MRI usage in a pediatric emergency department: an analysis of usage and usage trends over 5 years.

BACKGROUND: Magnetic resonance imaging (MRI) usage has anecdotally increased due to the principles of ALARA and the desire to Image Gently. Aside from a single abstract in the emergency medicine literature, pediatric emergency department MRI usage has not been described. OBJECIVE: Our objective was to determine whether MRI use is indeed increasing at a high-volume urban pediatric emergency department with 24/7 MRI availability. Also, we sought to determine which exams, time periods and demographics influenced the trend. MATERIALS AND METHODS: Institutional Review Board exemption was obtained. Emergency department patient visit and exam data were obtained from the hospital database for the 2011-2015 time period. MRI usage data were normalized using emergency department patient visit data to determine usage rates. The z-test was used to compare MRI use by gender. The chi-square test was used to test for trends in MRI usage during the study period and in patient age. MRI usage for each hour and each weekday were tabulated to determine peak and trough usage times. RESULTS: MRI usage rate per emergency department patient visit was 0.36%. Headache, pain and rule-out appendicitis were the most common indications for neuroradiology, musculoskeletal and trunk exams, respectively. Usage in female patients was significantly greater than in males (0.42% vs. 0.29%, respectively, P<0.001). Usage significantly increased during the 5-year period (P<0.001). Use significantly increased from age 3 to 17 (0.011% to 1.1%, respectively, P<0.001). Sixty percent of exams were performed after-hours, the highest volume during the 10 p.m. hour and lowest between 4 a.m. and 9 a.m. MRI use was highest on Thursdays and lowest on Sundays (MRI on 0.45% and 0.22% of patients, respectively). CONCLUSION: MRI use in children increased during the study period, most notably in females, on weekdays and after-hours.

Rickettsialpox in a Pediatric Patient.

Rickettsialpox is a rare vector-borne rickettsiosis that manifests in hosts living in urban populations, particularly in New York City. The following is a case discussion of a 12-year-old girl with history of fever and right-ankle swelling. She was initially evaluated and treated for cellulitis. She later developed a maculopapular rash completing the classic triad for rickettsialpox: black eschar, papular rash, and fever. Her convalescent rickettsial titers returned positive, confirming the diagnosis of rickettsialpox.

Acute Salpingitis in a Nonsexually Active Adolescent.

Acute salpingitis is an uncommon cause of an acute surgical abdomen, especially in an adolescent who is not sexually active. The following is a case of a 12-year-old girl who denied sexual activity, had a remote history of an appendectomy, and a recent diagnosis of a large, right-sided ovarian cyst, who presented with acute abdominal pain, urinary symptoms, and fever. The patient was ill-appearing and progressed to uncompensated septic shock in the emergency department despite aggressive fluid resuscitation and empiric antibiotics. She ultimately underwent an exploratory laparotomy and was diagnosed with acute bilateral salpingitis. This case highlights the diagnostic dilemmas facing those caring for an adolescent girl with abdominal pain and presents an extremely rare etiology for abdominal pain in a nonsexually active adolescent.

The heart of the matter: an atypical presentation of Takayasu arteritis in the Pediatric Emergency Department.

Takayasu arteritis (TA) is a rare chronic large-vessel vasculitis of unknown etiology. Although commonly thought of as an adult disease, initial manifestations frequently appear during adolescence. This is a case discussion of an 11-year-old boy with a recent history of fever who presented with shortness of breath, sore throat, chest pain, hypertension, and a new murmur. He had a markedly elevated antistreptolysin O titer, had a prolonged PR interval, and was initially evaluated with acute rheumatic fever. After admission, he had persistent hypertension, proteinuria, and hemoptysis, which prompted a magnetic resonance angiography that revealed aortic enhancement and thickening, and he was evaluated with TA. To our knowledge, this is the first case report in the pediatric literature of TA presenting with heart block. This case highlights the recondite nature of the systemic vasculitides and emphasizes the importance of keeping a broad differential diagnosis when seeing patients who present with common complaints.

Nebulized ketamine for managing acute pain in the pediatric emergency department: A case series.

Administration of sub-dissociative doses of ketamine is used via intranasal (IN) and intravenous routes in the pediatric emergency department for managing acute pain. Due to difficulties in both obtaining intravenous access and compliance with IN medications in children, administration of ketamine via breath-actuated nebulizer can serve as a valuable modality for timely analgesia in children where dosing titration is patient controlled. We describe five pediatric patients who received ketamine via breath-actuated nebulizer at 0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg, with all patients experiencing a decrease in pain score. This case series introduces ketamine inhalation as a modality for managing pain in children.

Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry are they?

A prospective consecutive case series of patients aged 5 to 20 years who presented to a pediatric emergency department with diabetic ketoacidosis (DKA) was studied to determine the actual percent loss of body weight during an episode of DKA to determine the degree of dehydration and thereby provide a guide for hydration therapy during such an episode. Patients' weights at the time of presentation, inpatient discharge, and at the first follow-up clinic visit were used to calculate the percent loss of body weight. Data from 33 episodes of DKA showed that the majority of patients with DKA had moderate (4% to 8%) dehydration. Clinical assessment was a poor predictor of severity of dehydration and overestimated the percent dehydration in 67% of patients. Based on these data it is recommend that initial fluid therapy for DKA should assume moderate dehydration with adjustment made according to clinical response.