57.1% (12/21; 95% confidence interval [CI], 36.5-75.5) of the intubations using the shorter blade were performed on the first attempt as compared with 89.7% (26/29; 95% CI, 73.6-96.4) of the intubations using the recommended length or 85.7% (6/7; 95% CI, 48.7-97.4) of the intubations using blades extending longer than 10 mm past the angle of the mandible. CONCLUSIONS: The distance from the upper incisor teeth to the angle of the jaw seems to be an excellent clinical landmark for laryngoscope blade length selection for pediatric intubations. When the blade (excluding the handle insertion block) is placed at the upper midline incisor teeth and the tip is located within 1 cm proximal or distal to the angle of the mandible, oral tracheal intubations are more consistently accomplished on the first attempt. Our observations suggest that facial landmarks can be used to estimate an appropriate laryngoscope blade length for oral endotracheal intubation in children.