Bilious emesis in the pediatric emergency department: etiology and outcome.

The objective of this study was to describe the emergency department (ED) diagnoses in an unselected pediatric population with bilious emesis. In a multicenter, prospective, observational case series, a convenience sample of patients less than 21 years old with yellow or green emesis were assembled. Clinical review of each case was performed 2 weeks or longer after ED disposition. Two hundred twenty-seven patients with 230 ED encounters were enrolled. Of the 189 encounters (82.2%) with follow-up, 20 had surgical disease (10.6%; 95% C.I. 6.6%, 15.9%). There was no significant association between the color of the emesis and surgical disease (OR = 2.3; 95% CI, 0.68, 8.6).

Admission predictor modeling in pediatric interhospital transport.

OBJECTIVE: The objective of this investigation was to determine if an existing general severity of illness measure describing pediatric emergency patients, calculated at referring hospitals, predicts the need for hospital admission and intensive care unit (ICU) admission at receiving hospitals. METHODS: A consecutive series of interhospital transports to an urban pediatric tertiary care hospital from other emergency departments (EDs) during a 1-year period were studied. The pediatric risk of admission score, a validated emergency department measure of severity of illness, was calculated by the transport team leader on arrival at the referring hospital using data available at that time. Outcomes examined in a logistic regression model and receiver operating characteristic curves included the need for hospital admission and ICU admission. RESULTS: From 52 referring emergency departments, 1920 consecutive interhospital transport records were analyzed. Of these, 1557 (81.1%) patients were ultimately admitted to the receiving hospital, including 131 (6.8%) to the ICU. Logistic regression for hospital admission demonstrated a significant independent association with higher age, higher pediatric risk of admission, trauma diagnosis, and the lack of a pediatric inpatient service. The receiver operating characteristic curve for hospital admission [area under the curve = 0.612 (0.576, 0.647)] was not useful to determine a suitable cut point below which hospital admission was unlikely to occur. Pediatric risk of admission score performance as a predictor of ICU admission by receiver operating characteristic curve was only slightly better (area under the curve = 0.721 [0.653, 0.788]). CONCLUSIONS: This form of the pediatric risk of admission score is not practical as a predictor of hospital and ICU admission among pediatric interhospital transport. Specific calibration could increase its utility for the transport population. This in turn may contribute to more effective interhospital transport triage and more efficient allocation of transport resources.

Recognition and management of pediatric fractures by pediatric residents.

BACKGROUND: Competence in basic orthopedic assessment and interpretation of radiographs is important for pediatricians because appropriate initial management of fractures can expedite therapy and minimize morbidity. However, requirements for training in orthopedics and radiology are poorly defined in pediatric residency programs. OBJECTIVE: To assess the ability of pediatric residents to recognize and to manage appropriately pediatric fractures. METHODS: This study involved administration of a case-based questionnaire with radiographs to volunteer categorical pediatric residents in 3 geographically diverse training programs. The diagnosis and management of 8 orthopedic complaints were evaluated. Responses were scored according to the number of features identified accurately, including the presence or absence of a fracture. Residents who were able to identify a fracture were assessed with respect to their ability to classify the fracture and to provide initial management. The study was pretested with a group of pediatric emergency medicine attending physicians, to establish the suitability of the cases. RESULTS: Among the 3 residency sites, 102 of 190 eligible pediatric residents (53.7%) participated, yielding 95 completed questionnaires. The mean number of cases in which a resident correctly answered the question, "Is a fracture present?" and correctly identified the fractured bone (if a fracture was present) was 6.5 +/- 1.2 of 8 cases (81.6%; 95% confidence interval: 78.5-84.7%). The diagnostic accuracy of Salter-Harris classification in cases in which such fractures were present was 40.9%. The mean score of correctly identified features for the resident group was 38.5 +/- 9.4, of a possible 64 points (proportion correct: 60.1%; 95% confidence interval: 57.2-63%). There was a small but significant difference in mean correct responses between first-year residents (proportion correct: 55.4%; 95% confidence interval: 50.8- 60.3%) and third-year residents (proportion correct: 65.1%; 95% confidence interval: 60.7-69.5%). There was no association between the proportion of correct responses and whether or not residents had taken radiology or orthopedics elective courses in medical school. Overall, 43% of cases were both identified and managed correctly by the pediatric residents. CONCLUSIONS: For residents from the participating training programs, skills in recognizing and managing pediatric fractures were suboptimal. Additional review of training requirements is necessary to identify more clearly areas of improvement for current curricula.