Outcomes of Children Admitted to a Pediatric Observation Unit With a Psychiatric Comanagement Model.

This cohort study describes outcomes of children requiring admission for mental health emergencies who receive psychiatric cotreatment in a pediatric observation unit.

The Evaluation and Management of Pediatric Diabetic Ketoacidosis: A Comprehensive Review.

Diabetic ketoacidosis (DKA) is a common, serious acute complication in children with diabetes mellitus (DM). DKA can accompany new-onset type 1 insulin-dependent DM, or it can occur with established type 1 DM, during the increased demands of an acute illness or with decreased insulin delivery due to omitted doses or insulin pump failure. In addition, DKA episodes in children with type 2 DM are being reported with greater frequency. Although the diagnosis is usually straightforward in a known diabetes patient with expected findings, a sizable proportion of patients with new-onset DM present with DKA. The purpose of this comprehensive review is to acquaint clinicians with details regarding the pathophysiology, treatment caveats, and potential complications of DKA.

Utility Of An Emergency Department Clinical Protocol For Early Identification of Coronavirus Infection.

INTRODUCTION: We assessed the utility of an emergency department (ED) protocol using clinical parameters to rapidly distinguish likelihood of novel coronavirus 2019 (COVID-19) infection; the applicability aimed to stratify infectious-risk pre-polymerase chain reaction (PCR) test results and accurately guide early patient cohorting decisions. METHODS: We performed this prospective study over a two-month period during the initial surge of the 2020 COVID-19 pandemic in a busy urban ED of patients presenting with respiratory symptoms who were admitted for in-patient care. Per protocol, each patient received assessment consisting of five clinical parameters: presence of fever; hypoxia; cough; shortness of breath/dyspnea; and performance of a chest radiograph to assess for bilateral pulmonary infiltrates. All patients received nasopharyngeal COVID-19 PCR testing. RESULTS: Of 283 patients studied, 221 (78%) were PCR+ and 62 (22%) PCR-. Chest radiograph revealed bilateral pulmonary infiltrates in 85%, which was significantly more common in PCR+ (94%) vs PCR- (52%) patients (P < 0.0001). The rate of manifesting all five positive clinical parameters was significantly greater in PCR+ (63%) vs PCR- (6.5%) patients (P < 0.0001). For PCR+ outcome, the presence of all five positive clinical parameters had a specificity of 94%, positive predictive value of 98%, and positive likelihood ratio of 10. CONCLUSIONS: Using an ED protocol to rapidly assess five clinical parameters accurately distinguishes likelihood of COVID-19 infection prior to PCR test results, and can be used to augment early patient cohorting decisions.

Utility of measuring serum creatinine to detect renal compromise in ED patients receiving IV contrast-enhanced CT scan.

OBJECTIVE: The objectives of this study are to determine the efficacy of a roster of clinical factors in identifying risk for renal insufficiency in emergency department (ED) patients requiring intravenous contrast-enhanced CT scan (IVCE-CT) and to help mitigate potential for developing contrast-induced nephropathy (CIN). METHODS: A review was conducted of consecutive ED patients who received IVCE-CT during a 4-month period in our urban ED. The values of ED serum creatinine (SCr) performed were tabulated. The medical records of all patients with an elevated SCr (> 1.4 mg/dL) were reviewed to determine and correlate the presence of clinical risk factors for underlying renal insufficiency. RESULTS: During the 4-month study period, there were 2260 consecutive cases who received IVCE-CT; of these, 2250 (99.6%) had concomitant measurement of SCr. Elevated SCr occurred in 141 patients (6.2%); of these, 75 had a SCr > 2 mg/dL. In all, 139/141 (98.6%) with an elevated SCr had an underlying chronic or acute medical condition identified by medical record review which potentially compromised renal function, including chronic renal disease, diabetes mellitus, HIV infection, cancer, hypertension, congestive heart failure, sepsis/septic shock, chronic alcoholism, and sickle cell disease. Two patients with no identified risk factor each had (mildly) elevated SCr; both had a normal SCr measured post-CT scan. The total cost of performing serum basic metabolic panel to measure SCr in all patients during the 4-month study period was $94,500. CONCLUSIONS: Elevated SCr is rarely present in ED patients without recognized risk factors who receive IVCE-CT scan. The vast majority with underlying renal insufficiency are readily identified by a review of the patient's medical history and/or clinical findings. Routine SCr measurement on all ED patients regardless of risk stratification prior to IVCE imaging is neither time nor cost-effective.

Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians.

BACKGROUND: Intussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists. OBJECTIVE: Our objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT. METHODS: We performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P-and radiology-performed US (RPUS) results was assessed. RESULTS: One hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51-99%; specificity 98%; 95% CI 92-100%; positive predictive value 80%; 95% CI 44-96%; negative predictive value 99%; 95% CI 93-100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07-162.36) and with a negative POCUS was 0.11 (95% CI 0.02-0.72). CONCLUSIONS: POCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department-performed POCUS is a rapid and accurate method for diagnosing INT.

Hepatic Portal Venous Gas Incidentally Associated With Bacterial Enteritis: A Case Report.

Hepatic portal venous gas (HPVG) has long been associated with catastrophic intraabdominal conditions. Advancements in ultrasound (US) and computed tomography (CT) imaging have resulted in an increased number of incidental and clinically benign HPVG cases identified. Causes of clinically benign HPVG include viral gastroenteritis, gastritis, pancreatitis, appendicitis and diverticulitis. Our case demonstrates the first reported case of HPVG in an adolescent patient associated with enteropathogenic E. coli (EPEC). The patient's course was favorable, marked by a short stay in the pediatric intensive care unit (ICU) and did not require surgical intervention. With higher sensitivity of imaging modalities to diagnose both suspected and incidental cases of HPVG, clinicians will be required to consider the risks and benefits of conservative treatment or surgical intervention.