Predictors for Acute Appendicitis in Children.

BACKGROUND: Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children. OBJECTIVE: The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US. METHODS: A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology. RESULTS: There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/µL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/µL, and appendix diameter of 7 mm or less had a negative predictive value of 100%. CONCLUSIONS: When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/µL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.

Adverse events and satisfaction with use of intranasal midazolam for emergency department procedures in children.

PURPOSE: Procedural sedation is commonly performed in the emergency department (ED). Having safe and fast means of providing sedation and anxiolysis to children is important for the child's tolerance of the procedure, parent satisfaction and efficient patient flow in the ED. OBJECTIVE: To evaluate fasting times associated with the administration of intranasal midazolam (INM) and associated complications. Secondary objectives included assessing provider and caregiver satisfaction scores. METHODS: A prospective observational study was conducted in children presenting to an urban pediatric emergency department who received INM for anxiolysis for a procedure or imaging. Data collected included last solid and liquid intake, procedure performed, sedation depth, adverse events and parent and provider satisfaction. RESULTS: 112 patients were enrolled. The mean age was 3.8 years. There were no adverse events experienced by any patients. Laceration repair was the most common reason for INM use. The median depth of sedation was 2.0 (cooperative/tranquil). The median liquid NPO time was 172.5 min and the median NPO time for solids was 194.0 min. 29.8% were NPO for liquids ≤2 h and 62.5% were NPO for solids ≤2 h. Parent and provider satisfaction was high: 90.4% of parents' and 88.4% of providers' satisfaction scores were a 4 or 5 on a 5 point Likert scale. CONCLUSION: Our data suggest that short NPO of both solids and liquids are safe for the use of INM. Additionally, parent and provider satisfaction scores were high with the use of INM.

Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix.

Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.

Imaging for Suspected Appendicitis: Variation Between Academic and Private Practice Models.

BACKGROUND: Little is known regarding the effect of different emergency department (ED) practice models on computed tomography (CT) and ultrasound (US) utilization for suspected appendicitis in the ED and through the potential inpatient hospital stay. OBJECTIVES: Examination rates of CT and US for suspected appendicitis at 2 different pediatric EDs (PEDs) through hospital admission: an academic affiliated tertiary PED (site A) compared with a private practice tertiary care PED (site B). METHODS: All visits with the ICD-9 (International Classification of Diseases, Ninth Revision) chief complaint of abdominal pain were retrospectively examined from May 1, 2009, to February 21, 2012. Suspected appendicitis visits were defined as any visit with the chief complaint of abdominal pain where a complete blood cell count was obtained. Abdominal CT and US in the PED and during hospital admission were compared across the 2 sites. Return visits within 72 hours were evaluated for any missed appendicitis. RESULTS: Overall appendicitis rates were similar at both sites: site A, 4.7%; site B, 4.0%. The odds of having a CT scan performed during visits to the PED for abdominal pain were significantly higher at site B (odds ratio [OR], 3.19; 95% confidence interval [95% CI], 2.74-3.71), whereas the odds of having an US at site B were the opposite (OR, 0.34; 95% CI, 0.28-0.40). When evaluating only the admitted visits, the odds of having a CT were also greater at site B (OR, 2.32; 95% CI, 1.86-2.94) and having an US were less (OR, 0.57; 95% CI, 0.44-0.73). CONCLUSIONS: In this study of 2 PEDs with differing practice models, we identified a dramatic difference in imaging utilization among patients with suspected appendicitis.

The use of ondansetron for nausea and vomiting after head injury and its effect on return rates from the pediatric ED.

BACKGROUND: The use of ondansetron in children with vomiting after a head injury has not been well studied. Concern about masking serious injury is a potential barrier to its use. OBJECTIVE: The aim of this study was to evaluate the use of ondansetron in children with head injury and symptoms of vomiting in the pediatric emergency department (PED) and its effect on return rates and masking of more serious injuries. DESIGN/METHODS: Visits to 2 PEDs from 2003 to 2010 with a diagnosis of head injury were evaluated retrospectively. Patients discharged home after a head computed tomography (CT) are the primary cohort for the study. A logistic regression model was used to analyze ondansetron's effects on the likelihood of return to the PED within 72 hours for persistent symptoms. A secondary analysis was performed on patients with a diagnoses of head injury who did not receive a head CT and were discharged. RESULTS: A total of 6311 patients had a diagnosis of head injury, had a head CT performed, and were discharged from the PED. The use of ondansetron increased significantly from 3.7% in 2003 to 22% in 2010 (P < .001). After controlling for demographic/acuity differences, receiving ondansetron in the PED was associated with a lower likelihood of returning within 72 hours (0.49, 95% confidence interval [0.26-0.92]). In patients with head injury who did not have a head CT performed and were sent home, the use of ondansetron in the PED was not associated with an increased risk of missed diagnoses. CONCLUSION: Ondansetron use in children with a CT scan who are dispositioned home is relatively safe, does not appear to mask any significant conditions, and significantly reduces return visits to the PED.

Acute neck infections in children: who is likely to undergo surgical drainage?

BACKGROUND: Superficial neck infections including lymphadenitis and abscesses are commonly encountered in pediatric emergency departments (PEDs). It is often unclear which patients are likely to develop an abscess that necessitates surgical drainage. In evaluating these patients, computed tomography (CT) and ultrasound are often used to identify/confirm abscess formation. The criteria for determining the need for imaging studies are not well defined. DESIGN/METHODS: All visits to the study PED were examined in 2009 to 2010. Visits with the diagnosis of cervical lymphadenitis or abscess were identified. Records were retrospectively reviewed to determine the duration of symptoms, fever, previous antibiotic therapy, prior PED visit, size of neck swelling, fluctuance on physical examination, white blood cell count, and results of CT and/or ultrasound obtained in the PED. Data were analyzed to determine which of these characteristics were more likely to be associated with an abscess that was operatively drained. RESULTS: A total of 768 patients were evaluated for neck infections. One hundred twelve (14%) of these pediatric patients underwent abscess drainage in the operating room. Two hundred eighty-nine patients underwent a neck CT and/or ultrasound, of which 119 were positive for abscess. Factors associated with surgical drainage included fluctuance (odds ratio [OR], 18.92; 95% confidence interval [CI], 3.66-31.37), previous emergency department visit (OR, 2.79; 95% CI, 1.34-5.84), and age less than 4 years (OR, 3.01; 95% CI, 1.15-9.87). A recursive partitioning model stratified patients' risk for going to the operating room. Patients without fluctuance and with no prior emergency department visit, along with no prior antibiotic use, have less than 4% chance of having an abscess that necessitates surgical drainage. CONCLUSIONS: Pediatric patients who are more likely to have a neck infection that necessitates surgical drainage can be stratified based on clinical characteristics. This knowledge may allow physicians to better predict the resource needs including hospital admission and emergent imaging for neck infection.

Clinical factors associated with invasive testing and imaging in patients with complex febrile seizures.

BACKGROUND: Complex febrile seizures (CFSs) are a common diagnosis in the pediatric emergency department (PED). Although multiple studies have shown a low likelihood of intracranial infections and abnormal neuroimaging findings among those who present with CFS, the absence of a consensus recommendation and the diversity of CFS presentations (ie, multiple seizures, prolonged seizure, focal seizure) often drive physicians to do a more extensive workup than needed. Few studies examine the factors that influence providers to pursue invasive testing and emergent neuroimaging. OBJECTIVE: The objective of this study was to determine the clinical factors associated with a more extensive workup in a cohort of patients who present to the PED with CFSs. METHODS: Patient visits to a tertiary care PED with an International Classification of Diseases, Ninth Revision, diagnosis of CFS were reviewed from April 2009 to November 2011. Patients included were 6 months to 6 years of age. Complex febrile seizures were defined as febrile seizures lasting 15 minutes or longer, more than 1 seizure in 24 hours, and/or a focal seizure. Charts were reviewed for demographics, clinical parameters (duration of fever, history of febrile seizure, focality of seizure, antibiotic use before PED, and immunization status), PED management (antiepileptic drugs given in the PED or by Emergency Medical Services, empiric antibiotics given in the PED, laboratory testing, lumbar puncture, or computed tomography [CT] scan), and results (cultures, laboratories, or imaging). A logistic regression model was created to determine which clinical parameters were associated with diagnostic testing. RESULTS: One hundred ninety patients were diagnosed with CFS and met study criteria. Clinical management in the PED included a lumbar puncture in 37%, blood cultures in 88%, urine cultures in 47%, and a head CT scan in 28%. There were no positive cerebral spinal fluid or blood cultures in this cohort. Of the 90 patients, 4 (4.4%) with urine cultures had a urinary tract infection. Of the 53 patients who had head CT imaging, there were no significant findings that guided therapy. The only factor associated with having a lumbar puncture performed was whether empiric antibiotics were used (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.28-6.8). History of a febrile seizure was associated with lower odds of a lumbar puncture (OR, 0.29; 95% CI, 0.12-0.69). In addition, higher age category was also associated with lower odds of a lumbar puncture (OR, 0.53; 95% CI, 0.31-0.91). Those who received an antiepileptic drug had a higher odds of getting a head CT (OR, 3.5; 95% CI, 1.5-8.6). Furthermore, patients presenting with a focal seizure also had higher odds of getting a head CT (OR, 4.89; 95% CI, 1.41-16.9). CONCLUSIONS: Despite the low utility of associated findings, there are important clinical parameters that are associated with obtaining a lumbar puncture or a head CT as part of the diagnostic workup. National practice parameters to guide evaluation for CFSs in the acute setting are warranted to reduce the amount of invasive testing and imaging.

Rare-earth magnet ingestion: a childhood danger reaches adolescence.

Ingestion of multiple magnets may cause serious gastrointestinal morbidity, such as pressure necrosis, perforation, fistula formation, or intestinal obstruction due to forceful attraction across bowel wall. Although the consequences of multiple magnet ingestion are well documented in young children, the current popularity of small, powerful rare-earth magnets marketed as "desk toys" has heightened this safety concern in all pediatric age groups. A recent US Consumer Product Safety Commission product-wide warning additionally reports the adolescent practice of using toy high-powered, ball-bearing magnets to simulate tongue and lip piercings, a behavior that may increase risk of inadvertent ingestion. We describe 2 cases of older children (male; aged 10 and 13 years, respectively) with unintentional ingestion of multiple rare-earth magnets. Health care providers should be alerted to the potential for misuse of these high-powered, ball-bearing magnets among older children and adolescents.

High-flow nasal cannula use in children with respiratory distress in the emergency department: predicting the need for subsequent intubation.

BACKGROUND: High-flow nasal cannula (HFNC) is a safe, well-tolerated, and noninvasive method of respiratory support that has seen increasing use in the care of children with respiratory distress. High-flow nasal cannula may be able to prevent intubations in infants and children with respiratory distress. OBJECTIVE: The objective of this study was to determine the clinical and patient characteristics that predict success or failure of HFNC therapy in children presenting to the pediatric emergency department (PED) with respiratory distress. DESIGN/METHODS: A retrospective cohort review was conducted of all children younger than 2 years evaluated in 2 PEDs between June 2011 and September 2012 who received HFNC therapy within 24 hours of initial triage. Data extraction included clinical variables, demographic variables, and patient outcomes. Therapy failure was defined as the clinical decision to intubate a patient after an antecedent trial of HFNC. Multivariable logistic regression was performed to identify factors associated with intubation following HFNC. RESULTS: Four hundred ninety-eight cases meeting criteria for inclusion were identified. The most common final diagnosis was acute bronchiolitis (n = 231, 46%), followed by pneumonia (n = 138, 28%) and asthma (n = 38, 8%). Of the 498 patients, 42 (8%) of patients failed therapy and required intubation following HFNC trial. Risk factors associated with HFNC failure were triage respiratory rate greater than 90th percentile for age (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.01-4.43), initial venous PCO2 greater than 50 mm Hg (OR, 2.51; 95% CI, 1.06-5.98), and initial venous pH less than 7.30 (OR, 2.53; 95% CI, 1.12-5.74). A final diagnosis of bronchiolitis was observed to be protective with respect to intubation (OR, 0.40; 95% CI, 0.17-0.96). CONCLUSIONS: In infants with all-cause respiratory distress presenting in the PED, triage respiratory rate greater than 90th percentile for age, initial venous PCO2 greater than 50 mm Hg, and initial venous pH less than 7.30 were associated with failure of HFNC therapy. A diagnosis of acute bronchiolitis was protective with respect to intubation following HFNC. This finding may help guide clinicians who use HFNC by identifying a patient population at higher risk of failing therapy.

Ondansetron use in the pediatric emergency room for diagnoses other than acute gastroenteritis.

BACKGROUND: Ondansetron is widely used in the pediatric emergency department (PED) for vomiting and acute gastroenteritis (GE). Little is known about the spectrum of its use in diagnoses other than acute GE. OBJECTIVE: The objective of this study was to evaluate the spectrum of diagnoses for which ondansetron is used in the PED. METHODS: Medical records from 2 tertiary care PEDs from January 2006 to December 2008 were retrospectively reviewed. Patients 3 months to 18 years of age given ondansetron in the PED were identified. Patients without a primary discharge diagnosis (based on International Classification of Diseases, Ninth Revision code) of vomiting or GE were defined as non-GE. Patient age, initial triage level (1 = lowest acuity, 5 = highest), route of administration (enteral vs parenteral), primary diagnosis, disposition, and prescription for ondansetron at discharge were recorded; GE and non-GE patients were compared based on age and triage acuity. RESULTS: There were 32,971 patients who received ondansetron in the PED; 12,620 (38%) were non-GE patients. Non-GE patients were older (8.3 vs 4.3 years, P < 0.001) and of higher average initial triage level (2.95 vs 2.33, P < 0.001) compared with GE patients. Within non-GE patients, 79% received ondansetron enterally, 71% were discharged, and 37% of those discharged received an ondansetron prescription. The most common primary diagnoses for non-GE discharged patients were fever (15%), abdominal pain/tenderness (13%), head injury/concussion (7%), pharyngitis (6%), viral infection (6%), migraine variants (5%), and otitis media (5%). The most common diagnoses of patients admitted were appendicitis (11%), asthma (6%), pneumonia (4%), and diabetes (4%). CONCLUSIONS: Although ondansetron is a widely accepted treatment for GE in children, this study identifies a broader spectrum of primary diagnoses for which ondansetron is being used.

Effects of a system-wide fracture care program to enhance access and follow-up for orthopedics.

OBJECTIVES: Fractures of the extremities are commonly encountered in pediatric emergency departments (PEDs) nationwide. These fractures can lead to bone malformation and deformities if not managed properly. There are multiple barriers to obtaining necessary outpatient follow-up for fracture care, which leads to increased return to the PED for management. Because of these barriers, a "Fracture Care Program" was implemented at the study hospital's network. This study aimed to determine implementation of a Fracture Care Program would lead to reduced PED utilization. METHODS: All visits to the study PEDs were examined from January 1 to August 30, 2010. At PED discharge, patients were given a Fracture Care Program handout, which outlined step-by-step instructions for identifying and scheduling an appointment with a local orthopedic surgeon as an outpatient. A telephone hotline number was also provided where they could speak with a representative of the orthopedics department for assistance in obtaining follow-up. Detailed records were reviewed to determine whether these instructions were associated with lower rates of return. RESULTS: A total of 2120 patients met inclusion criteria. Of these, 1233 (58%) received the Fracture Care discharge instructions. After controlling for differences in payor status and demographic differences, patients who received instructions were less likely to return to the PED (odds ratio, 0.616; 95% confidence interval, 0.40-0.95) within 30 days for orthopedic care than patients who did not receive the instructions. CONCLUSIONS: This systematic coordination of services of a large tertiary care pediatric health care system, local pediatric orthopedic surgery private practices, academic practices, and hospital-affiliated practices improved overall access for families related to orthopedic follow-up care. This model may also aid in helping to improve follow-up in other pediatric subspecialties.

Pediatric abscess characteristics associated with hospital admission from the ED.

OBJECTIVE: To determine the characteristics of pediatric soft tissue abscesses that result in hospital admission. METHODS: All visits for soft tissue abscesses to the study emergency department (ED) were examined during 2008. Detailed records were reviewed to determine ED disposition, abscess size, location, presence of fever, duration of symptoms, previous antibiotic therapy, prior ED visit(s), and wound and blood culture results. Data were analyzed to determine which of these characteristics were associated with hospital admission from the ED. RESULTS: Six hundred twenty-two patients met the inclusion criteria. One hundred thirteen (18%) patients were admitted to the hospital and 509 (82%) were discharged home. Compared to those sent home, abscesses resulting in admission were more likely to be located in the genital area (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.37-6.90), breast (OR, 4.8; 95% CI, 1.08-21.4), or face (OR, 4.39; 95% CI, 1.86-10.3), and were more likely to be larger than 3 cm (OR, 3.66, 95% CI, 2.10-6.36). Patients who were admitted to the hospital were also more likely to have fever (OR, 5.93; 95% CI, 3.4-10.3) and have had a prior ED visit with the same complaint (OR, 3.81; 95% CI, 1.77-8.2). Seventy-seven percent of abscesses that were cultured were positive for methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Size and location (especially those in the genital region, breast, and face), appear to be associated with admission for pediatric abscesses. History of fever and previous ED visit also appear to be associated with hospital admission. Obtaining blood cultures for pediatric abscesses is likely of little clinical benefit.

Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain.

BACKGROUND: Chest pain is a frequent chief complaint among the pediatric population. To date, limited data exist on the full spectrum of emergent cardiac disease among such patients; and existing data have been limited to relatively small cohorts. OBJECTIVES: The aims of the study were to investigate the emergent cardiac etiologies of chest pain in a large cohort of patients presenting to a tertiary care pediatric emergency department (PED) and to examine the use of resources (electrocardiogram, chest radiograph, echocardiogram, and laboratories) in those with and without cardiac-related chest pain. METHODS: Patient visits to 2 tertiary care PEDs were evaluated over a 3 and half-year period. Records of patients less than 19 years of age with a chief complaint of chest pain and no history of cardiovascular disease were reviewed. Patients were categorized as having cardiac or noncardiac etiologies or history of cardiovascular disease at the time of discharge, based on PED attending's final diagnoses. Final diagnoses classified as emergent cardiac etiologies were determined a priori. RESULTS: Four thousand four hundred thirty-six patients reported a chief complaint of chest pain during the study period. Three percent were excluded secondary to a history of heart disease. Only 24 (0.6%) of the remaining 4288 were determined to have chest pain of cardiac origin. Those with cardiac-related chest pain had a rate of admission of 50% compared to those without cardiac disease at 4% (P < .001). Nine patients had an arrhythmia, 6 had pericarditis, 4 had myocarditis, 3 had acute myocardial infarction, and 1 had pulmonary embolism and pneumopericardium. Ninety-two percent of the cardiac-related chest pain cohort received electrocardiograms compared to those without cardiac-related chest pain at 27% (P < .01). Only 1 (4%) of 24 subjects with cardiac-related chest pain had a prior emergency department visit within 72 hours suggesting a high detection rate upon initial presentation. The most common noncardiac etiologies for the chest pain were 56% musculoskeletal disorders; 12% related to wheezing, asthma, and cough; 8% infectious causes; 6% gastrointestinal; and 4% related to sickle cell anemia. CONCLUSION: Cardiac-related chest pain in pediatric patients is rare but potentially serious. Arrhythmia was the most common cardiac-related etiology among this cohort. Those with myocarditis and myocardial infarction were the most acutely ill. An electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain. Using a thorough physical examination and potentially an electrocardiogram evaluation by a pediatric emergency care physician has an excellent rate of detection of cardiac-related causes.

Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses?

STUDY OBJECTIVE: We evaluate the effect of ondansetron use in cases of suspected gastroenteritis on the proportion of hospital admissions and return visits and assess whether children who receive ondansetron on their initial visit to the pediatric emergency department (ED) for suspected gastroenteritis return with an alternative diagnosis more frequently than those who did not receive ondansetron. METHODS: This is a retrospective review of visits to 2 tertiary care pediatric EDs with an International Classification of Diseases, Ninth Revision diagnosis of vomiting or gastroenteritis. A logistic regression model was developed to determine the effect of ondansetron use during the initial pediatric ED visit on hospital admission, return to the pediatric ED within 72 hours, and admission on this return visit. For patients who returned within 72 hours and were admitted, hospital discharge records were reviewed. The proportions of alternative diagnoses, defined as a hospital discharge diagnosis that was not a continuation of gastroenteritis or vomiting, were compared between the groups. RESULTS: During the 3-year study period (2005 to 2007), 34,117 patients met study criteria. Ondansetron was used for 19,857 (58.2%) of these patients on their initial pediatric ED visit. After controlling for differences between the groups, patients who received ondansetron were admitted on their initial visit less often: odds ratio (OR) 0.47 (95% confidence interval [CI] 0.42 to 0.53). However, those who received ondansetron were more likely to return to the pediatric ED within 72 hours (OR 1.45; 95% CI 1.27 to 1.65) and be admitted on the return visit (OR 1.74; 95% CI 1.39 to 2.19). The proportions of alternative diagnoses at hospital discharge were not significantly different in the group that received ondansetron on the initial pediatric ED visit (14.9%) compared with the group that did not (22.4%) (absolute difference 7.5% [95% CI -0.5% to 16.4%). CONCLUSION: Ondansetron use in the pediatric ED reduces hospital admissions for suspected gastroenteritis and vomiting. However, children who receive ondansetron in the pediatric ED appear more likely to return to the pediatric ED and be admitted on this return visit than their counterparts. Furthermore, the use of ondansetron does not appear to be associated with increased risks of masking serious diagnoses in children.

Access to outpatient follow-up orthopedic care after pediatric emergency department visits: impact of implementation of a managed Medicaid program.

OBJECTIVE: A Medicaid managed care (MMC) program was instituted regionally with the goal of improving quality and access to care for underserved populations. The purpose of this study was to determine whether the implementation of an MMC program has affected access to timely orthopedic follow-up care. METHODS: All visits to 2 tertiary care pediatric emergency departments (PED) with a diagnosis of extremity fracture or dislocation were examined for a 5-month period after implementation of MMC and compared with the same periods during 2004 and 2005. Repeat visits for orthopedic concerns to the PED within 30 days of the initial fracture care were compared across the pre- and post-MMC periods. RESULTS: Six thousand four hundred nine visits with a diagnosis of extremity fracture or dislocation were identified (4110 in the two 5-month pre-MMC periods and 2299 in the 5-month post-MMC period). A total of 167 return visits for orthopedic concerns were identified in the pre-MMC period (4.0%) compared with 150 return visits in the post-MMC period (6.5%) (P<0.001). Of these, 12 (7.2%) in the pre-MMC period and 55 (36.6%) in the post-MMC period were identified as related to the inability to access outpatient orthopedic follow-up (P<0.001). In both periods, Medicaid patients were more likely to return to the PED for inability to access care, compared with privately insured patients (odds ratio [OR], 6.1; 95% confidence interval [CI], 3.54-10.32). CONCLUSIONS: After the implementation of a regional MMC program, patients were increasingly unable to access routine outpatient follow-up. This may shift additional cost and resource load to PED, while limiting access to vital services for medically vulnerable patients.

Predictors of abnormal electrocardiograms in the pediatric emergency department.

BACKGROUND: Electrocardiograms (ECGs) are ordered in the pediatric emergency room for a wide variety of chief complaints. OBJECTIVES: Criteria are lacking as to when physicians should obtain ECGs. This study uses a large retrospective cohort of 880 pediatric emergency department (ED) patients to highlight objective criteria including significant medical history and specific vital sign abnormalities to guide clinicians as to which patients might have an abnormal ECG. METHODS: Retrospective review of Pediatric ED charts in all patients aged < 18 years who had ECG performed during ED stay. Pediatric ED physician interpretation of the ECG, clinical data on vital signs and past medical history was collected from the medical record for analysis. RESULTS: Of 880 ECGs performed in the ED, 17.4% were abnormal. When controlled for medical history and demographic differences, abnormal ECGs were associated with age-adjusted abnormal ED vital signs including increased heart rate (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.1-3.09) and increased respiratory rate (OR 1.74, CI 1.42-2.62). In a logistic regression analysis, certain chief complaints and history components were less likely to have abnormal ECGs including complaints of chest pain (OR 0.38, CI 0.18-0.80) and known history of gastrointestinal or respiratory condition (i.e., asthma) (OR 0.48, CI 0.29-0.79). CONCLUSIONS: In this cohort of patients, those with a chief complaint of chest pain or known respiratory conditions and normal age-adjusted vital signs in the ED have low likelihood of an abnormal ECG.

Trampoline Park and Home Trampoline Injuries.

BACKGROUND AND OBJECTIVE: Trampoline parks, indoor recreational facilities with wall-to-wall trampolines, are increasing in number and popularity. The objective was to identify trends in emergency department visits for trampoline park injuries (TPIs) and compare TPI characteristics with home trampoline injuries (HTIs). METHODS: Data on trampoline injuries from the National Electronic Injury Surveillance System from 2010 to 2014 were analyzed. Sample weights were applied to estimate yearly national injury trends; unweighted cases were used for comparison of injury patterns. RESULTS: Estimated US emergency department visits for TPI increased significantly, from 581 in 2010 to 6932 in 2014 (P = .045), whereas HTIs did not increase (P = .13). Patients with TPI (n = 330) were older than patients with HTI (n = 7933) (mean 13.3 vs 9.5 years, respectively, P < .001) and predominantly male. Sprains and fractures were the most common injuries at trampoline parks and homes. Compared with HTIs, TPIs were less likely to involve head injury (odds ratio [OR] 0.64; 95% confidence interval [CI], 0.46-0.89), more likely to involve lower extremity injury (OR 2.39; 95% CI, 1.91-2.98), more likely to be a dislocation (OR 2.12; 95% CI, 1.10-4.09), and more likely to warrant admission (OR 1.76; 95% CI, 1.19-2.61). TPIs necessitating hospital admission included open fractures and spinal cord injuries. TPI mechanisms included falls, contact with other jumpers, and flips. CONCLUSIONS: TPI patterns differed significantly from HTIs. TPIs are an emerging concern; additional investigation and strategies are needed to prevent injury at trampoline parks.

Reconnecting patients with their primary care provider: an intervention for reducing nonurgent pediatric emergency department visits.

OBJECTIVE: Intervention to reduce nonurgent pediatric emergency department (PED) visits over a 12-month follow-up. METHODS: Prospective, randomized, controlled trial enrolled children seen in the PED for nonurgent concerns. Intervention subjects received a structured session/handout specific to their primary care provider (PCP), which outlined ways to obtain medical advice. Visitation to the PED and PCP were followed over 12 months. RESULTS: A total of 164 patients were assigned to the intervention and 168 patients to the control. At 12-month follow-up, the intervention group had a lower rate of nonurgent PED utilization compared with the control group (70 [43%] patients in the intervention compared with 91 [54%] in the control; P = .047). At 12 months, there was an increase in the rate of sick visits to PCP in the intervention group when compared with the control (P = .036). CONCLUSIONS: Intervention designed in cooperation with pediatricians was able to decrease nonurgent PED utilization and redirect patients to their PCP for future sick visits over a 12-month period.

Supraventricular tachycardia in the pediatric trauma patient: a case report.

Any injured patient who is cool and tachycardic is considered to be in shock until proven otherwise.(1) We describe the diagnostic challenge when evaluating persistent tachycardia in the setting of multiple system trauma with hemorrhagic shock. This is a unique case of a 17-year-old patient with the secondary condition of cardiogenic shock due to supraventricular tachycardia (SVT) complicating ongoing hemorrhagic shock from a facial laceration. She had sustained tachycardia despite aggressive resuscitation and required medical cardioversion 30 minutes after arrival to the emergency department. After successful conversion, she maintained normal sinus rhythm for the rest of her hospitalization. During her follow-up cardiac catheterization, she was found to have a left-sided accessory pathway, consistent with atrioventricular reciprocating tachycardia. This is a unique and rare case of SVT in the traumatic patient. We review causes of tachycardia in the setting of pediatric multisystem trauma, as well as discuss acute SVT evaluation and management in the pediatric emergency department.

Pulmonary embolism in the pediatric emergency department.

OBJECTIVE: To describe patients who present to the pediatric emergency department (PED) and are subsequently diagnosed with pulmonary embolism (PE). METHODS: Electronic medical records from 2003 to 2011 of a tertiary care pediatric health care system was retrospectively reviewed to identify patients <21 years who had a final International Classification of Diseases, Ninth Revision diagnosis of PE. Patient demographics, and hospital course were recorded. Adult validated clinical decision rules Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) were retrospectively applied. PERC identified 8 clinical criteria for adult patients using logistic regression modeling to exclude PE without additional diagnostic evaluation. If all criteria are met, further evaluation is not indicated. RESULTS: Of 1 185 794 PED visits, 105 patients had an ultimate diagnosis of PE. Twenty-five met study criteria, and all were admitted. Forty percent of these patients had PE diagnosed in the PED. The most common risk factors were BMI ≥25 (50%, 10 of 20), oral contraceptive use (38% 5 of 13 female patients), and history of previous thrombus without PE (28%, 7 of 25). When the PERC rule was applied retrospectively, 84% of patients could not be ruled out, indicating additional evaluation for PE was needed. CONCLUSIONS: Pulmonary embolism is rare in children but does occur. This study emphasizes risk factors among children that should raise the suspicion of PE. Additional studies are needed to further evaluate risk factors and signs and symptoms of PE to develop pediatric specific clinical decision rules to provide reliable and reproducible means of determining pretest probability of PE.