Long-Acting Reversible Contraception Knowledge Among Female Adolescents Presenting to a Pediatric Emergency Department.

OBJECTIVES: The objective of this study was to assess awareness and use of long-acting reversible contraception (LARC) among female adolescents presenting to a pediatric emergency department (PED). STUDY DESIGN: During routine presentation to an urban PED in New Jersey, female adolescents, aged 15-19 years, were asked to voluntarily complete an electronic survey about sexual practices and contraception. The PED is in an urban teaching hospital, treating 35,000 children annually. Patients could schedule a follow-up appointment at the hospital's obstetrics/gynecology clinic. Data were collected over 13 months, and follow-up was monitored to determine if they attended an outpatient appointment, and if so, what the outcome was. RESULTS: Data for 199 participants were analyzed. The median age of participants was 18 years, whereas 79% self-identified as Black, and 17.6% self-identified as Latina. Twenty-one percent of participants used a form of birth control during their first sexual encounter, the largest percentage being condoms (77.8%). Forty percent of participants reported some prior knowledge about contraceptive implants, and 20% had knowledge about intrauterine devices, whereas only 3 (1.5%) intrauterine devices and 2 (1%) arm implants had been previously used. Of the 78 participants that requested a follow-up, 14 (17.9%) completed their appointment. Of those, 2 (14%) were prescribed contraception (Depo-Provera shot and oral contraceptive pills). CONCLUSIONS: Knowledge about LARC remains low in our PED, despite it being the most effective method of contraception. Even when interventions were made to link interested respondents to outpatient women's health services, follow-up attendance was poor, and no patients obtained LARC. There is a significant discrepancy between the consensus standard of contraception care across all relevant medical specialties and current utilization by high-risk populations. Future efforts must focus on how to close this gap, and the ED could be pivotal for improving both reproductive health education and intervention among adolescent patients.

Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region.

OBJECTIVES: Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock. METHODS: We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors. RESULTS: Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]). CONCLUSIONS: Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception.

OBJECTIVES: The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS: We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS: Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS: Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests.

STUDY OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

Interpretation Accuracy and Interrater Agreement of Pediatric Skin and Soft Tissue Point-of-Care Ultrasound Images among Residents and Faculty.

BACKGROUND: Point-of-care ultrasound (POCUS) is commonly used to facilitate care in the emergency department. Acquired images are often reviewed by local experts for educational and quality assurance purposes. However, no published study has examined the accuracy and reliability of POCUS image interpretation by multiple reviewers. OBJECTIVES: We studied the accuracy and interrater agreement among expert and trainee reviewers of prerecorded pediatric skin and soft tissue (SST) POCUS images. METHODS: POCUS faculty and emergency medicine (EM) residents blindly reviewed deidentified pediatric SST POCUS images and indicated whether a drainable fluid collection was present, absent, or indeterminate. This was then compared with the gold standard based on discharge diagnoses and telephone follow-up. Images rated as indeterminate were excluded from the initial analysis. Sensitivity analysis assuming indeterminate answers were inaccurate was subsequently conducted. RESULTS: In phase 1, 6 pediatric EM POCUS directors reviewed 168 images. The overall accuracy was 79.7% (range 66.1-86.0%). The mean Cohen's kappa was 0.58 (range 0.24-0.84). Sensitivity analysis yielded an overall accuracy of 71.3% (range 56.5-76.9%) and a Cohen's kappa of 0.43 (range 0.20-0.59). In phase 2, 6 general EM POCUS faculty and 20 EM residents reviewed 120 images. The overall accuracy among residents was 72.2% (range 51.4-84.7%) and among faculty was 83.6% (range 77.9-88.8%). Sensitivity analysis yielded an overall resident accuracy of 63.0% (range 49.5-80.7) and an overall faculty accuracy of 73.9% (range 67.0-79.8%). Fleiss' kappa was 0.322 for residents and 0.461 for faculty. CONCLUSIONS: We found moderate accuracy and fair to good interrater agreement among POCUS faculty and EM residents reviewing pediatric SST POCUS images.

A Multi-institutional Case Series With Review of Point-of-Care Ultrasound to Diagnose Malrotation and Midgut Volvulus in the Pediatric Emergency Department.

Point-of-care ultrasound can be used to screen for malrotation with and without volvulus in the newborn with bilious vomiting, as well as children with unexplained intermittent abdominal pain. We discuss cases where infants and children presenting to pediatric emergency departments with bilious vomiting and/or intermittent abdominal pain were initially screened for small bowel pathology with point-of-care ultrasound. Bedside findings suggestive of midgut volvulus were confirmed with radiology-performed ultrasound or upper gastrointestinal fluoroscopy. In all cases, operative findings were consistent with malrotation of the small bowel with or without evidence of midgut volvulus.

The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease.

STUDY OBJECTIVE: We evaluate the additive value of pelvic examinations in predicting sexually transmitted infection for young female patients with suspected cervicitis or pelvic inflammatory disease in a pediatric emergency department (ED). METHODS: This was a prospective observational study of female patients aged 14 to 20 years who presented to an urban academic pediatric ED with a complaint of vaginal discharge or lower abdominal pain. Enrolled patients provided a urine sample for chlamydia, gonorrhea, and trichomonas testing, which served as the criterion standard for diagnosis. A practitioner (pediatric ED attending physician, emergency medicine or pediatric resident, pediatric ED fellow, or advanced practice provider) obtained a standardized history from the patient to assess for cervicitis or pelvic inflammatory disease according to the Centers for Disease Control and Prevention criteria. They then recorded the likelihood of cervicitis or pelvic inflammatory disease on a 100-mm visual analog scale. The same practitioner then performed a pelvic examination and again recorded the likelihood of cervicitis or pelvic inflammatory disease on a visual analog scale with this additional information. Using the results of the urine sexually transmitted infection tests, the practitioner calculated and compared the test characteristics of history alone and history with pelvic examination. RESULTS: Two hundred eighty-eight patients were enrolled, of whom 79 had positive urine test results for chlamydia, gonorrhea, or trichomonas, with a sexually transmitted infection rate of 27.4% (95% confidence interval [CI] 22.6% to 32.8%). The sensitivity of history alone in diagnosis of cervicitis or pelvic inflammatory disease was 54.4% (95% CI 42.8% to 65.5%), whereas the specificity was 59.8% (95% CI 52.8% to 66.4%). The sensitivity of history with pelvic examination in diagnosis of cervicitis or pelvic inflammatory disease was 48.1% (95% CI 36.8% to 59.5%), whereas the specificity was 60.7% (95% CI 53.8% to 67.3%). The information from the pelvic examination changed management in 71 cases; 35 of those cases correlated with the sexually transmitted infection test and 36 did not. CONCLUSION: For young female patients with suspected cervicitis or pelvic inflammatory disease, the pelvic examination does not increase the sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomonas compared with taking a history alone. Because the test characteristics for the pelvic examination are not adequate, its routine performance should be reconsidered.

Comparison of Ultrasound Guidance vs. Clinical Assessment Alone for Management of Pediatric Skin and Soft Tissue Infections.

BACKGROUND: Point-of-care ultrasound (POCUS) can potentially help distinguish cellulitis from abscess, which can appear very similar on physical examination but necessitate different treatment approaches. OBJECTIVE: To compare POCUS guidance vs. clinical assessment alone on the management of pediatric skin and soft tissue infections (SSTI) in the emergency department (ED) setting. METHODS: Children ages 6 months to 18 years presenting to participating EDs with SSTIs ≥ 1 cm were eligible. All treatment decisions, including use of POCUS, were at the discretion of the treating clinicians. Patients were divided into those managed with POCUS guidance (POCUS group) and those managed using clinical assessment alone (non-POCUS group). Primary outcome was clinical treatment failure at 7-10 days (unscheduled ED return visit or admission, procedural intervention, change in antibiotics therapy). Secondary outcomes were ED length of stay, discharge rate, use of alternative imaging, and need for procedural sedation. POCUS utility and impact on management decisions were also assessed by treating clinicians. RESULTS: In total, 321 subjects (327 lesions) were analyzed, of which 299 (93%) had completed follow-up. There was no significant difference between the POCUS and non-POCUS groups in any of the primary or secondary outcomes. Management plan was changed in the POCUS group in 22.9% of cases (13.8% from medical to surgical, 9.1% from surgical to medical). Clinicians reported increased benefit of POCUS in cases of higher clinical uncertainty. CONCLUSIONS: Use of POCUS was not associated with decreased ED treatment failure rate or process outcomes in pediatric SSTI patients. However, POCUS changed the management plan in approximately one in four cases.

Think ultrasound first for peritonsillar swelling.

Peritonsillar abscess (PTA) is one of the most common deep neck space infections that can potentially have life-threatening complications if inadequately diagnosed and not treated promptly. The ability of clinicians to reliably differentiate PTA from peritonsillar cellulitis by physical examination alone is limited and blind needle aspiration, the typical method of diagnosis of PTA, is also unreliable. We review the available evidence supporting the use of ultrasound, either intraoral ultrasound or transcutaneous ultrasound to be the initial imaging modality of choice for evaluation of PTA and be used for real-time needle guidance.

Evaluation of acute appendicitis by pediatric emergency physician sonography.

STUDY OBJECTIVE: We investigate the accuracy of pediatric emergency physician sonography for acute appendicitis in children. METHODS: We prospectively enrolled children requiring surgical or radiology consultation for suspected acute appendicitis at an urban pediatric emergency department. Pediatric emergency physicians performed focused right lower-quadrant sonography after didactics and hands-on training with a structured scanning algorithm, including the graded-compression technique. We compared their sonographic interpretations with clinical and radiologic findings, as well as clinical outcomes as defined by follow-up or pathologic findings. RESULTS: Thirteen pediatric emergency medicine sonographers performed 264 ultrasonographic studies, including 85 (32%) in children with pathology-verified appendicitis. Bedside sonography had a sensitivity of 85% (95% confidence interval [CI] 75% to 95%), specificity of 93% (95% CI 85% to 100%), positive likelihood ratio of 11.7 (95% CI 6.9 to 20), and negative likelihood ratio of 0.17 (95% CI 0.1 to 0.28). CONCLUSION: With focused ultrasonographic training, pediatric emergency physicians can diagnose acute appendicitis with substantial accuracy.

Does the use of bedside pelvic ultrasound decrease length of stay in the emergency department?

OBJECTIVES: Diagnostic ultrasounds by emergency medicine (EM) and pediatric emergency medicine (PEM) physicians have increased because of ultrasonography training during residency and fellowship. The availability of ultrasound in radiology departments is limited or difficult to obtain especially during nighttime hours. Studies have shown that EM physicians can accurately perform goal-directed ultrasound after appropriate training. The goal of this study was to compare the length of stay for patients receiving an ultrasound to confirm intrauterine pregnancies. The hypothesis of this study is that a bedside ultrasound by a trained EM/PEM physician can reduce length of stay in the emergency department (ED) by 1 hour. METHODS: This was a case cohort retrospective review for patients aged 13 to 21 years who received pelvic ultrasounds in the ED during 2007. Each patient was placed into 1 of 2 groups. Group 1 received bedside ultrasounds done by institutionally credentialed EM/PEM attending physicians. Group 2 received radiology department ultrasound only. Each group had subanalysis done including chief complaint, time of presentation, time to completion of ultrasound, length of stay, diagnosis, and disposition. Daytime was defined as presentation between 7 AM and 9 PM when radiology ultrasound technologists were routinely available. RESULTS: We studied 330 patients, with 244 patients (74%) in the bedside ultrasound group. The demographics of both groups showed no difference in age, presenting complaints, discharge diagnoses, and ultimate disposition. Group 1 had a significant reduction (P < 0.001) in time to complete the ultrasound compared with group 2 (mean, 82 minutes [range, 1-901 minutes] vs 149 minutes [range, 7-506 minutes]) and length of stay (142 [16-2268] vs. 230 [16-844]). Of those presenting during the day (66%), group 1 showed a significant reduction in length of stay (P < 0.001) compared with group 2 (220 [21-951] vs 357 [156-844]). Of those who presented at night (34%), group 1 showed a significant reduction in length of stay (P < 0.002) compared with group 2 (270 [16-2268] vs. 326 [127-691]). CONCLUSIONS: The use of ED bedside ultrasound by trained EM/PEM physicians produced a significant reduction in length of stay in the ED, regardless of radiology ultrasound technologist availability.

Acute acalculous cholecystitis in a 10-year-old girl with cystic fibrosis.

Acute acalculous cholecystitis is uncommon in pediatrics and more likely to be encountered in adult patients. Signs and symptoms of acute cholecystitis are similar to other causes of acute abdominal pain such as pancreatitis, gastritis, and acute appendicitis, further making diagnosis difficult. We present a case of acute acalculous cholecystitis in a child with cystic fibrosis and discuss the role of emergency physician bedside sonography in the evaluation of right-upper-quadrant pain.

Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one?

OBJECTIVES: Our primary objective was to investigate whether urine drug screen (UDS) results affected the medical management of pediatric psychiatric patients presenting to the pediatric emergency department (ED) for psychiatric evaluation and whether it affected the final disposition of these patients. METHODS: This was a retrospective chart review of patients who presented to an urban pediatric ED in Newark, NJ, with psychiatric or behavior problems for medical clearance before psychiatric evaluation between June 3, 2008, and June 3, 2009. Inclusion criteria were any patient between the ages of 0 to 20 years who presented to the pediatric ED and had a UDS performed. Exclusion criteria were if the UDS was obtained for a primary medical workup such as altered mental status, known or admitted overdose, or accidental ingestions, or no psychiatric consultation was made from the ED. Abstracted descriptive data include patient's age, sex, race, and insurance status. Visit-specific data include patient's reason for visit, results of the UDS, psychiatric diagnosis if any, history of substance abuse if any, and management decisions other than psychiatric evaluation after medical clearance. RESULTS: A total of 875 charts were identified from laboratory records; 539 of those patients presented to the pediatric ED for psychiatric evaluation. A total of 62 patients had at least 1 substance detected on the UDS and were referred to psychiatry. All of the patients who had presented for psychiatric evaluation, including those with a positive result on the UDS, were medically cleared with no documented change in management or medical intervention in the pediatric ED. CONCLUSIONS: Obtaining a UDS on patients who presented to the pediatric ED for medical clearance before psychiatric evaluation did not alter medical decision for clearance nor necessitate any change in management or interventions before psychiatric evaluation.

Implementing routine HIV screening in an urban pediatric emergency department.

OBJECTIVE: In 2006, the Centers for Disease Control and Prevention recommended that all outpatient health care settings offer routine, opt-out HIV screening for patients aged 13 to 64 years, except where the prevalence of undiagnosed HIV infection is known to be less than 0.1%. Most emergency departments (EDs) lack routine HIV screening. The objective of this investigation was to describe the results of the implementation of routine, nontargeted opt-in HIV screening for patients aged 13 to 20 years in an urban pediatric ED (PED) in a city in which 1 of 30 residents has HIV/AIDS. METHODS: This was a retrospective chart review from an urban, academic PED. The implementation of routine HIV screening in the ED was funded by the New Jersey Department of Health and Senior Services and planned independently of the study investigator. Patients aged 13 to 64 years were offered HIV screening by nursing staff, physicians, and/or HIV counselors. Patients who accepted were screened with rapid HIV fingerstick testing performed via Clearview HIV 1/2 STAT-PAK by HIV counselors as per the New Jersey Department of Health and Senior Services protocol. Data collected by the study investigator were done by chart review from October through December 2009, the first 3 months after implementation of routine HIV screening. Data were collected from patients aged 13 to 20 years presenting to the PED. Primary outcomes measured included the proportion of patients offered and accepted screening, newly diagnosed HIV cases, and the rate of linking newly diagnosed HIV patients to treatment. Demographic data collected included patient age, sex, and ethnicity. Results from the first 3 months of routine, nontargeted screening were compared with the HIV screening results of October through December 2008, during which time rapid HIV screening was provided to patients in the ED based on clinical indication. Patients who were not offered testing or who refused testing were measured by forms that were placed in every chart and collected by physicians. Emergency department census data were queried to identify the total number of patients seen in the ED within age range and time frame studied. RESULTS: Three hundred (11%) of the 2645 patients aged 13 to 20 years were offered routine HIV screening in the PED from October through December 2009. Two hundred twenty-four patients (74%) accepted HIV testing. No new cases of HIV were identified. There was an increase in acceptance of HIV testing that correlated with increasing age (P < 0.05). There was no significant difference between male and female acceptance rates (P < 0.05). Eleven (4.9%) of the patients accepting testing did not have testing performed because of unavailability of the counselor and/or the patient could not wait. Review of HIV testing performed in the PED from October through December 2008 showed 39 patients aged 13 to 20 years were tested. Routine testing increased the number of patients tested by 446%. CONCLUSIONS: Pediatric patients in this urban setting are very accepting of HIV testing. HIV screening is increased when routine screening is offered.

Heart failure secondary to dilated cardiomyopathy: a role for emergency physician bedside ultrasonography.

Heart failure as a result of cardiomyopathy is an uncommon presentation in the pediatric emergency department (PED). The initial presenting symptoms in these cases are often nonspecific and may be confused with more common pediatric illnesses. We report a case of a 3-year-old girl initially discharged from a PED after routine evaluation of vomiting and diarrhea with a diagnosis of acute gastroenteritis only to return 1 week later in heart failure from a dilated cardiomyopathy. A bedside ultrasound performed by the emergency physician in the PED allowed for the initiation of appropriate, rapid, goal-directed therapy and expedited timely transport to a facility with pediatric cardiothoracic surgery. We will review dilated cardiomyopathy and the role of emergency physician echocardiography.

Right lower-quadrant pain-more than one diagnosis.

When a patient presents with right-lower-quadrant pain in the emergency room, the diagnosis of appendicitis must always be considered, but the differential diagnosis for this symptom includes many other etiologies. We describe a case of an 8-year-old girl with von Willebrand disease who presented with right-lower-quadrant pain and was found to have an appendiceal wall hematoma. During her evaluation, an ultrasound of the abdomen was performed, and the results were initially interpreted as an intussusception. Although ultrasound is a highly reliable way to diagnose appendicitis and intussusception, the case illustrates that the thickened abdominal wall that occurs in a mural hematoma can appear like the "target sign" that is usually associated with intussusception, and in certain clinical scenarios, alternative forms of imaging may be of value.