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.

A Prospective Observational Crossover Study Comparing Intubation by Pediatric Residents Using Video Laryngoscopy and Direct Laryngoscopy on a Pierre Robin Simulation Manikin.

INTRODUCTION: Video laryngoscopy (VL) has been proposed to increase the likelihood of successful intubation in patients with predicted difficult airways such as those with Pierre Robin sequence (PRS). Prior studies have focused on the performance of anesthesiologists, who are generally considered airway experts. Our primary aim was to investigate the success rate of intubation using VL compared with direct laryngoscopy (DL) when attempted by pediatric residents on a PRS model. METHODS: Participants were administered a 5-minute refresher video on 2 VL techniques (CMAC, conventional geometry VL, and McGrath, unconventional geometry VL) and DL. The participants were asked to intubate the AirSim PRS infant manikin. The order of VL and DL use was randomly selected. All intubations were video recorded, and the recordings were analyzed by 3 anesthesiologists blinded to the participant's identity and previous experience. RESULTS: Seventeen of 23 residents succeeded in intubating the PRS model using DL. Only 9 residents succeeded in intubating the PRS model using VL (conventional or unconventional geometry). Intubation success rate was higher when comparing DL with VL ( P = 0.04) and similar when comparing VL devices ( P = 0.69). DISCUSSION: Contrary to expectation, the intubation success rate was lower using VL than with DL among pediatric residents. This should be considered when designing residency training and in real-life resuscitation.

Risk Factors for Failure of Closed Forearm Fracture Reduction in the Pediatric Emergency Department.

OBJECTIVES: This study aimed to explore risk factors for failure of forearm fracture closed reduction in the pediatric emergency department (ED) and to suggest indications for initial surgery. METHODS: This retrospective cohort study included all patients aged 0 to 18 years who presented to our pediatric ED with an extraarticular forearm fracture treated with closed reduction between May 2017 and April 2021. We explored risk factors for procedural failure, defined as a need for surgical intervention within 6 weeks of the closed reduction attempt. RESULTS: Of 375 patients (median age 8.1 years, 294 [78.2%] boys), 44 (11.7%) patients sustained a reduction failure, of whom 42 (95.5%) had both radius and ulna fractures. Of the 259 patients with fractures of both bones, the following parameters were independent predictors for reduction failure: refracture (adjusted odds ratio [aOR] 17.6, P < 0.001), open fracture (aOR 10.1, P = 0.007), midshaft fracture (aOR 2.6, P = 0.004), radial translation rate 37% and higher in either plane (aOR 5.1, P = 0.004), and age of 10 years and older (aOR 2.9, P = 0.01). CONCLUSIONS: Most pediatric forearm fractures can be successfully managed by closed reduction in the ED. Two-bone fractures had the strongest association with reduction failure. Refracture, open fracture, midshaft location, initial radius bone translation of 37% and higher (and not initial angulation), and patient age of 10 years and older are independent risk factors for reduction failure in two-bone fractures. We propose a risk score for reduction failure that can serve as a decision-making tool.

C-Reactive Protein and the Outcome of a Pediatric Emergency Department 7 Days Revisit.

BACKGROUND: Pediatric emergency department (PED) return visits represent an important quality of care metric and constitute a patient-centered outcome. C-reactive protein (CRP) is an inflammatory biomarker that is commonly used as screening tool in the PED. In this study, we assessed the clinical outcomes of children whose levels of CRP are 150 mg/L or higher at the initial PED visit and if such levels could be useful in predicting outcomes at a second PED visit. METHODS: A historical cohort study of all patients who visited the PED between July 2007 and June 2017 and had a CRP value of 150 mg/L or greater in the setting of a febrile illness. Data of patients with a return visit to the PED within 7 days were assessed for an association between laboratory values, diagnosis and clinical outcome. RESULTS: One hundred thirty-six index visits were included in this study. One hundred fifteen (84.6%) of the revisits were discharged after their second visit, and 21 (15.4%) were admitted to the inpatient unit. Admitted patients did not differ from patients who were discharged home in diagnosis and CRP levels, but a difference in white blood cell and absolute neutrophil counts was observed. CONCLUSIONS: The intensity of the inflammatory response, as expressed by the high concentrations of CRP in children, does not seem to predict the outcome at a repeat PED visit within 7 days.

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.

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.

Emergency department impaired adherence to personal protective equipment donning and doffing protocols during the COVID-19 pandemic.

OBJECTIVES: Coronavirus Disease 2019 (COVID-19) is a highly infectious viral pandemic that has claimed the lives of millions. Personal protective equipment (PPE) may reduce the risk of transmission for health care workers (HCWs), especially in the emergency setting. This study aimed to compare the adherence to PPE donning and doffing protocols in the Emergency Department (ED) vs designated COVID-19 wards and score adherence according to the steps in our protocol. DESIGN: Prior to managing COVID-19 patients, mandatory PPE training was undertaken for all HCWs. HCWs were observed donning or doffing COVID-19 restricted areas. SETTING: Donning and doffing was observed in COVID-19 designated Emergency department and compared to COVID-19 positive wards. PARTICIPANTS: All HCWs working in the aforementioned wards during the time of observation. RESULTS: We observed 107 donning and doffing procedures (30 were observed in the ED). 50% HCWs observed donned PPE correctly and 37% doffed correctly. The ED had a significantly lower mean donning score (ED: 78%, Internal: 95% ICU: 96%, p < 0.001); and a significantly lower mean doffing score (ED: 72%, Internal: 85% ICU: 91%, p = 0.02). CONCLUSIONS: As hypothesized, HCWs assigned to the designated ED wing made more protocol deviations compared with HCWs positive COVID-19 wards. Time management, acuity, lack of personnel, stress and known COVID-19 status may explain the lesser adherence to donning and doffing protocols. Further studies to assess the correlation between protocol deviations in use of PPE and morbidity as well as improvement implementations are required. Resources should be invested to ensure PPE is properly used.

Heat stroke: knowledge and practices of medical professionals in pediatric emergency medicine departments - a survey study.

BACKGROUND AND IMPORTANCE: Heat stroke is a life-threatening condition affecting children worldwide. Rapid cooling remains the most important feature of emergency management. The accepted preferred method of evaporative cooling in the ED as listed by the reference text book endorsed by the Israeli Society of Pediatric Emergency Medicine (PEMI), is actively cooling the patient by spraying him with water and positioning fans to blow air across the body. OBJECTIVE: This study aimed to assess Israeli health care workers (HCWs) medical professionals' knowledge and preparedness of treating heat stroke and recommend policy changes to ensure better treatment based on survey results. DESIGN, SETTINGS AND PARTICIPANTS: A cross-sectional survey of all HCWs working in an ED that accepts children was conducted. An online questionnaire was utilized to assess heat stroke management practices and available resources in all Israeli pediatric emergency departments (PEDs). MAIN RESULTS: Data from 208 health care workers was analyzed. Only 30% of the participants reported ever treating a patient with exertional heat stroke. Two scenarios were presented to the participants: motor vehicle-related child hyperthermia (MVRCH) in an infant and an adolescent with exertional heat stroke. One hundred twenty-five (60%) and 83 (40%) participants, respectively, listed cool water with a fan as the primary mode of cooling, which is considered the appropriate preferred method of evaporative cooling in the PED. Certificated pediatric emergency medicine (PEM) physicians answered significantly more correctly regarding both scenarios' management (P < 0.001). Participants who were trained via simulation in the past, answered significantly more correctly regarding the exertional heat stroke scenario (P < 0.01), however no difference was found regarding the MVRCH case. CONCLUSIONS: The present study exposes weaknesses in HCW knowledge, PED resources, and published PED policies for appropriate management of children following heat stroke. Our finding emphasizes the importance of both certificated PEM physicians attendance and simulation performance for implementing proper management of patients with heat stroke. A policy change should be performed among the Israeli PED community, with respect to establishing and implementing guidelines for treatment of exertional heat stroke. A future study, following an interventional simulation program is planned to be performed.

Pediatric Electric Bicycle Injuries: The Experience of a Large Urban Tertiary Care Pediatric Hospital.

BACKGROUND: Electric bicycles (E-bikes) are one of a wide range of light electric vehicles that provide convenient local transportation and attractive recreational opportunities. The aim of this study was to report E-bike-related injuries in children presenting to a trauma center. METHODS: Retrospective observational study, from December 2014 to November 2015, which included all pediatrics patients admitted to the emergency department with an injury related to E-bike use, was performed. RESULTS: A total of 97 E-bike injuries presented to the emergency department during this period. Mean age of E-bikers was 13.7 years (range, 7.5-16 years). Injuries to the head and the upper and the lower extremities were the most common. Thirteen patients (15%) were admitted, and 4 underwent surgery. CONCLUSIONS: Children are mainly injured as riders when using E-bikes. There is a need for regulation regarding the use of E-bikes to enhance the safety of both bikers and other road and pavement users.

Comparison Between Small and Large Bowel Intussusception in Children: The Experience of a Large Tertiary Care Pediatric Hospital.

BACKGROUND: Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to serious sequelae. The objective of this study was to determine the prevalence of ileoileal intussusception and to document and compare clinical outcomes with ileocolic intussusception. METHODS: A retrospective cohort study of children with an abdominal ultrasound that diagnosed intussusception. Clinical data and diagnostic studies were retrieved, to compare ileoileal with ileocolic intussusception. RESULTS: A total of 488 patients were evaluated with an abdominal ultrasound on suspicion of intussusception; 54 (11%) had ileoileal intussusception and 30 (6%) ileocolic intussusception. The significant features distinguishing the 2 conditions were fever, more common in patients with ileoileal intussusception, and an abdominal mass, which was papable more commonly in ileocolic intussusception. None of the ileoileal intussusception patients required surgical intervention, and all were discharged without complication. CONCLUSIONS: With recent advances in abdominal ultrasound, the diagnosis of ileoileal intussusception has become easier than before. Patients presenting with small bowel intussusception may not need any immediate intervention. The presence of fever supports the diagnosis of ileoileal intussusception.

Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study.

BACKGROUND: Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported. OBJECTIVE: To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. METHODS: A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. RESULTS: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid. CONCLUSIONS: A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.

Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning.

Drowning is a leading cause of injury-related death worldwide, but there are limited data on the management and disposition of asymptomatic and mildly symptomatic adults and children following a drowning event. Some authors have recommended admission for all drowning victims due to the possibility of respiratory and clinical deterioration in a seemingly well patient. In order to identify predictors for admission and to establish a unified approach for management, we retrospectively collected all children ≤ 16 years old presented following a drowning event to the pediatric ED over a period of 12 years. The children were divided into two groups, those who were discharged home from the ED and those who were admitted. Seventy-one surviving and non-intubated children were asymptomatic to moderately symptomatic, and they comprised the study group. Crepitations on lung auscultation, oxygen desaturation, and respiratory distress were significantly higher in the admitted group (n = 26) compared with the discharged group (n = 45) (P < 0.05). Respiratory distress and lung crepitations were independent predictors for admission. Eventually, 30% of the hospitalized patients required oxygen therapy, but there were no cases that deteriorated and required invasive ventilation. No readmissions occurred in the group of children who were discharged from the ED.Conclusion: Children who after six hours show no respiratory distress and have normal oxygen saturation and normal auscultation can be safely discharged home. Respiratory distress and lung crepitations should both warrant the physician to consider admission of asymptomatic to moderately symptomatic children following a drowning event. An algorithm to assist patient management is proposed. What is Known: •There are few data in the literature regarding the management and disposition of asymptomatic to moderately symptomatic children after drowning. What is New: •We found that respiratory distress and lung crepitations are independent predictors for admission. An algorithm to assist patient management is proposed.

A Comparison of Manual versus Electric Bicycle Injuries Presenting to a Pediatric Emergency Department.

BACKGROUND: The use of electric bicycles (E-bikes) has dramatically increased over the last decade. E-bikes offer an inexpensive, alternative form of transport, but also pose a new public health challenge in terms of safety and injury prevention. OBJECTIVE: The aim of this study was to describe the epidemiology and severity of E-bike related injuries among children treated in the emergency department (ED) and to compare these to manual bicycle related injuries. METHODS: A retrospective observational study of all pediatric patients presenting to the ED between December 2014 and November 2015 with an injury related to E-bike or manual bicycle use. Data including demographics, diagnosis, injury severity score (ISS), and outcome were compared. RESULTS: A total of 196 cyclist injuries presented to the ED; 85 related to E-bike use and 111 to manual bicycle riders. The mean age of E-bikers was 13.7 years (7.5-16 years) and of manual bicycle riders was 9.9 years (3-16 years). Injuries to the head and the extremities were common in both groups. E-bikers had significantly more intra-abdominal organ injury (P=0.047). Injury severity scores were low overall, but injuries of higher severity (ISS>9) only occurred among the E-bikers. CONCLUSIONS: Pediatric E-bike injuries tend to be more severe than those sustained during manual bicycle riding. Further research into bicycle and other road and pavement users could lead to enhanced regulation regarding E-bike usage.

Routine funduscopy in immune thrombocytopenic purpura-is it really necessary?

Immune thrombocytopenic purpura (ITP) is a common cause of symptomatic thrombocytopenia in children, most of whom present with cutaneous and mucosal bleeding. Complications, such as intracranial hemorrhage and occult hemorrhage from various sites, are rare, and retinal hemorrhage is exceptionally rare. Our institutional clinical practice guidelines for managing ITP in the pediatric emergency department (PED) include routine funduscopy. The aim of this retrospective case series is to provide evidence-based recommendations for a tertiary care PED work-up of ITP, with special emphasis on the guidelines for funduscopy. The medical records of all pediatric patients diagnosed with ITP over a 4-year period (2013-2016) who had a platelet count < 50,000/mm3 were retrieved and reviewed. Seventy-five patients with thrombocytopenia (platelet count < 50,000/mm3) were diagnosed as having ITP in the PED. Sixty-one (79%) of these patients underwent funduscopy and retinal hemorrhage was ruled out in all of them, indicating that retinal hemorrhage as a complication of ITP is very rare.Conclusion: Our data suggest that funduscopy should not be performed routinely on pediatric ITP patients, but rather be reserved for those who present with concurrent anemia or visual complaints. What is Known: • Many internal institutional protocols in Israel call for retinal hemorrhage bleeding surveillance in work up of ITP. Our study found no case of ITP with retinal bleeding. What is New: • Many internal institutional protocols in Israel call for retinal hemorrhage bleeding surveillance in work up of ITP. Our study found no case of ITP with retinal bleeding.

Accidental Rivaroxaban Intoxication in a Boy: Some Lessons in Managing New Oral Anticoagulants in Children.

Novel oral anticoagulants offer equivalent or improved therapeutic profiles compared with warfarin, with less risk of bleeding, no interactions with food, and no need for routine laboratory monitoring. Caution must be exercised in using these drugs in certain patient populations, for example, renal insufficiency, those receiving additional antithrombotic therapy, those with questionable compliance, children, and those with a high risk of gastrointestinal bleeding. One of the novel oral anticoagulants, rivaroxaban, is a direct Factor Xa inhibitor, used to reduce risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, deep vein thrombosis, and pulmonary embolism. We report a child who presented abnormal coagulation tests after unintended ingestion of 4 tablets of rivaroxaban. The patient was treated with fresh frozen plasma as well as admitted to intensive care and improved several hours later. We discuss his presentation and review of the literature on this topic.

Short and long arm cast and pain after discharge in children who underwent reduction of distal forearm fracture in the Emergency Department: A study protocol for a randomized comparative effectiveness study.

Distal forearm fracture is the most common fracture in childhood. Patients with this type of injury suffer from meaningful pain after Emergency Department (ED) discharge. Previous studies demonstrated that short arm (below-the-elbow) casts perform as well as long arm (above-the-elbow) casts for maintaining the reduction of distal forearm fractures, with a similar rate of complications. Consequently, short casts are the commonly used method of immobilization after closed reduction of a distal forearm fractures in children older than 4 years. However, short casts carry a potential disadvantage; since they cannot prevent supination in a wrist that is held in pronation, and vice versa, their use might be associated with pain. We initiated this study to examine the effect of the type of casting on post discharge pain. We will conduct an open-label randomized, controlled trial comparing short cast immobilization with long cast immobilization in children who had a reduction of distal forearm fracture in the ED. Our hypothesis is that children with distal forearm fractures who are treated with a long cast, experience less pain during the first 48 h after ED discharge than children who are treated with a short cast.

Trends in the diagnosis and management of anaphylaxis in a tertiary care pediatric emergency department.

BACKGROUND: Underdiagnosis of anaphylaxis is a major concern in the pediatric emergency department (PED), leading to failure to administer and prescribe intramuscular epinephrine treatment. OBJECTIVE: To examine the clinical features, triggers, and management of anaphylaxis in the PED, with a special focus on the rate of cases diagnosed and treated correctly over time, and to compare correctly diagnosed and misdiagnosed cases. METHODS: All records of patients presenting to a tertiary care PED between 2013 and 2016 with a final diagnosis of anaphylaxis or allergic reaction were reviewed. RESULTS: The rate of anaphylaxis increased from 0.1% between 2013 and 2014 and 0.24% between 2015 and 2016. Symptoms such as breathing difficulties and wheezing were found significantly less among misdiagnosed patients compared with patients correctly diagnosed with anaphylaxis. Food was the most common causative agent in both of the study periods (88% in 2013-2014 and 91% in 2015-2016), with milk (20% in 2013-2014 and 28% in 2015-2016) and tree nuts (23.1% in 2013-2014 and 23.7% in 2015-2016 as the most prevalent identified triggers. Intramuscular epinephrine treatment in the prehospital and hospital settings and the automatic epinephrine injector prescription rate did not change significantly throughout the study. Referral to an allergist increased from 68% in 2013 to 2014 to 90% in 2015 to 2016. CONCLUSION: The rate of visits attributable to anaphylaxis in our PED doubled during the study period, with milk allergy as the most common trigger. Most cases of misdiagnosed and undertreated anaphylaxis had no respiratory signs and symptoms. Novel methods to improve recognition of anaphylaxis and adherence to treatment guidelines are needed.