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.

Does Intravenous Acetaminophen Reduce Opioid Requirement in Pediatric Emergency Department Patients With Acute Sickle Cell Crises?

OBJECTIVE: We evaluated the ability of intravenous (IV) acetaminophen to reduce the amount of opioid medication administered in pediatric patients with sickle cell disease (SCD) having vasoocclusive crisis (VOC) in an emergency department (ED) setting. METHODS: This was a prospective, randomized, double-blind placebo-controlled trial at an academic urban pediatric ED. Participants included patients with SCD, aged 4 to 16 years, with VOC pain. All patients received a 0.1 mg/kg dose of IV morphine, 0.5 mg/kg ketorolac, or both. Patients were randomized to receive either 15 mg/kg IV acetaminophen or placebo. Patients were reassessed every 30 minutes to see whether additional opioid doses were indicated to a maximum of three doses. The total morphine given, pain scores, rates of admissions, 72-hour return visits, and adverse events were assessed for each group. RESULTS: Of 71 subjects randomized, 35 patients in the acetaminophen group and 36 patients in the control group were analyzed. Baseline characteristics and initial pain scores were similar in both groups. The mean total amount of morphine given was 8.6 mg (95% confidence interval [CI] = 6.5 to 10.8) in the acetaminophen group and 8.0 mg (95% CI = 5.9 to 10.2) in the placebo group. The mean total cumulative morphine dosing was 0.2 mg/kg (95% CI = 0.1 to 0.2 mg/kg) in the acetaminophen group and 0.2 mg/kg (95% CI = 0.1 to 0.2 mg/kg) in the control group. The mean pain score at time of disposition was 5.5 (95% CI = 4.3 to 6.6) in the acetaminophen group and 5.2 (95% CI = 4.2 to 6.3) in the placebo group. There were no clinical or statistically significant differences between the rates of admission, 72-hour return visits, or adverse events. CONCLUSION: In this study, patients who received IV acetaminophen did not receive less morphine than patients in the placebo group. Disposition pain scores for the two groups were also equivalent. We conclude that IV acetaminophen, when used in addition to morphine for pediatric sickle cell VOC pain, does not provide an opioid-sparing effect. Further searches for adjunctive nonaddictive pain medicines are indicated.

Lower Gastrointestinal Bleeds: False-Negative and False-Positive Tests.

Lower gastrointestinal bleeding in infants and children is a symptom with a broad differential diagnosis. The diagnosis depends on the quantity and quality of the bleeding and on the patient's age. We describe a case of a 10-month-old infant who presented to our pediatric emergency department 4 times with lower gastrointestinal bleeding before a diagnosis of Meckel diverticulum was made. Although this pathology was strongly suspected at an earlier visit, the initial Meckel scan result was interpreted as normal, and the result of a stool test for Clostridium difficile was positive. The case illustrates that repeat scintigraphy might be necessary when significant bleeding is present even if the results of other tests for diagnosis are positive.

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.

A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures.

OBJECTIVES: The primary objective was to compare the cosmetic outcomes of traumatic trunk and extremity lacerations repaired using absorbable versus nonabsorbable sutures. The secondary objective was to compare complication rates between the two groups. METHODS: This was a randomized controlled trial comparing wounds repaired with Vicryl Rapide and Prolene sutures. Pediatric and adult patients with lacerations were enrolled in the study. At a 10-day follow-up, the wounds were evaluated for infection and dehiscence. After 3 months, patients returned to have the wounds photographed. Two plastic surgeons blinded to the method of closure rated the cosmetic outcome of each wound using a 100-mm visual analog scale (VAS). Using a noninferiority design, a VAS score of 13 mm or greater was considered to be a clinically significant difference. We used a Student's t-test to compare differences between mean VAS scores and odds ratios (ORs) to compare differences in complication rates between the two groups. RESULTS: Of the 115 patients enrolled, 73 completed the study including 35 in the Vicryl Rapide group and 38 in the Prolene group. The mean (±SD) age of patients who completed the study was 22.1 (±15.5) years, and 39 were male. We found no significant differences in the age, race, sex, length of wound, number of sutures, or layers of repair in the two groups. The observer's mean VAS for the Vicryl Rapide group was 54.1 mm (95% confidence interval [CI] = 44.5 to 67.0 mm) and for the Prolene group was 54.5 mm (95% CI = 45.7 to 66.3 mm). The resulting mean difference was 0.5 mm (95% CI = -12.1 to 17.2 mm; p = 0.9); thus noninferiority was established. Statistical testing showed no differences in the rates of complications between the two groups, but a higher percentage of the Vicryl Rapide wounds developed complications. CONCLUSIONS: The use of absorbable sutures for the repair of simple lacerations on the trunk and extremities should be considered as an alternative to nonabsorbable suture repair.

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.

Evaluation of hypertrophic pyloric stenosis by pediatric emergency physician sonography.

OBJECTIVES: The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS). METHODS: This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS. RESULTS: Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively). CONCLUSIONS: Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.

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.