Pediatric Ovarian Torsion: Should You Go With the Flow?

OBJECTIVES: Ovarian torsion (OT) is an emergency that mandates early detection and surgical detorsion to avoid catastrophic consequences of further adnexal injury. Prompt ultrasound is critical for accurate diagnosis. Traditionally, evaluation of arterial and venous flow was used as a diagnostic tool for OT, but recent radiologic research has indicated that ovarian size and size discrepancy between sides is a better diagnostic criterion. This study seeks to determine whether ovarian size discrepancy or vascular flow to the ovary is more accurate in the diagnosis of OT in the pediatric emergency population and to better describe symptoms that distinguish OT from other abdominal and pelvic pathology. METHODS: This was a retrospective, cross-sectional study evaluating all female pediatric patients, aged 1 to 18 years, who underwent a pelvic ultrasound to evaluate for OT over a 2-year period in our pediatric emergency department. Patients suitable for inclusion were identified via Nuance mPowerTM, a search engine that provides clinical analytics based on radiology reports generated within our institution. RESULTS: We reviewed the medical records of 193 female patients aged 1 to 18 years, all of whom had a pelvic ultrasound (with or without Doppler) to evaluate for OT during the study period. In comparing ovarian size on ultrasound, patients with OT had a significantly larger magnitude of difference in ovarian volume than patients without torsion (5.57× [interquartile range, 3-12.5] vs 1.56× [interquartile range, 1.24-2.25; P < 0.001]). Ovarian torsion was associated with a 33-fold increased risk of lack of arterial flow (relative risk, 33.33) and with a 9-fold increased risk of lack of venous flow (relative risk, 9.27), when compared with those patients without OT. Patients with OT were significantly more likely to have emesis and peritoneal signs on examination, as well as previous history of OT (P = 0.01, 0.02, and 0.002, respectively) than those without OT. All patients with OT reported abdominal pain. CONCLUSIONS: We found that a large size discrepancy between ovaries is indicative of OT. Our data also suggest that presence of Doppler flow on ultrasound cannot be used to exclude OT but that lack of Doppler flow on ultrasound is a significant diagnostic marker. As previous studies have also found, clinical symptoms of OT are nonspecific and do not offer any certainty in differentiating OT from other pathologies.

Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines.

OBJECTIVES: Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. METHODS: A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. RESULTS: This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. CONCLUSIONS: Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.

Dazed and Confused: Altered Mental Status in an Adolescent Male.

BACKGROUND: Absence status epilepticus (ASE) is a form of generalized nonconvulsive status epilepticus. ASE is characterized by impairment in consciousness, which can vary widely, making the diagnosis more difficult. The typical patient with ASE will be confused yet responsive and in a "trance-like state" with delayed speech, clumsy gait, and the ability to perform simple tasks after prompting. With treatment, typical ASE has an excellent prognosis and does not appear to be associated with significant neuronal damage. CASE PRESENTATION: An 11-year-old boy with history of febrile seizures presented to the emergency department (ED) with altered mental status without trauma or ingestion. His vital signs and physical examination were normal, with the exception of appearing intoxicated with sparse verbalization and inappropriate emotional responses. All laboratory results and imaging were unremarkable. While in the ED, his neurologic examination trended toward normal, returning almost to baseline. He was admitted to the hospital for video electroencephalogram, which revealed status epilepticus. After benzodiazepine therapy, epileptic electrical activity ceased and the patient's symptoms resolved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ASE is a rare condition that is uncommonly described in the pediatric population. These patients are frequently misdiagnosed on initial presentation as their alteration in mental status can be easily confused with ingestion, trauma, psychiatric illness, or infectious etiologies. Overturning the long-standing emergency dogma of "if they're talking to you, it's not a seizure" is undoubtedly difficult, but both pediatric and adult providers should be aware of this clinical entity.

Pediatric Emergency Medicine Training in Procedural Sedation: Is It Time for a Standardized Curriculum?

OBJECTIVES: Pediatric procedural sedation (PS) has been performed with increasing frequency by pediatric emergency physicians for recent years. Accreditation Council for Graduate Medical Education Pediatric Emergency Medicine fellowship core competency requirements do not specify the manner in which fellows should become proficient in pediatric PS. We surveyed the variety of training experience provided during fellowship and whether those surveyed felt that their training was sufficient. METHODS: A 35-question survey offered to pediatric emergency fellows and recent (within 10 years) graduates collected data on pediatric PS training during fellowship. A follow-up questionnaire was sent to fellowship directors at programs where fellow or graduate respondents stated that a sedation curriculum that existed asked details of their program. RESULTS: There were 95 respondents to the survey, 62% of which had completed pediatric emergency medicine fellowship training. Of respondents, 65% reported having a formal sedation curriculum during fellowship. Of those who participated in a formal curriculum, 82% of respondents felt comfortable performing sedation, whereas the remaining 18% required additional preceptorship and/or more formal training to feel proficient. Fifty-six percent of respondents reported having to complete a set number of sedations before being allowed to sedate independently. Of 17 programs contacted, 9 fellowship directors responded. All 9 included didactics, 6 (66.6%) of 9 included evidence-based medicine literature review, and 6 (66.6%) of 9 included simulation. Other modalities used included supervised clinical experience in a pediatric sedation unit, a 2-week rotation with a hospital sedation team, online sedation modules, and precepted sedations using each pharmacologic agent including nitrous oxide, ketamine, propofol, and ketamine-propofol combination. Ketamine was the most frequently used agent for sedation (87%). CONCLUSIONS: Pediatric emergency medicine fellowship requirements lack a clearly defined pathway for training in PS. Data collected from both current and former fellows depict inconsistency in training experience and suboptimal comfort level in performing these procedures. We suggest that fellows receive a more comprehensive and varied experience with multiple teaching modalities to improve proficiency with this critical and complex aspect of emergency pediatric care.