An assessment of the psychometric properties of the Stoplight Pain Scale in a Canadian paediatric emergency department.

OBJECTIVE: This study aimed to validate a novel, three faced, colour-coded, action-oriented tool: The Stoplight Pain Scale (SPS). METHODS: A prospective observational cohort study was conducted at a Canadian paediatric emergency department from November 2014 to February 2017. Patients aged 3 to 12 years and their caregivers were asked to rate pain using the SPS and the Faces Pain Scale-Revised (FPS-R). Pain was measured just before analgesia administration, 30 minutes after analgesia administration, and immediately following a painful procedure. RESULTS: A total of 227 patients were included; 26.9% (61/227) were 3 to 5 years old while 73.1% (166/227) were 6 to 12 years old. Using Cohen's κ, agreement for SPS and FPS-R was 'fair' for children (0.28 [95% confidence interval {CI} 0.20 to 0.36]) and 'poor' for caregivers (0.14 [95% CI 0.07 to 0.21]), at initial measurement. The SPS had 'fair' agreement between child and caregiver scores, (0.37 [95% CI 0.27 to 0.47]), compared to FPS-R which showed 'poor' agreement (0.20 [95% CI 0.12 to 0.29]). Absolute agreement between child and caregiver SPS scores improved with repeat exposure; 30 minutes after analgesia administration, caregivers and children had fair agreement (κ=0.38, 95% CI 0.28 to 0.48); they had moderate agreement directly following painful procedures (κ=0.46, 95% CI 0.34 to 0.59). Overall, 72.4% (139/192) of children and 60.2% (118/196) of caregivers preferred SPS over FPS-R. CONCLUSION: The SPS demonstrates fair agreement with FPS-R for children and fair-moderate agreement between children and caregivers; agreement improved with repeat use. The SPS is simple and easy to use; it may have a role in empowering direct child and family involvement in pain management.

Appendix not seen: the predictive value of secondary inflammatory sonographic signs.

BACKGROUND: Acute appendicitis is the most prevalent emergency surgical diagnosis in children. Although traditionally a clinical diagnosis, the diagnosis of acute appendicitis is uncertain in approximately 30% of pediatric patients. In attempts to avoid a misdiagnosis and facilitate earlier definitive care, imaging modalities such as ultrasonography have become important tools. In many pediatric studies, the absence of a visualized appendix with no secondary sonographic features has been reported as a negative study result, and a study where the appendix is not seen but demonstrates secondary features is often deemed equivocal. With ultrasound appendiceal detection rates reported at 60% to 89%, the dilemma of the nonvisualized appendix or equivocal study is frequently faced by clinicians. OBJECTIVE: This study aimed to assess the value of the nonvisualized appendix on ultrasound and the association of secondary sonographic findings in pediatric patients with acute right lower quadrant pain undergoing ultrasound, in whom acute appendicitis was a diagnostic consideration. METHODS: Retrospective case review of 662 consecutive children (age < 18 years) presenting to a pediatric emergency department with clinically suspected appendicitis, who had graded compression sonographic studies during the 24-month study period, was performed. RESULTS: The appendix could not be visualized in 241 studies (37.7%). An alternate diagnosis was identified via sonography in 47 patients (19.5%). Twenty-five patients (12.9%) were taken for surgery where 17 (8.8%) had acute appendicitis confirmed via pathology. The specificity of moderate-to-large amounts of free fluid is 98%, phlegmon at 100%, pericecal inflammatory fat changes at 98%, and any free fluids with prominent lymph nodes at 81%. The odds ratio of appendicitis increases from 0.56 to 0.64 to 2.3 and 17.5, respectively, when there were 2 and 3 ultrasonographic inflammatory markers identified. CONCLUSIONS: Although uncommonly seen, large amounts of free fluid, phlegmon, and pericecal inflammatory fat changes were very specific signs of acute appendicitis. In the absence of a distinctly visualized appendix, the presence of multiple secondary inflammatory changes provides increasing support of a diagnosis of acute appendicitis.

Sudden-onset back pain and cauda equina syndrome in an adolescent: a case report.

Recent epidemiological studies have shown that childhood back pain is a common complaint often prompting medical attention and that it is infrequently the result of serious etiology. This challenges the traditional view that childhood back pain was an uncommon and ominous symptom, always indicative of significant pathology. We report the case of an adolescent boy who presented to the pediatric emergency department with what initially seemed to be benign back pain. This case illustrates an extremely rare ED presentation of myxopapillary ependymoma, which rapidly evolved into cauda equina syndrome requiring urgent neurosurgical intervention. A review of pediatric back pain and cauda equina syndrome is presented.

Cerebral sinovenous thrombosis masquerading as migraine: a case report.

Headaches are common during childhood and a common pediatric presentation to emergency departments (EDs). The most common diagnoses for acute headache in the pediatric ED are viral upper respiratory tract infection with fever, sinusitis, and migraine, accounting for 70% to 75% of presentations; serious neurologic diagnoses are rare. Most literature recommends against neuroimaging for uncomplicated headache given the absence of any other signs or symptoms associated with causes of intracranial pathology and the presence of a normal physical examination. Cerebral sinovenous thrombosis (CSVT) is a rare entity whose diagnosis relies heavily on neuroimaging and which carries high morbidity and mortality if untreated. Pediatric CSVT has yet to be presented in the emergency medicine literature. We report the case of a child who presented to the pediatric ED with headache, which was complicated by background difficulties with aggression and other behavioral issues. This case illustrates an extremely rare ED presentation of CSVT masquerading as migraine headache and discusses the diagnostic dilemma of neuroimaging.