Predictive Variables for Abnormal Comprehensive Metabolic Panel Testing and Potential Cost Savings in Children Receiving Pediatric Emergency Department Care.

OBJECTIVE: The aim of this study was to determine variables predictive of abnormal comprehensive metabolic panel (CMP) results in pediatric emergency department (PED) patients and the potential cost savings of a basic metabolic panel (BMP) versus a CMP. METHODS: This is a retrospective cross-sectional descriptive study of children (<18 y) at an urban academic PED (annual census, 22,000). Clinical data included 12 clinical variables: right upper quadrant pain, overdose, emesis, liver disorder, malignancy, heart disease, bleeding disorder, jaundice, right upper quadrant tenderness, hepatomegaly, ascites/peripheral edema and shock, and the liver function test (LFT) results not in a BMP (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, total protein, and albumin). RESULTS: There were 207 children in the study population. The mean age was 8 years. There were 106 boys (51%).Variables significantly associated with abnormal LFT result were history of liver disease (P = 0.007), history of heart disease (P = 0.040), jaundice (P = 0.045), and hepatomegaly (P = 0.048). The false-negative rate was 16%. However, of the 10 patients for whom this false-negative rate remained true, the LFT values were marginally abnormal, and performance of further investigation of these results was minimal to none. There were 66 patients with no clinical variables and normal CMP results. With a cost difference of $21 between BMP and CMP, this gives a potential savings of $7125 if extrapolated for 1 year in our PED. CONCLUSIONS: Limiting testing to a BMP for patients with none of the 12 clinical variables has the potential annual cost savings of $7125.

Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED.

BACKGROUND: Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes. OBJECTIVES: We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets. METHODS: We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates. RESULTS: There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates. CONCLUSIONS: An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock.

Hyperglycaemic hyperosmolar syndrome in children: Patient characteristics, diagnostic delays and associated complications.

AIMS: The aim of this study was to describe the demographical and clinical characteristics, diagnostic difficulties, and morbidity and mortality in children with hyperglycaemic hyperosmolar syndrome (HHS). METHODS: Retrospective cross-section descriptive study of children (<18 years of age) at an urban, tertiary, academic Children's Hospital diagnosed with HHS from January 2002 to December 2011. RESULTS: Six patients met inclusion criteria for the diagnosis of HHS. Age ranged from 6 to 16 years with 4 (67%) patients younger than 13 years. Four (67%) patients were women and 5 (83%) were African-American. Body mass index (BMI)-for-age percentile was >97% in four (67%) patients. Three (60%) of five patients seen as outpatients were misdiagnosed, two cases were seen twice before an accurate diagnosis of HHS was made. There was one (17%) death. Complications included three patients with acute renal failure, one patient with seizures, and one patient with rhabdomyolysis and compartment syndrome leading to below the knee amputation. Malignant hyperthermia and ventricular arrhythmias occurred in the patient who expired. Three of the five patients who had autoantibody tests had positive results and were diagnosed with type 1 diabetes mellitus. CONCLUSIONS: Characteristics of children with HSS are variable for age, gender and BMI-for-age percentile and not predominately limited to obese male adolescent African-American. Delay in diagnosis is common and morbidity and mortality in paediatric HHS are significant. The subsequent diagnosis of patients presenting with HHS includes type 1 and 2 diabetes mellitus.

Successful flumazenil reversal of paradoxical reaction to midazolam in a child.

BACKGROUND: Greater attention to and management of anxiety and pain in pediatric patients signifies a healthy evolution in the care of children in emergency departments (EDs). Interventions to address such distress may involve unanticipated adverse effects. Midazolam, a benzodiazepine commonly administered to children for anxiolysis, may precipitate paradoxical agitation and delirium, a rare but alarming effect that warrants prompt identification and treatment. CASE REPORT: The case presented is that of a 4-year-old girl who received oral midazolam and developed a paradoxical reaction, which was reversed successfully with flumazenil. This is the first such case report in an ED involving a child. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must stay abreast of the adverse and unintended effects of the treatments provided. The literature on benzodiazepine-induced paradoxical reactions is reviewed, and flumazenil as well as other treatment options and anxiolytic alternatives are presented.

Clinical effectiveness of bougienage for esophageal coins in a pediatric ED.

OBJECTIVE: To describe a tertiary care pediatric emergency department (PED) experience with bougienage for esophageal coins. METHODS: This was a large retrospective case series of children with esophageal coins presenting to a tertiary PED from January 2004 to October 2012. Bougienage eligibility criteria were medically stable, no prior gastro-esophageal surgery or disease, single coin, and witnessed ingestion within 24 hours. Abstracted data were age, signs and symptoms, coin type, management, efficacy, complications, returns, length of stay (LOS), and hospital charges. Main outcomes included procedural success and complications. Secondary outcomes included LOS and hospital charges. RESULTS: There were 245 patients with esophageal coins with 136/145 (94%) successful bougienage procedures and 109/109 (100%) successful surgical retrievals. There were 18 minor complications and 5 return visits for patients with bougienage. There were 10 minor and 2 major complications with surgical retrieval. Patients undergoing bougienage were 4 years (SD 2) vs 3 years (SD 3) for surgical retrieval (P < 0.001). Mean LOS for successful bougienage was 137 minutes (SD 54) vs 769 (SD 535) for surgical retrieval. The difference in the means was 632, 95% CI for the difference in means of -723 to -541 (P < .001). Mean charges for successful bougienage were $984 (SD $576) vs. $7022 (SD $3132) for surgical retrieval. The difference in means was $6038, 95% CI -$6,580 to -$5,496 (P < .001). CONCLUSIONS: Esophageal bougienage is safe and highly effective. It is also more time and cost efficient than other treatment options.

Ultrasound-guided diagnosis of occult mandibular osteomyelitis.

BACKGROUND: Skin and soft-tissue infections (SSTIs) are common disease presentations to the emergency department (ED), with the majority of the infections attributed to community-acquired methicillin-resistant Staphylococcus aureus. Rapid and accurate identification of potentially serious SSTIs is critical. Clinician-performed ultrasonography (CPUS) is increasingly common in the ED, and assists in rapid and accurate identification of a variety of disease processes. CASE REPORT: A 21-year-old female presented to the ED with chin swelling and "boils." Although her visual examination was benign, CPUS of her facial swelling quickly established a more concerning disease process, which was eventually confirmed by aspiration and bone biopsy to be mandibular osteomyelitis. The causative organism, Serratia odorifera, is rarely associated with infections, and we are aware of no previously reported cases of osteomyelitis due to this species. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case of mandibular osteomyelitis, CPUS rapidly and accurately identified abnormal bony cortex of the mandible and an associated fluid collection. CPUS of an otherwise benign presentation of a facial infection led to a maxillofacial computed tomography scan, aspiration and biopsy, and then elective debridement of the bone infection. Emergency physicians should be aware of the utility of CPUS and the need to carefully investigate SSTIs presenting to the ED.

All that wheezes is not asthma: cognitive bias in pediatric emergency medical decision making.

OBJECTIVE: The objectives of this study were to highlight the intimate role that cognitive biases play in clinical decision making in the pediatric emergency department and to recommend strategies to limit their negative impact on patient care outcomes. METHODS: This was a descriptive study of 3 cases of presumed asthma exacerbation evolving into alternate diagnoses. RESULTS: The role cognitive biases played in either delay to diagnosis or missed diagnosis contributing to patient morbidity are illustrated in each case. CONCLUSIONS: Common cognitive biases play a role in the unique milieu of the pediatric emergency department. A case series of presumed patients with asthma illustrates how mental shortcuts (heuristics) taken in times of high decision density and uncertainty may lead to diagnostic errors and patient harm. Suggestions to address and prevent cognitive biases are presented.

A new after-hours clinic model provides cost-saving, faster care compared with a pediatric emergency department.

OBJECTIVE: The objective of this study was to compare the charges and length of stay of demographically and clinically matched nonemergent patients managed in a new After-Hours Clinic (AHC) model versus a pediatric emergency department (PED). METHODS: Retrospective cross-sectional study conducted in a tertiary-care urban academic children's hospital. The AHC was off-site from the children's hospital emergency department. After-Hours Clinic patients were matched with PED patients for age, date and time of presentation, and chief complaint. The 95% confidence intervals for the difference in the means were used to compare the outcome variables of charges and length of stay. RESULTS: Of 471 patients seen at AHC in January 2008, 130 were matched to PED patients for date and time of presentation, age, and chief complaint, giving 260 study patients. There was no significant difference between AHC and PED patients in relationship to date and time of presentation, sex, age, and chief complaint. Comparing the length of stay and charges between AHC and PED patients revealed a significant difference in each. The patient-visit length-of-stay mean time for the AHC was 81.2 minutes less than the mean time for the PED (95.6 vs 176.8 minutes). The patient-visit mean charge for the AHC was $236.20 less than the mean charge for the PED ($226.00 vs $462.20). CONCLUSIONS: Our AHC model showed a significant reduction in length of stay and charges in compared demographically and clinically matched PED patients. This may be an effective model to help address emergency department overcrowding and promote patient safety.

Emergency department poisoning visits in children younger than 6 years: comparing referrals by a regional poison control center to referrals by other sources.

OBJECTIVE: The study purpose was to compare medical appropriateness and costs of regional poison control center (RPCC) versus non-RPCC referrals to children's hospital emergency department (ED) for acute poison exposure. METHODS: This is a retrospective cross-sectional study of children (<6 years) during an 8-month period, who presented for poison exposure. Demographic and clinical patient characteristics were abstracted onto a uniform data form. Medical appropriateness was determined by presence of 1 of 4 criteria by 3 independent reviewers blinded to the patients' race, source of referral, charges, and disposition. RESULTS: Determination of medical appropriateness was matched by all 3 reviewers in 187 patients who make up the study population. There were 92 RPCC-referred cases and 95 non-RPCC-referred controls. Groups were comparable by age, sex, toxin, and symptoms. For RPCC referrals, 84 were self-transported, and 8 were transported by emergency medical services. For non-RPCC referrals, 60 were self-referred/transported, 26 were transported by emergency medical services, and 9 were physician referred. Regional poison control center referrals had a 39.1% higher rate of medical appropriateness than did non-RPCC referrals (odds ratio, 13.0; 95% confidence interval, 3.6-36.1). For this sample, mean charges for inappropriate ED poison exposure visits were $313.42, and the cost per RPCC call was $25, thus giving a potential return on investment of 12.54 to 1 favoring RPCC triage. CONCLUSIONS: When compared with other referral sources, RPCC triage results in fewer unnecessary ED visits in this age group. Increasing prehospital use of poison centers would likely decrease unnecessary ED referrals and related costs.

Cerebral sinovenous thrombosis in children: diagnosis and treatment.

Cerebral sinovenous thrombosis (CSVT) is a pediatric stroke syndrome that occurs uncommonly in association with a number of common pediatric problems, most notably dehydration and infection-otitis media in older children, in particular. Cerebral sinovenous thrombosis involves considerable risk of morbidity and mortality. In the pediatric population, neonates are most commonly affected, but no age group is spared. The clinical manifestations of CSVT vary across age groups and include headache, nausea/vomiting, diplopia, seizures, altered mental status, cranial nerve palsies, and papilledema. Neuroimaging is critical to establishing the diagnosis, and although a variety of modalities are available, the diagnosis is most convincingly made via magnetic resonance imaging with venographic sequencing. Management of CSVT combines medical and surgical approaches and should occur in a multidisciplinary pediatric hospital setting. Anticoagulation is a controversial but generally recommended element of CSVT treatment. Prognosis is related to the extent of vessel and brain parenchymal involvement as well to timeliness of diagnosis and institution of therapy. Long-term follow-up should involve pediatric neurology and ophthalmology and, whenever indicated, rehabilitational therapy as well.

Delayed repeat enema in the management of intussusception.

OBJECTIVE: To describe the demographic and clinical characteristics of children with intussusception and failed initial air enema reduction who were managed by delayed repeat enema attempts and identify predictors associated with successful reduction. METHODS: This is a retrospective cross-sectional study of children diagnosed with intussusception who received care at an urban 110-bed children's hospital. Patients who had failed initial enema reduction attempts under fluoroscopic guidance and had subsequent delayed (≥2 hours from the initial attempt) repeat enemas made up the study population. The primary outcome variable was success of delayed repeat enema reduction. Predictor variables included duration of presenting symptoms (≤1 day vs ≥2 days), gross bloody stools, dehydration, altered mental status, ileus per radiograph, time from initial to delayed repeat enema, and lack of partial reduction to the ileocecal valve with the first attempt. RESULTS: During a 74-month period, 20 patients with 21 intussusception events managed by delayed repeat air enemas were identified. Of the 20 patients, there were 12 boys (60%). Distribution of race was as follows: 9 white (45%), 7 African Americans (35%), and 4 Hispanics (20%). Of the 21 events, the mean (SD) age at the time of intussusception was 14.4 (12.8) months, with a median of 8 months and ranging from 2.5 to 43 months. Of the first 21 attempted delayed repeat enemas, 9 (43%) were successful. Of the 12 unsuccessful attempts, 4 had a second delayed repeat enema attempt and 3 were successful. Overall delayed repeat enemas were successful in 12 patient events (57%). For the total 25 delayed repeat enemas, 12 (48%) were successful.Surgical reduction was performed in 9 patient events (43%). Of these, manual reduction was performed in 7 and surgical incision was performed in 2, with resection of a portion of the distal ileum. There were 19 ileocolic (90%) and 2 ileoileocolic (10%) intussusceptions. There were no pathologic lead points and no patient deaths.In comparing the successful from the failed delayed repeat enema reduction groups, there was no significant difference in demographic characteristics, clinical characteristics, or time from initial enema to first repeat enema. However, there was a trend toward a significant difference regarding the failed group having a greater rate of bloody stools, dehydration, or altered mental status. There was a significant difference for the degree of partial reduction achieved on the initial enema. For the successful delayed repeat enema reduction group, the location of the lead point of the intussusceptum after the initial enema was at the ileocecal valve for 9 patients (90%) versus 3 patients (33%) in the failed group. Although not significantly different, the successful versus failed delayed repeat enema reduction group trended toward significance regarding more patients with clinical improvement after initial enema (82% vs 43%). CONCLUSIONS: With the coordinated care of emergency medicine, surgery, and radiology services, delayed repeat enema seems to be an option to consider in the management of clinically stable children who, on initial air enema, have partial reduction. Our study showed that the success rate of delayed repeat enemas was greatest when the intussusceptum was initially reduced to the ileocecal valve.

Anaphylaxis management in the pediatric emergency department: opportunities for improvement.

PURPOSE: To determine the rate, immediate treatment, and outpatient management for anaphylaxis in patients receiving care in a pediatric emergency department (ED). METHODS: This is a retrospective cross-sectional descriptive study of patients (21 years or younger) who received care for anaphylaxis for a 5-year period in the ED of the Children's Hospital of Alabama in Birmingham, AL, which has an annual census of 55,000. The diagnostic criteria for anaphylaxis were symptoms and/or signs involving 2 or more organ systems (dermatologic, respiratory, gastrointestinal, and cardiovascular), hypotension for age, 1 organ system involvement with admission to the hospital, and/or dermatologic system involvement treated with intramuscular epinephrine. RESULTS: There were 124 patient visits by 103 patients (4.5 events/10,000 ED patient visits) who met the diagnostic criteria for anaphylaxis. This included 114 (92%) patients who had involvement of two or more organ systems. There were 66 (64%) males and 33 (27%) patient visits that resulted in hospitalization. The most common organ system involvement was dermatologic in 121 (98%), followed by respiratory in 101 (81%), gastrointestinal in 33 (27%), and cardiovascular in 11 (9%). Medical interventions include 69 patients treated with intramuscular epinephrine (56%; either in pre-hospital setting and/or during ED visit), 97 patients treated with corticosteroids (79%), 114 patients treated with H1 and/or H2 antihistamine (93%), 15 patients treated with intravenous fluid bolus (12%), and 37 patients treated with albuterol nebulization (30%). Food was the most common inciting allergen (in 45 or 36% of patients). Among the foods that were listed as causing reactions were peanuts, shellfish, milk, ice cream, fruit, nuts, and fried chicken. Compared with ED care-only patients, the hospitalized patients had a significantly greater rate of cardiovascular system involvement and of receiving more ED interventions. Of 91 ED care-only patients, autoinjection epinephrine was prescribed to 63% and referral to an allergist was recommended to 33%. Patients treated with intramuscular epinephrine had a significantly greater rate of hospitalization and of receiving more ED interventions compared with patients who were not treated with epinephrine. There were no patient deaths. CONCLUSIONS: This study is the first to describe the management of anaphylaxis in a pediatric ED. The results revealed opportunities for improvement. Although our ED treatment and outpatient management of patients with anaphylaxis did not meet the recommended standards of care with regard to administration of intramuscular epinephrine, prescribing autoinjection epinephrine, or referral to an allergist for all patients who had a diagnosis of anaphylaxis, we do report a higher concordance with published recommendations than those reported in previous studies performed in adults.

Alignment of cricoid cartilage and esophagus and its potential influence on the effectiveness of Sellick maneuver in children.

OBJECTIVE: The effectiveness of cricoid pressure in preventing aspiration of gastric contents during rapid sequence intubation may be limited if the esophagus is laterally displaced from the trachea at the level of the cricoid cartilage. Esophageal lateral displacement has been reported to occur in 50% to 90% of adults. Children 8 years and older assume the anatomic airway characteristics of adults, and therefore, we hypothesized that esophageal displacement would be significantly more common in older versus younger children. The purposes of this study were to determine the alignment of the trachea to the esophagus at the level of the cricoid cartilage on cervical spine or neck computed tomographic (CT) scans and to compare the frequency and quantity of esophageal displacement between children younger than 8 years and children 8 years and older. METHODS: This is a retrospective cross-sectional study of children (aged 0-17 years) who had cervical spine/neck CT scans performed at a 110-bed urban children's hospital. Two pediatric radiologists blinded to the patients' clinical symptoms and signs and final diagnosis independently determined the alignment of the airway at the level of the cricoid cartilage with the esophagus from cervical spine/neck CT scans. Lateral displacement of the esophagus from the airway was determined by measuring the distance from the ipsilateral outer wall edges of the esophagus and trachea. RESULTS: There were 172 cervical spine/neck CT scans reviewed. Of 87 children younger than 8 years, 27 were excluded, and of 85 children 8 to 17 years, 25 were excluded. The remaining 120 patients were eligible for the study, 60 patients were younger than 8 years and 60 patients were aged 8 to 17 years. For children younger than 8 years, their mean age was 3.58 years. There were 34 (57%) males. The most common indication for CT scan of the cervical spine/neck was motor vehicle crash 26 (46%). For children aged 8 to 17 years, their mean age was 13.3 years. There were 30 (50%) males. The most common indication for CT scan of the cervical spine/neck was motor vehicle crash 34 (57%). Alignment of the airway with the esophagus showed esophageal displacement in 36 (30%) of the patients with displacement in 27 (45%) of the younger children compared with 9 (15%) of the older children. The rate of displacement was significantly greater in the younger children (difference in rates was 30% and 95% confidence interval was 14%-46%). All displacements were to the left. The mean distance of esophageal displacement was significantly greater in the older children (2.42 vs 1.81 mm). The difference in the means was 0.61 mm, and the 95% confidence interval was 1.2 to 0.02 mm. CONCLUSIONS: This is the first pediatric study on the rate and degree of esophageal displacement from the airway at the level of the cricoid cartilage. Lateral displacement of the esophagus occurred at a significantly greater rate in the younger (45%) compared with the older (15%) children, which was directly opposite of our hypothesis. Of the 36 children (30%) with esophageal displacement, all had displacement to the left of the cricoid cartilage.

Central venous access via external jugular vein in children.

OBJECTIVE: To determine the success rate and complications of using the external jugular (EJ) vein for central venous access in pediatric patients. METHODS: Prospective cohort study of children who underwent attempts at EJ vein central venous access while receiving care in an 11-bed pediatric intensive care unit at an urban children's hospital. RESULTS: Over a period of 15 months, 50 patients had EJ venous cannulation attempts. Central venous access was achieved in 45 patients (90%). Successful central venous access was performed in 4 children (50%) younger than 1 year and in 36 older children (98%). Catheter-tip malposition on chest radiograph required subsequent line manipulation in 2 patients. No complications of pneumothorax or carotid artery puncture occurred during line insertion. The catheters were used for an average of 7.5 days (range, 1-28 days). Catheter malfunction occurred in 4 (1.21/100 catheter-days), and catheter-related bloodstream infections occurred in 2 patients (6.04/1000 catheter-days). No thrombotic complications were clinically detected. CONCLUSIONS: The EJ vein is a viable site for central venous access with a low complication rate in pediatric patients.

Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Temporal artery thermometry utilization in pediatric emergency care.

OBJECTIVE: To determine the effectiveness of temporal artery thermometry (TAT) as an alternative for temperature assessment of children 1 to 4 years of age in the pediatric emergency department. METHODS: Prospective cross-sectional study conducted at an urban children's hospital emergency department. TAT and rectal temperatures are compared in a convenience sample of children 1 to 4 years of age. Comparison of the temperatures is performed using Pearson correlation coefficient and regression analysis. RESULTS: TAT and rectal temperatures are measured in 42 children 1 to 4 years of age. TAT predicts 83% of rectal temperatures. A receiver operating characteristic curve analysis shows that a cutoff of 37.7 degrees C or greater for fever in TAT is equivalent to rectal temperature greater than or equal to 38.3 degrees C with 100% sensitivity and 93.5% specificity. CONCLUSION: TAT is an effective screening tool in identifying fever in children 1 to 4 years of age.

Dacryocystitis: Diagnosis and initial management in pediatric emergency medicine.

Complications of dacryocystoceles can be life-threatening in neonates. Dacryocystitis is a common complication of dacryocystoceles. The following case report illustrates the clinical characteristics of dacryocystitis in a 4-day-old infant. The pathophysiology, associated anatomical abnormalities, differential diagnosis, complications, and management of dacryocystoceles are reviewed.

Enema-reduced intussusception management: is hospitalization necessary?

OBJECTIVES: To describe the demographic and clinical characteristics of hospitalized children with enema-reduced intussusception and to determine the necessity of hospitalization. METHODS: Retrospective cross-sectional study of patients (0-17 years of age) with enema-reduced intussusception hospitalized at a 110-bed urban children's hospital. For this study, potential necessity of hospitalization was defined as the presence of associated dehydration, persistent symptoms and signs of intussusception requiring repeated radiographic studies, and/or enema-reduced serious complications (bowel perforation and/or sepsis). RESULTS: For a 12-year period (January 1995 to December 2006), 45 patients who had enema-reduced intussusception were hospitalized. There were 32 males (71%). Three (6.7%) of the 45 patients had recurrent episodes of intussusception occurring at 2, 7, and 45 months after the initial episode. The initial episode for only 1 of these 3 was an enema-reduced hospitalization event. Thus, the following results include 46 episodes among 45 patientsThe mean (SD) age at the time of intussusception was 19.6 (25.4) months, and the median age was 10 months (range, 2-135 months). There were 27 episodes (59%) of patients 12 months or younger. The types of intussusception were ileocolic, 44 and ileoileum, 2. In 13 episodes (28%), patients were described as dehydrated and/or having an abnormal basic metabolic panel test result and meeting one of the study criteria for potential necessity of hospitalization. During the hospitalization, enema was repeated in 1 patient (2%) who had recurrent pain. The repeated enema was normal. No patient had a recurrent intussusception or developed signs of bowel perforation or sepsis while hospitalized. The mean (SD) hospital length of stay was 25.6 (9.9) hours, and the median time was 23 hours (range, 12-60 hours). CONCLUSIONS: Hospitalized children with enema-reduced intussusception required minimal interventions, had a low rate of signs and symptoms requiring further radiographic studies, and had no enema-reduced serious complications during hospitalization. These results support outpatient management as an acceptable alternative.

Rehydration: role for early use of intravenous dextrose.

Acute gastroenteritis is a common reason for children to seek health care. Among the potential complications of acute gastroenteritis, the most common is dehydration. For mild to moderate dehydration, treatment options include oral and intravenous rehydration. Outpatient treatment failure for either method, when it occurs, is often due to persistent nausea and vomiting. Some authorities have suggested that the early administration of dextrose to patients receiving intravenous rehydration may help terminate vomiting and result in fewer outpatient treatment failures. The purpose of this report was to review the evidence supporting the effectiveness of early intravenous dextrose administration in the outpatient management of dehydration in children with acute gastroenteritis.