Cosmetic Outcomes of Simple Pediatric Facial Lacerations Repaired With Skin Adhesive Compared With Skin Adhesive With Underlying Adhesive Strips: A Randomized Controlled Trial.

OBJECTIVES: A randomized controlled trial was designed to compare 2 methods of repairing simple pediatric facial lacerations. We hypothesized that wounds repaired with skin adhesive and underlying adhesive strips compared with skin adhesive alone would be superior in regard to cosmetic outcome. METHODS: Patients aged younger than 18 years presenting to the emergency department with simple facial lacerations requiring repair were eligible for enrollment. Patients were randomly assigned to repair with either skin adhesive alone or skin adhesive with underlying adhesive strips. Families were contacted by phone 1 week after enrollment to discuss short-term complications. The cosmetic appearance of photographs of the scars at 2 months was analyzed using a visual analog scale by a blinded pediatric emergency physician and pediatric plastic surgeon. RESULTS: One hundred twenty patients were enrolled, with 92 returning for the 2-month follow-up. The visual analog scale scores for the skin adhesive with adhesive strips group were similar to the skin adhesive alone group (60 mm vs 58 mm, P = 0.540). Spearman ρ correlation coefficient between the raters was 0.669, indicating strong agreement. There was no significant difference in rates of return visits, wound dehiscence, or infection. The skin adhesive with adhesive strips group had a longer time to perform the repair (195 seconds vs 107 seconds, P < 0.001). CONCLUSIONS: Using adhesive strips to first approximate a wound before applying skin adhesive leads to a similar cosmetic outcome compared with simple facial lacerations repaired with skin adhesive alone. Although the study showed longer time to complete the repair, this approach may still be useful in settings where approximation is difficult to obtain manually.

Safety and effectiveness of intranasal midazolam and fentanyl used in combination in the pediatric emergency department.

OBJECTIVE: To examine the safety and effectiveness of intranasal midazolam and fentanyl used in combination for laceration repair in the pediatric emergency department. METHODS: We performed a retrospective chart review of a random sample of 546 children less than 18 years of age who received both intranasal midazolam and fentanyl for laceration repair in the pediatric emergency department at a large, urban children's hospital. Records were reviewed from April 1, 2012 to June 31, 2015. The primary outcome measures were adverse events and failed laceration repair. RESULTS: Of the 546 subjects analyzed, 5.1% had multiple lacerations. Facial lacerations were the most common site representing 70.3%, followed by lacerations to the hand (9.9%) and leg (7.0%). The median length of lacerations was 1.5 cm [1.0-2.5]. The median dose of fentanyl was 2.0 µg/kg [1.9-2.0] and midazolam was 0.2 mg/kg [0.19-0.20]. There were no serious adverse events reported. The rate of minor side effects was 0.7% (95% CI 0.2% to 1.9%); 0.5% (95% CI 0.1% to 1.6%) experienced anxiety and 0.2% (95% CI 0.0% to 1.0%) vomited. No patients developed hypotension or hypoxia. Of the 546 patients, 2.4% (95% CI 1.3% to 4.0%) experienced a treatment failure. 2.0% (95% CI 1.3% to 4.0%) required IV sedation and 0.4% (95% CI 0.0% to 1.3%) were repaired in the operating room. CONCLUSIONS: Our results suggest that the combination of INM and INF may be a safe and effective strategy for procedural sedation in young children undergoing simple laceration repair.

Making the Quick Diagnosis: A Case of Neonatal Shock.

BACKGROUND: The work-up and initial management of a critically ill neonate is challenging and anxiety provoking for the Emergency Physician. While sepsis and critical congenital heart disease represent a large proportion of neonates presenting to the Emergency Department (ED) in shock, there are several additional etiologies to consider. Underlying metabolic, endocrinologic, gastrointestinal, neurologic, and traumatic disorders must be considered in a critically ill infant. Several potential etiologies will present with nonspecific and overlapping signs and symptoms, and the diagnosis often is not evident at the time of ED assessment. CASE REPORT: We present the case of a neonate in shock, with a variety of nonspecific signs and symptoms who was ultimately diagnosed with tachycardia-induced cardiomyopathy secondary to a resolved dysrhythmia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the diagnostic and therapeutic approach to the critically ill neonate in the ED, and expands the differential diagnosis beyond sepsis and critical congenital heart disease. Knowledge of the potential life-threatening etiologies of shock in this population allows the Emergency Physician to appropriately test for, and empirically treat, several potential etiologies simultaneously. Additionally, we discuss the diagnosis and management of supraventricular tachycardia and Wolff-Parkinson-White syndrome in the neonatal and pediatric population, which is essential knowledge for an Emergency Physician.

Not by the Red on My Chinny Chin Chin: A Case of Mandibular Osteomyelitis in a 5-Year-Old Girl.

BACKGROUND: Osteomyelitis is not an uncommon emergency department diagnosis in pediatric patients, and most cases are in the lower extremities. Children can present with acute, subacute, or chronic erythema, pain, swelling, or decreased use of the extremity; some patients will also have fever or elevated serum inflammatory markers, or both. CASE REPORT: We present the case of a healthy 5-year-old girl who presented to the emergency department with 3 weeks of painless chin swelling and 2 days of erythema and pain. While laboratory testing was normal, magnetic resonance imaging demonstrated osteomyelitis of the mandible, later confirmed by biopsy. After 4 weeks of intravenous antibiotics and an additional 2 weeks of oral antibiotics, the patient recovered completely without any residual findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case demonstrates that osteomyelitis can develop in previously healthy, fully vaccinated children with competent immune systems. Systemic findings (ie, fever and elevated serum inflammatory markers) may be absent, and osteomyelitis should always be considered in the differential diagnosis for a child presenting with subacute to chronic cutaneous findings without other clear explanation.

Etomidate versus pentobarbital for sedation of children for head and neck CT imaging.

OBJECTIVES: We compare etomidate to pentobarbital for sedation of children for head and neck computed tomography imaging. METHODS: We performed a prospective, randomized, double-blinded trial of patients aged 6 months to 6 years enrolled from the emergency department or radiology department at a large urban children's hospital. The primary outcome measure was sedation success rate. RESULTS: A total of 61 patients were enrolled in the study (27 etomidate group, 34 pentobarbital group) at 2 different dosing regimens for etomidate. The final analysis group included 17 etomidate patients and 33 pentobarbital patients. The success rate for the etomidate group was 57% at total doses of up to 0.3 mg/kg (n = 7) and 76% at total doses of up to 0.4 mg/kg (n = 17), in contrast to a success rate of 97% for pentobarbital at a total dose of up to 5 mg/kg (n = 33). The success rate for pentobarbital was significantly greater than the final etomidate group (P = 0.04; difference in proportions 20.5%, 95% CI 1.9% to 44.4%). Patients receiving etomidate had significantly shorter induction times (P = 0.02; difference of means 2.1 minutes, 95% CI 0.35 to 3.86), sedation times (P < 0.001; difference of means 31.3 minutes, 95% CI 24.0 to 38.5), and total examination times (P < 0.001; difference of means 53.1 minutes, 95% CI 40.8 to 65.3). Significantly more parents in the etomidate group perceived their child to be back to baseline by discharge from the hospital (P < 0.001; difference of proportions 60.7, 95% CI 29.1 to 92.4) and expressed fewer concerns about their child's behavior after discharge (P = 0.024; difference of proportions 28.6, 95% CI 6.5 to 50.7). CONCLUSIONS: At the dosing used in this study, pentobarbital is superior to etomidate when comparing success rates for sedation. However, among the successful sedations, the duration of sedation was shorter in the etomidate group than in the pentobarbital group. Pentobarbital is associated with more frequent side effects and parental concerns compared to etomidate.

Third place winner. Three-year-old female with intermittent ovarian torsion.

We report an atypical case of ovarian torsion, an uncommon cause of abdominal pain in a very young girl. She presented with intermittent episodes of groin and thigh pain over a 10-week period. The child had minimal objective findings at the time of each evaluation. Despite the delay in diagnosis, the ovary was preserved. Despite its rarity, ovarian torsion must be considered in the differential diagnosis of abdominal pain in young girls.