The Jerusalem tribune collapse incident: Challenges in the management of a pediatric mass casualty incident.

OBJECTIVES: Children comprise up to 30-50 percent of all disaster victims. Pediatric disaster medicine is a poorly established field, and most protocols are designed without adequate emphasis on the special needs of the pediatric population. During the 2021 Shavuot holiday in Israel, the collapse of temporary steel bleachers in a partially constructed synagogue resulted in a mass casualty incident (MCI) with a majority of pediatric casualties. This study analyzed the differences in post-incident casualty management, treatment, and outcomes in three Jerusalem medical centers. METHODS: Multicenter retrospective data were collected from two tertiary level 1 trauma centers and one secondary hospital in Jerusalem. The data included demographics, triage scores, injury mechanisms, medical workups, and the management of the pediatric patients. RESULTS: A total of 171 children and adolescents aged 9-18 years presented to three centers. In two institutions, the triage was performed by a senior emergency medicine physician, and in the third institution, by a senior trauma physician. Different protocols were applied, resulting in significant differences in triage, identification and documentation, admission strategies, adherence, and analgesic treatment. Most patients presented with orthopedic injuries (115/171, 67 percent). A small number had head, chest, abdominal, and multisystem injuries (11, 5, 2, and 2 percent, respectively). CONCLUSION: Pediatric MCI management presents specific challenges. The lack of consistency in triage, registry, and management highlights the need for robust pediatric MCI training programs.

Jerusalem's CoVID-19 Experience-The Effect of Ethnicity on Disease Prevalence and Adherence to Testing.

BACKGROUND: The management of the SARS-CoV-2 pandemic depends amongst other factors on disease prevalence in the general population. The gap between the true rate of infection and the detected rate of infection may vary, especially between sub-groups of the population. Identifying subpopulations with high rates of undetected infection can guide authorities to direct resource distribution in order to improve health equity. METHODS: A cross-sectional epidemiological survey was conducted between April and July 2021 in the Pediatric Emergency Department of the Shaare Zedek Medical Center, Jerusalem, Israel. We compared three categories: unconfirmed disease (UD), positive serology test result with no history of positive PCR; confirmed disease (CD), history of a positive PCR test result, regardless of serology test result; and no disease (ND), negative serology and no history of PCR. These categories were applied to local prevailing subpopulations: ultra-orthodox Jews (UO), National Religious Jews (NRJ), secular Jews (SJ), and Muslim Arabs (MA). RESULTS: Comparing the different subpopulations groups, MAs and UOs had the greatest rate of confirmed or unconfirmed disease. MA had the highest rate of UD and UO had the highest rate of CD. UD significantly correlated with ethnicity, with a low prevalence in NRJ and SJ. UD was also associated with larger family size and housing density defined as family size per number of rooms. CONCLUSION: This study highlights the effect of ethnicity on disease burden. These findings should serve to heighten awareness to disease burden in weaker populations and direct a suitable prevention program to each subpopulation's needs. Early awareness and possible intervention may lower morbidity and mortality.

Central Line Repair in Pediatric Patients in the Pediatric Emergency Department by Emergency Physicians-A Single-Center Experience.

INTRODUCTION: Central venous catheters are more common with advanced treatments for a variety of conditions. These catheters may need to be repaired after local damage. This has been performed by those more involved with catheter placement such as pediatric surgeons and interventional radiologists. Gastroenterologists who treat many of these patients have also been involved with catheter repair. Repair by pediatric emergency physicians has not been explored. Such repairs by the emergency physician may be time saving and avoid unnecessary admissions. METHODS: This was a retrospective study of a single center's experience with catheter repair. The performers and outcomes were compared. RESULTS: During the study period, 52 catheter repairs were performed on 7 children. Forty of the repairs were performed by a pediatric emergency physician, 5 by pediatric surgeons, and 5 by interventional radiology. All but 1 repair was successful. Infectious complications were reported in 3 cases. None required catheter removal. The length of stay was significantly shorter for repair by emergency physician. CONCLUSIONS: Central line catheter repair can be performed successfully by pediatric emergency physician with minimal complications. A dedicated process of repair tutoring is required and may avoid infectious complications.

Return Visits in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department for Fever.

Fever in infants presenting to pediatric emergency departments (PEDs) often results in significant return visits (RVs). This retrospective study aimed to identify factors associated with RVs in febrile infants aged 0 to 90 days. Data from infants presenting to PED between 2018 and 2021 and returning within 7 days (RV group) were compared to age-matched febrile infants without RVs (control group). Each group had 95 infants with similar demographics and medical history. RVs were primarily due to positive cultures and persistent fever. The control group had higher initial hospitalization rates, longer PED stays, and increased antibiotic treatment. Prevalence of serious bacterial infections (SBIs) did not significantly differ. Higher hospitalization, prolonged PED stays, and initial antibiotic treatment were associated with reduced RV incidence despite similar SBI rates. Return visits in infants <90 days were primarily driven by persistent fever and positive cultures. Addressing these factors through targeted parental education and improved care protocols may reduce RVs.

Bacterial Infections and Clinical Outcomes Among Febrile Infants up to 90 Days Old With SARS-CoV-2 Infection: A Multicenter Cohort Study.

We present a large, multicenter, cohort study that aimed to assess bacterial infection rates among febrile infants up to 90 days old presenting to the pediatric emergency department with severe acute respiratory syndrome coronavirus 2 infection during 2021-2022 throughout successive variant waves. Overall, 417 febrile infants were included. Twenty-six infants (6.2%) had bacterial infections. All bacterial infections consisted of urinary tract infections, and there were no invasive bacterial infections. There was no mortality.

Serious Bacterial Infections in Preterm Infants: Should Their Age Be "Corrected"?

Adjusting the chronological age of preterm infants according to their gestational age is a widely accepted practice in the field of neurodevelopment. It has been suggested for the assessment of preterm infants with suspected infection, but has been poorly validated. Correcting for chronological age is especially critical in infants with a chronological age above 3 months, but a corrected age below 3 months due to the differences in assessment protocols. This study assessed the difference in incidence of serious bacterial infection (SBI) according to chronological and corrected age in preterm infants. A retrospective analysis of pediatric emergency department (PED) presentations was conducted for all 448 preterm infants born in between January 2010 and August 2019. Of the 448 preterm infants, 204 (46%) presented at one of 3 PEDs in Jerusalem, Israel, during their first year of life. Overall, 141 (31.4%) presented with fever and were included in the study. The infants were divided into 3 age groups: 1-corrected age >3 months; 2-chronological age >3 months, but corrected age <3 months; 3-chronological and corrected age <3 months. SBI was diagnosed in 2.6%, 16.7%, and 33.3% of the infants in groups 1, 2 and 3, respectively; (p < 0.01, p = 0.17, p < 0.001). The incidence of SBI in the control group of 300 term infants <3 months presenting to the PED due to fever was 15.3%. Preterm infants with a corrected age <3 months are at increased risk for SBI, similarly to term infants <3 months of age. Age correction should thus be considered for preterm infants presenting with fever.

Leukocytosis and C-Reactive Protein Levels as Indicators of Infection in Children With Diabetic Ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is one of the serious complications of type 1 diabetes mellitus and may be aggravated by infection. Diagnosing an infection in a patient with DKA is often complicated because of the overlap of symptoms and the presence of leukocytosis in both conditions. Reliable indicators for the diagnosis of bacterial infection in DKA may reduce unnecessary use of antibiotics and enable closer monitoring of patients at risk. METHODS: This is a retrospective study. The study cohort included 180 children and adolescents with type 1 diabetes mellitus who were admitted to the Pediatric Emergency Department at Shaare Zedek Medical Center and had blood test results. We compared white blood cell count, C-reactive protein (CRP) levels, blood glucose levels, pH, the degree of acidosis, and the incidence of infection in patients with and without DKA. RESULTS: The incidence of probable bacterial infection in the entire cohort was 13.9%: 15.7% in the DKA group and 7.5% in the non-DKA group ( P = 0.65). The incidence of leukocytosis was significantly higher in patients with DKA ( P = 0.0003), although this was not related to bacterial infection. The CRP levels were higher in the DKA group with infection than without infection, and this was statistically significant ( P = 0.008). CONCLUSIONS: Our findings suggest that leukocytosis in DKA is not a reliable indicator of concomitant bacterial infection. In contrast, CRP levels were not related to the DKA or degree of acidosis and were significantly higher in patients with infection within the DKA group, and are therefore a more reliable indicator of concomitant infection in these patients.

Antibiotics for Clinical Dysentery in the Pediatric Emergency Department.

BACKGROUND: Clinical dysentery causes hundreds of thousands of deaths annually worldwide. However, current recommendations reserve antibiotics for those either clinically sick or with highly suspected cases of shigellosis. This treatment stems from rising antibiotic resistance. Children diagnosed with clinical dysentery in the pediatric emergency department (PED) are regarded more cautiously. OBJECTIVES: To explore the use of antibiotics in children diagnosed with clinical dysentery in the PED. METHODS: A retrospective case study of children with clinical dysentery at a single PED during the years 2015 and 2018. Demographics as well as clinical findings were compared to culture results and antibiotic treatment. RESULTS: The study included 281 children who were diagnosed with clinical dysentery during the study period; 234 (83%) were treated with antibiotics. However, cultures were positive in only 162 cases (58%). Only 32% were Shigella spp. Younger age, fever, and leukocytosis were related to antibiotic treatment. CONCLUSIONS: The diagnosis of clinical dysentery is misgiven commonly in the PED leading to widespread use of antibiotics when not indicated. This treatment may impact antibiotic resistance patterns. Further studies and interventions are necessary to create clear guidelines in the PED setting.

Nighttime Sedations in the Pediatric Emergency Department: A Single-Center Experience.

INTRODUCTION: Procedural sedation and analgesia (PSA) is the standard of care for many procedures in the pediatric emergency department (PED). Although generally performed by skilled PED physicians, in Israeli PEDs, during nighttime hours, it is mainly performed by pediatric residents. The safety of PSA by residents is considered comparable yet has not been evaluated regarding nighttime performance. METHODS: A retrospective study review of PSA performed in the PED at night (1:00 a . m .-7:00 a . m .). To evaluate these events, we compared each case of nighttime PSA to 2 daytime PSA cases from 2017 to 2019. Adverse events were evaluated using the Quebec criteria. RESULTS: The study included 451 sedations performed on 438 children from January 2017 to January 2019. Adverse events (AEs) occurred in 29 (6.4%) of the sedations. Serious AEs were uncommon. This included mostly bag-valve-mask ventilation used in 13 (2.9%) of the cases. Of these, 12 were daytime sedations. There was a clear association between abscess drainage during daytime hours and AEs. CONCLUSIONS: Sedations performed during nighttime hours by pediatric residents seem safe and effective. This should strengthen the empowerment of residents to perform sedations when necessary even at late hours of the night. Recognizing cases at higher risk may avoid possible AEs.

Removal of external auditory canal foreign bodies in the pediatric emergency department - A retrospective comparison study.

INTRODUCTION: The removal of foreign bodies from the external auditory canal (EAC) is a common cause of referral to the pediatric emergency department (PED). The attempt at removal of foreign bodies can lead to complications ranging from mild canal injuries and through severe inner ear damage. The removal requires knowledge and expertise. Ear, Nose and Throat (ENT) physicians are considered the most qualified to remove these foreign bodies. The decision of when the ENTs need to be involved is debated. METHODS: A retrospective analytical comparison study was conducted. The study included all children admitted to the PED for EAC foreign body removal, between the years 2009-2019. RESULTS: A total of 333 children were included in the study. The mean age was 6.53 years. Success rate of the procedure on the first attempt performed by pediatricians was 82.4% and when performed by ENT physicians the success rate was 96.1%. However, when those with a previous attempt of removal were removed from the study the success rates of PED physicians were 93.9% and of ENT physicians were 96.8%. CONCLUSION: This single center study shows that with correct case evaluation, the PED physician can and should succeed in EAC FB removal with minimal complications and comparable to ENT performance. If a first attempt failed, an ENT consult is warranted.

Triage performance in adolescent patients with SARS-CoV-2 infection in Israel.

OBJECTIVE: The aim of this study was to assess the performance of the Pediatric Canadian Triage and Acuity Scale (PaedCTAS) in adolescent patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: A time-series study was conducted in the Emergency Departments (EDs) of 17 public hospitals during the Delta (B.1.617.2) variant spread in Israel. Data were collected prospectively from June 11, 2021 to August 15, 2021. Multivariate regression analyses were performed to identify independent variables associated with hospital admission and with admission to an Intensive Care Unit (ICU). RESULTS: During the study period, 305 SARS-CoV-2 patients ages 12-18 years presenting to the ED were included, and 267 (87.5%) were unvaccinated. Sixty-seven (22.0%) and 12 (3.9%) patients were admitted to pediatric wards and ICUs, respectively. PaedCTAS level 1-2 and the presence of chronic disease increased the odds of hospital admission (adjusted odds ratio (aOR) 5.74, 95% CI, 2.30-14.35, p < 0.0001), and (aOR 2.9, 95% CI, 1.48-5.67, p < 0.02), respectively. PaedCTAS level 1-2 and respiratory symptoms on presentation to ED increased the odds of ICU admission (aOR 27.79; 95% CI, 3.85-176.91, p < 0.001), and (aOR 26.10; 95% CI, 4.47-172.63, p < 0.0001), respectively. PaedCTAS level 3-5 was found in 217/226 (96%) of the patients who were discharged home from the ED. CONCLUSIONS: The findings suggest that PaedCTAS level 1-2 was the strongest factor associated with hospital and ICU admission. Almost all the patients who were discharged home had PaedCTAS level 3-5. Study findings suggest good performance of the PaedCTAS in this cohort.

"Feed and Swaddle" method of Infants Undergoing Head CT for minor head injury in the pediatric emergency department - A comparative case review.

INTRODUCTION: Brain imaging for suspected significant head injuries in pediatric emergency departments is an important and time-sensitive procedure. The use of sedation to successfully complete imaging can be limited due to young age and other injury related factors. Using a non-pharmacological method using feeding and swaddling can be used. This may obviate the need for sedation but can be time consuming. METHODS: A retrospective study of all children undergoing brain imaging for head injury during the years 2016-2021. Use of sedation, time to completion and imaging findings were compared. RESULTS: Of 281 children requiring brain imaging, 268 (95.4%) were completed using the feed and swaddle method. Time to imaging completion was similar between sedation and feed and swaddle groups (85.5 min vs. 86 min). Abnormal findings on imaging were found in 186 (69.4%) in the feed and swaddle group and in 10 (77%) of the sedation group. No adverse events were seen in the sedation group. CONCLUSION: Using the feed and swaddle method can help lower the need for sedation in the under 1 year age group with a successful and timely completion of brain imaging.

Management of intraorbital infections in the pediatric emergency department.

Intraorbital infections may lead to severe complications, necessitating rapid diagnosis and intervention. The decision process regarding the need for emergent imaging and possible surgical intervention is unclear in the literature. This retrospective cohort study included two major pediatric emergency departments in Israel between 2010 and 2020. Patients arriving at the emergency department with an admission diagnosis of intraorbital infection and at least one high-risk symptom for orbital involvement were included in the study. The main outcome measures were the computerized tomography (CT) timing and results, whether the case was managed surgically or conservatively and whether the patient returned to the same hospital with significant complications. Ninety-five patients were included; 70 underwent a CT scan in the first 24 h, and of those 21 were managed surgically; 16 were treated based on clinical findings alone, with no imaging performed. When comparing groups based on management, we found no significant differences based on presenting symptoms, duration of complaints, or severity of CT findings. However, having three or more high-risk presenting symptoms was associated with a greater likelihood of surgical intervention (multivariate logistic regression p = 0.069, odds ratio 1.73, 95% confidence interval 0.96-3.11; one-way ANOVA and Fisher's exact test p < 0.05). CONCLUSION: The decision to treat intraorbital infections at our institutions appears to be based on clinical impression of disease severity rather than radiologic findings. This suggests a need for further interdisciplinary studies to clarify optimal management. WHAT IS KNOWN: • Orbital c ellulitis is associated with significant potential complications, necessitating rapid diagnosis and treatment. • Present literature provides insufficiently clear guidance on emergency department management. WHAT IS NEW: • Consideration of all relevant factors (clinical features, laboratory findings, timing of imaging, and conservative vs. surgical management) in a single retrospective cohort. • Our findings suggest that decision-making in practice may be guided by clinical impression rather than imaging.

Pediatric Hospitalizations After School Reopening During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Alpha (B.1.1.7) Variant Spread: A Multicenter Cross-sectional Study in Israel.

This multicenter, cross-sectional study provides evidence on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated emergency department visits and hospitalizations in pediatric wards and intensive care units after school reopening during the SARS-CoV-2 Alpha (B.1.1.7) variant spread in Israel. Study findings suggest that school reopening was not followed by an increase in SARS-CoV-2-related pediatric morbidity.

The ongoing indirect effect of the COVID-19 pandemic on a pediatric emergency department.

INTRODUCTION: The SARS-CoV-2 coronavirus pandemic may cause significant morbidity and mortality in adults, yet severe cases are rare among children. The indirect impact of the pandemic on health care delivery in general and pediatric emergency department (PED) visits in particular has been widely reported. AIMS: To assess the impact of the pandemic and the social restrictions imposed in its wake on PED visits and hospitalization rates in our Israeli medical center. We also sought to track these data in relation to the variation in pandemic severity and social restrictions over time. A comparison of this data with that of the adult emergency department was also performed. METHODS: Data for this study were drawn from the Shaare Zedek Medical Center (SZMC), Jerusalem, Israel computerized databank. The daily number of PED and adult ER visits as well as hospitalizations resulting from these visits during the months January-July during the years 2018, 2019, 2020 were recorded. We compared the risk ratio for hospitalization in 2019 and 2020, as well as the incidence rate ratio. RESULTS: During March and April there was a decrease in PED visits from 4,588 visits in 2019 to 2,527 visits in 2020 (ratio = .551, 95%CI [.52,.58]. Despite the drop in PED visits, the rate of hospitalizations rose with respect to 2019 (Risk Ratio = 1.31, p < .001, 95%CI [1.17,1.47]). Similar but more moderate trends were seen in the adult ED. From May-July 2020, after the lockdown was lifted, PED visits remained 30% below the same time period from 2018 and 2019, while the hospitalization rate returned to its pre-pandemic level. CONCLUSIONS: A significant drop in PED visits is seen to extend well beyond the peak of the pandemic and the lockdown period. This highlights the potential risk of children with serious emergencies becoming casualties of the pandemic by their not being brought to medical attention. Efforts should be made to raise public awareness among parents and other caretakers of children regarding this matter.

The role of Staphylococcus lugdunensis as a pathogen in children: a multicentre retrospective study.

Introduction: Staphylococcus lugdunensis (SL), a tube coagulase negative Staphylococcus, is known to be pathogenic in adults, causing mainly skin infections.Gap Statement: Previous studies assessing SL's role in paediatric populations are sparse and are mainly limited to case reports.Aim: Present the clinical characteristics consistent with SL infections and its putative role as a pathogen in the paediatric population.Methodology: A retrospective multicentre study was conducted in four paediatric medical centres in Israel. Patients with isolates of SL presenting between 2009-2019 were included.Results: SL was isolated from 40 patients. Average (±SD) age at presentation was 5.9 (±6.2) years, with 22 (55 %) being female. Skin, soft tissue and musculoskeletal infections were the most common (n=20, 50%) followed by ear infections (n=13, 32.5%). Five cases of urine isolates and two isolates from blood culture samples were also reported. Skin abscess was the most common infection among skin and soft tissue isolates, reported in 17 children (85%) with SL being the only pathogen in 15 (75%). Otitis media was the most common ear infection accounting for 12 (92%) of all cases with SL as the only isolate reported in 6 (46%). Five cases of SL isolates from urine specimens were reported, all of which with poor growth of bacteria and normal urinalysis. Two cases of SL growth in blood culture were found in children presenting with signs and symptoms consistent with invasive blood stream infection.Conclusions: In the paediatric population, studied infections caused by SL are increasingly observed. The results of this study highlight its role as a pathogen in soft tissue infections and its putative role in otitis media and invasive blood stream infections. However, the role of SL as an uropathogen was not established.

Can parental simulation improve neonatal CPR performance? A pilot study.

Basic life support training and instruction is recommended for parents of premature infants discharged from the hospital. In order to assess the short-term efficacy of basic life support simulation, in addition to the institutional training, a prospective single-blinded randomized interventional study was performed. The study group received, besides the institutional training, an additional simulation training. The control group had only traditional training. A test assessment was followed approximately a week later and evaluated by two investigators. Fifty parents participated. Nineteen (38%) were in the study group. The study group showed a significant improvement in all the parameters assessed.Conclusion: The addition of a simulation encounter before discharge may improve short-term parental performance of basic life support. What is Known: • Parents of newborns at risk receive institutional training in basic life support. • The retention of knowledge from this training is a point of concern for parents. What is New: • A single simulation encounter for parents improved resuscitation performance. • Simulation for parents may be an important and useful tool to improve the efficacy of basic life support training.

Diabetic Ketoacidosis at Emergency Department Presentation During the First Months of the SARS-CoV-2 Pandemic in Israel: A Multicenter Cross-Sectional Study.

INTRODUCTION: We aimed to examine the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on diabetic ketoacidosis (DKA) rates in children with type 1 diabetes (T1D). METHODS: A retrospective cross-sectional study of 11 Israeli pediatric emergency departments (ED) was conducted. Children with T1D who attended the ED between March 1, 2020 and May 31, 2020 were compared with those who attended the ED between March 1, 2019 and May 31, 2019. RESULTS: Overall, 150 and 154 children with T1D attended the EDs during the 3-month study periods in 2020 and 2019, respectively. Among patients with established T1D, DKA rates significantly increased in 2020 compared to 2019 [38/64 (59.3%) vs 31/74 (41.9%); p < 0.043]. There was a non-statistically significant trend toward a higher rate of DKA in patients with newly diagnosed T1D [46/86 (53.4%) vs 31/80 (38.7%); p = 0.063]. No differences were observed in the rates of severe DKA in 2020 compared to 2019 among patients with established T1D [10/64 (15.6%) vs 6/74 (8.1%); p = 0.184], and newly diagnosed T1D [16/86 (18.6%) vs 14/80 (17.5%); p = 0.858]. No differences were observed in the rates of intensive care unit admissions in 2020 compared to 2019 among patients with established T1D [14/64 (21.8%) vs 14/74 (18.9%); p = 0.672], and newly diagnosed T1D [26/86 (30.2%) vs 21/80 (26.2%); p = 0.977]. CONCLUSIONS: Increased rates of DKA in children with established T1D were observed during the first 3 months of the outbreak in Israel. The findings suggest that the severity of DKA at ED presentation in children with T1D was not influenced by the pandemic.