Metabolic Emergency in Flight.

Young children with inborn errors of metabolism often present to medical care in extremis, although their symptoms can be nonspecific. Rare metabolic disorders are not always on the statewide newborn screening panels, so infants and children can present later in life with vomiting, altered mental status, seizures, coma, or death, without any indication prior of a metabolic disorder. Swift transport to a pediatric specialty center can be lifesaving and prevent neurologic damage in these patients while awaiting definitive testing for these genetic disorders. Transport of these patients is complicated because they are often critically ill yet do not respond normally to routine resuscitation. In this case, we describe the transport of a patient with a rare, undifferentiated inborn error of metabolism with a pediatric specialty flight team and the considerations made in resuscitation and treatment of this patient in flight.

Human Trafficking: When to Suspect in the Pediatric Emergency Department?

ABSTRACT: Human trafficking, which includes sexual exploitation and forced labor, affects youth throughout the world. Victims are subject to coercion, exploitation, and repeated trauma. Given the secretive nature of this abuse, it can be difficult to identify victims. Past experience shows that most victims interact with the healthcare system at some time while they are in the control of a trafficker, providing an opportunity for healthcare providers to identify, support, and intervene. In this CME review article, we describe human trafficking, its estimated prevalence, and the identification, evaluation, and management of patients who are victims of human trafficking. Finally, we provide additional resources for practitioners and patients.

Confidential Screening for Sex Trafficking Among Minors in a Pediatric Emergency Department.

OBJECTIVES: Child sex trafficking is a global health problem, with a prevalence of 4% to 11% among high-risk adolescents. The objective of this study was to confidentially administer a validated screening tool in a pediatric emergency department by using an electronic tablet to identify minors at risk for sex trafficking. Our hypothesis was that this modality of administration would adequately identify high-risk patients. METHODS: English- and Spanish-speaking patients from the ages of 12 to 17 years presenting to a large urban pediatric emergency department with high-risk chief complaints were enrolled in a prospective cohort over 13 months. Subjects completed a previously validated 6-item screening tool on an electronic tablet. The screening tool's sensitivity, specificity, and positive and negative predictive values were calculated. Multivariable logistic regression was performed to identify additional risk factors. RESULTS: A total of 212 subjects were enrolled (72.6% female; median age: 15 years; interquartile range 13-16), of which 26 patients were subjected to child sex trafficking (prevalence: 12.3%). The sensitivity and specificity of the electronic screening tool were 84.6% (95% confidence interval [CI] 70.8%-98.5%) and 53.2% (95% CI 46.1%-60.4%), respectively. The positive predictive value and negative predictive value were 20.2% (95% CI 12.7%-27.7%) and 96.1% (95% CI 92.4%-99.9%), respectively. A previous suicide attempt and history of child abuse increased the odds of trafficking independent of those who screened positive but did not improve sensitivity of the tool. CONCLUSIONS: A confidentially administered, previously validated, electronic screening tool was used to accurately identify sex trafficking among minors, suggesting that this modality of screening may be useful in busy clinical environments.

Latrodectus Facies After Latrodectus Hesperus Envenomation in a Pediatric Patient.

BACKGROUND: Black widow spider (Latrodectus spp) envenomation represents the most medically significant spider envenomation in the United States, prompting more than 2500 calls to poison centers annually. The female spider, which is responsible for symptomatic envenomations, is classically described as a shiny black spider with a red hourglass-shaped marking on the ventral abdomen. Clinical features of envenomation include painful muscle cramping, abdominal pain, and autonomic disturbances, such as tachycardia, hypertension, and diaphoresis. "Latrodectus facies" or "facies latrodectismica" is an additional distinctive but rarely described clinical finding characterized by periorbital edema, lacrimation, and blepharospasm. CASE REPORT: A 6-year-old female developed the typical clinical features of Latrodectus envenomation after being found in bed with a Western black widow spider (Latrodectus hesperus) with no ventral marking. She initially improved with opioid analgesia, but 6 h later her symptoms worsened again, and concurrent with this worsening she developed Latrodectus facies. She received additional opioid analgesia and all her symptoms resolved within 24 h. Her mother provided informed and written consent for the acquisition and publication of the facial photographs presented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A high degree of clinical suspicion is necessary to correctly diagnose Latrodectus envenomation, especially when the spider escapes unnoticed or in young children in whom the bite is not witnessed. To our knowledge, Latrodectus facies has not been reported previously in a young child, and recognition of this finding will aid clinicians in limiting unnecessary interventions and administering appropriate therapy.

Structured inpatient evaluation of neonatal cardiac ectopy.

OBJECTIVE(S): In well-appearing newborns with suspected cardiac ectopy, we sought to evaluate our practice and test whether initial electrocardiogram (ECG) findings were associated with neonatal arrhythmias (NA). STUDY DESIGN: We identified well-appearing, non-anomalous infants >34 weeks' gestation with suspected ectopy over 3.5 years. NA was defined as ≥10% premature atrial contractions (PAC), ≥5 beats of atrial tachycardia, ≥2% premature ventricular contractions (PVCs), or ≥3 beats of ventricular tachycardia. The unadjusted associations between initial ECG findings and NA are reported. RESULT: Among 126 infants with ECGs and Holters performed, NA was observed in 38 patients (30%) and was similar whether PACs were present or not on the initial ECG (33% vs. no PACs: 29%, p = 0.6). However, NAs were identified more frequently based on the presence of PVCs on the initial ECG (83% vs. 25%, p < 0.01). CONCLUSION: NAs were prevalent and both their etiologies and impact on infants warrant future study.