The Effects of Dexamethasone on the Time to Pain Resolution in Dental Periapical Abscess.

BACKGROUND: Dental infections are frequently encountered in the emergency department (ED), with periapical abscesses being among the most painful. Traditional pain management strategies include local anesthetic injections, oral analgesics, and intravenous opioids. OBJECTIVES: We sought to identify an alternative pain management strategy with early use of dexamethasone as adjunct to conventional therapies for inflammation and pain at the site of infection. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled study comparing the analgesic effect of dexamethasone and placebo in ED patients with periapical abscess during a 2-year timeframe at two urban academic EDs. Adult patients presenting with physical examination findings consistent with a diagnosis of periapical abscess were randomized to receive oral dexamethasone or an identical placebo. Pain was assessed using the verbal numeric scale in person at discharge and via telephone at 12, 24, 48, and 72 h after discharge from the ED. RESULTS: Seventy-three patients were enrolled, with 37 receiving dexamethasone and 36 receiving placebo. Follow-up pain scores were obtained for 52 patients at 12, 24, 48, and 72 h. Ten patients from the dexamethasone group and 11 from placebo group were lost to follow-up. Patients who received dexamethasone reported a greater reduction in pain at 12 h compared with the placebo group (p = 0.029). Changes in pain scores from baseline and at 24, 48, and 72 h were not statistically significant. No adverse events were reported. CONCLUSIONS: Single-dose dexamethasone as adjunct to conventional medical management for pain caused by periapical abscess demonstrated a significant reduction in pain 12 h post treatment compared with placebo.

Optimizing the workforce: a proposal to improve regionalization of care and emergency preparedness by broader integration of pediatric emergency physicians certified by the American Board of Pediatrics.

BACKGROUND: Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children. OBJECTIVES: The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub-committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors. DISCUSSION: Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP-certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP-certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP-certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care. CONCLUSION: Recognition that the training of ABP-certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.

A Roadmap for the Student Pursuing a Career in Pediatric Emergency Medicine.

INTRODUCTION: Three pathways are available to students considering a pediatric emergency medicine (PEM) career: pediatric residency followed by PEM fellowship (Peds-PEM); emergency medicine residency followed by PEM fellowship (EM-PEM); and combined EM and pediatrics residency (EM&Peds). Questions regarding differences between the training pathways are common among medical students. We present a comparative analysis of training pathways highlighting major curricular differences to aid in students' understanding of these training options. METHODS: All currently credentialed training programs for each pathway with curricula published on their websites were included. We analyzed dedicated educational units (EU) core to all three pathways: emergency department (ED), pediatric-only ED, critical care, and research. Minimum requirements for primary residencies were assumed for fellowship trainees. RESULTS: Of the 75 Peds-PEM, 34 EM-PEM, and 4 EM&Peds programs screened, 85% of Peds-PEM and EM-PEM and all EM&Peds program curricula were available for analysis. Average Peds-PEM EUs were 20.4 EM, 20.1 pediatric-only EM, 5.8 critical care, and 9.0 research. Average EM-PEM EUs were 33.2 EM, 18.3 pediatric-only EM, 6.5 critical care, and 3.3 research. Average EM&Peds EUs were 26.1 EM, 8.0 pediatric-only EM, 10.0 critical care, and 0.3 research. CONCLUSION: All three pathways exceed pediatric-focused training required for EM or pediatric residency. Peds-PEM has the most research EUs, EM-PEM the most EM EUs, and EM&Peds the most critical care EUs. All prepare graduates for a pediatric emergency medicine career. Understanding the difference in emphasis between pathways can inform students to select the best pathway for their own careers.

Consensus Statement on Urgent Care Centers and Retail Clinics in Acute Care of Children.

This article provides recommendations for pediatric readiness, scope of services, competencies, staffing, emergency preparedness, and transfer of care coordination for urgent care centers (UCCs) and retail clinics that provide pediatric care. It also provides general recommendations for the use of telemedicine in these establishments. With continuing increases in wait times and overcrowding in the nation's emergency departments and the mounting challenges in obtaining timely access to primary care providers, a new trend is gaining momentum for the treatment of minor illness and injuries in the form of UCCs and retail clinics. As pediatric visits to these establishments increase, considerations should be made for the type of injury or illnesses that can be safely treated, the required level training and credentials of personnel needed, the proper equipment and resources to specifically care for children, and procedures for safe transfer to a higher level of care, when needed. When used appropriately, UCCs and retail clinics can be valuable and convenient patient care resources.

A pilot study demonstrating the efficacy of transcutaneous bilirubin meters to quantitatively differentiate contusions from Congenital Dermal Melanocytosis.

OBJECTIVE: Congenital Dermal Melanocytosis (CDM) can be difficult to differentiate from contusions. The need for a prompt and accurate diagnosis is best illustrated in cases where child abuse and maltreatment is of concern. Transcutaneous bilirubin (TCB) spectrophotometry has been well established to measure bilirubin under the skin for jaundice in infants. The use of TCB spectrometry has not been used to identify or differentiate contusions from CDM. We hypothesized that bilirubin, a degradation product of hemoglobin, would be elevated in contusions but not in CDM thus demonstrating the efficacy of a novel diagnostic technique to compliment or improve on physical assessment alone. METHODS: Pilot study with thirty-seven infants and children noted to have CDM and fifty-six infants, children and adults with contusions underwent measurement of their lesion with TCB spectrometry. In each patient, the affected skin was scanned along with the adjacent unaffected native skin allowing an internal control for individual pigment variation. RESULTS: TCB measurements of CDM resulted in lower transcutaneous bilirubin values that were not significantly different from adjacent native skin pigmentation. This was in contrast to cutaneous contusions, which resulted in a higher measured value (mean 5.01 mg/dL) compared to adjacent native tissue (1.24 mg/dL) demonstrating a four-fold increase in measurement at the lesion site (P < 0.001). Direct comparison of a ΔTCB value (lesion measurement minus the adjacent tissue) demonstrated a significantly higher value in contusions compared to CDM with a mean value of 3.77 and 0.12 mg/dL, respectively (P < 0.001). CONCLUSIONS: TCB Spectrometry as a novel diagnostic technique has the potential to discern contusions from CDM and may therefore have the ability to compliment the use of physical assessment alone.

Emergency department diagnosis of an ovarian inguinal hernia in an 11-year-old female using pointof-care ultrasound / 世界急诊医学杂志（英文）

@#Inguinal hernias affect 5% of children and are usually defined as a protrusion of intestine or omentum through abdominal wall or inguinal canal defects.[1] Inguinal hernias may contain structures other than bowel and unique cases have been documented since the early 1900's.[2–10] Ultrasound has been demonstrated to differentiate superficial swellings and has been used by radiologists to evaluate inguinal masses for decades.[1–5,11–13] Although the use of radiology-performed ultrasound for the diagnosis of congeni tal inguinal hernias containing ovaries, uterus, and fallopian tubes has been documented; the use of point-of-care ultrasound for the evaluation of the acute inguinal mass prior to reduction has not been demonstrated. Accurate identification by the emergency physician of the herniated structures may lead to earlier diagnosis, faster consultation, improve patient management, and superior patient outcomes.

Obstructed Infradiaphragmatic Total Anomalous Pulmonary Venous Return in a 13-Day-Old Infant Presenting Acutely to the Emergency Department: A Case Report.

BACKGROUND: Total anomalous pulmonary venous return (TAPVR) is an uncommon congenital heart defect. Obstructed forms are more severe, and typically present earlier in life, usually in the immediate newborn period, with symptoms of severe cyanosis and respiratory failure. CASE REPORT: A 13-day-old boy presented to the emergency department (ED) with respiratory extremis. He appeared cyanotic and limp, and was found to have significant hypoxia with oxygen saturation of 40%. He had no improvement of oxygenation with bag-valve-mask ventilation despite a fraction of inspired oxygen near 100%. This gave clear indication that the hypoxia was caused by a shunt and not by hypoventilation, a ventilation/perfusion mismatch, or a barrier to diffusion. Next, the patient was intubated emergently. Broad spectrum antibiotics and fluid resuscitation with normal saline were initiated. A chest radiograph showed evidence of pulmonary edema vs. diffuse interstitial disease. Cardiology was consulted and evaluated the child with an echocardiogram, which revealed TAPVR with infradiaphragmatic obstructed veins. Once stabilized, he was transferred for definitive surgical repair. This is, to our knowledge, the first reported case of TAPVR with infradiaphragmatic obstruction presenting to the ED with hemodynamic and respiratory compromise beyond the first week of life. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite improvements in antenatal and newborn screening, congenital heart disease often remains an elusive diagnosis. Some patients with these critical lesions are discharged home before the manifestation of their disease becomes apparent. Once symptomatic, these patients often present to the ED in extremis. We conclude that it is important to recognize this presentation to ensure proper evaluation and early diagnosis. If misdiagnosed, many of the usual therapies for other diseases could be detrimental.

The Impact of a Pediatric Emergency Department Facility Verification System on Pediatric Mortality Rates in Arizona.

BACKGROUND: The Emergency Medical Services for Children State Partnership Program, as well as the Institute of Medicine report on pediatric emergency care, encourages recognition of emergency departments (EDs) through categorization and verification systems. Although pediatric verification programs are associated with greater pediatric readiness, clinical outcome data have been lacking to track the effects and patient-centered outcomes by implementing such programs. OBJECTIVE: To describe pediatric mortality rates prior to and after implementation of a pediatric emergency facility verification system in Arizona. METHODS: This was a cross-sectional study conducted using data from ED visits between 2011 and 2014 recorded in the Arizona Hospital Discharge Database. The primary outcome measure was the mortality rate for ED visits by patients under 18 years old. Rates were compared prior to and after facility certification by the Arizona Pediatric Prepared Emergency Care program. RESULTS: The total number of ED visits by children during the study period was 1,928,409. Of these, 1,127,294 were at facilities undergoing certification. For hospitals becoming certified, overall ED mortality rates were 35.2 deaths/100,000 ED visits (95% confidence interval [CI] 29.5-41.7) in the precertification analysis and 34.4 deaths/100,000 ED visits (95% CI 30.4-38.9) in the postcertification analysis. The injury-related ED visit mortality rate for certified hospitals showed a decrease from 40.0 injury-related deaths/100,000 ED visits (95% CI 28.6-54.4) in the precertification analysis to 25.8 injury-related deaths/100,000 ED visits (95% CI 18.7-34.8) in the postcertification analysis. CONCLUSION: The implementation of the Arizona pediatric ED verification system was associated with a trend toward lower mortality. These results offer a platform for further research on pediatric ED preparedness efforts and their effects on improved patient outcomes.

The Case of an Obstructed Stone at the Distal Urethra.

This report highlights a presentation of urinary calculus impacted at the urethral meatus and bedside extraction after evaluation with point-of-care ultrasound (POCUS). Visualization of a stone at the urethral meatus prompted a point-of-care ultrasound of the penile shaft and glans. The ultrasound ruled out anatomic variations such as urethral diverticula and as a result bedside removal was expedited. The stone was successfully removed with traction and intraurethral lidocaine gel without urethral lesions or injury to the meatus. Bedside ultrasound is readily available in the emergency department and can be used to characterize urethral foreign bodies, evaluate urethral anatomy, and assess the likelihood of bedside removal.

A Survey of Graduates of Combined Emergency Medicine-Pediatrics Residency Programs: An Update.

BACKGROUND: In 1998, emergency medicine-pediatrics (EM-PEDS) graduates were no longer eligible for the pediatric emergency medicine (PEM) sub-board certification examination. There is a paucity of guidance regarding the various training options for medical students who are interested in PEM. OBJECTIVES: We sought to to determine attitudes and personal satisfaction of graduates from EM-PEDS combined training programs. METHODS: We surveyed 71 graduates from three EM-PEDS residences in the United States. RESULTS: All respondents consider their combined training to be an asset when seeking a job, 92% find it to be an asset to their career, and 88% think it provided added flexibility to job searches. The most commonly reported shortcoming was their ineligibility for the PEM sub-board certification. The lack of this designation was perceived to be a detriment to securing academic positions in dedicated children's hospitals. When surveyed regarding which training offers the better skill set for the practice of PEM, 90% (44/49) stated combined EM-PEDS training. When asked which training track gives them the better professional advancement in PEM, 52% (23/44) chose combined EM-PEDS residency, 27% (12/44) chose a pediatrics residency followed by a PEM fellowship, and 25% (11/44) chose an EM residency then a PEM fellowship. No EM-PEDS respondents considered PEM fellowship training after the completion of the dual training program. CONCLUSION: EM-PEDS graduates found combined training to be an asset in their career. They felt that it provided flexibility in job searches, and that it was ideal training for the skill set required for the practice of PEM. EM-PEDS graduates' practices varied, including mixed settings, free-standing children's hospitals, and community emergency departments.

Arizona's Emergency Medical Services for Children Pediatric Designation System for Emergency Departments.

BACKGROUND: In 2012, a voluntary certification program called Pediatric Prepared Emergency Care (PPEC) was established in Arizona as a system for pediatric emergency preparedness. Emergency medicine and pediatric specialists generated basic, intermediate, and advanced designation criteria. Dedicated medical management by a pediatric emergency specialist is required for advanced centers. Designation follows a site visit, review, and approval by the subcommittee and the Arizona Chapter of the American Academy of Pediatrics. DISCUSSION: Arizona has 5 designated pediatric emergency departments, all of which are in the southeast part of the state. Therefore, a designation system was implemented so that all emergency departments statewide can receive more training, support, and supervision of pediatric care. The goal was to create a self-sustaining network with active participation from member institutions while fostering the pediatric commitment. Since its inception, 39 hospitals and 5 tribal facilities have joined PPEC, equating to 51% of Arizona's emergency facilities. Of the hospitals, 7 are advanced, 6 are intermediate, and 17 are basic centers. In 2015, all of the 9 sites due for recertification were recertified. The multiple tiers allow for mutual accountability, sharing of resources, and improved quality of care for pediatrics in emergency departments statewide. CONCLUSION: PPEC enhances the quality of pediatric emergency preparedness by means of voluntary certification. The primary limitations are sustainability and funding, because an Emergency Medical Services for Children grant has offset the cost until now. The number of member facilities in this designation system is continually growing, and universal recertification shows sustainability.

Appendicitis in the Infant Population: A Case Report and Review of a Four-Month Old With Appendicitis.

BACKGROUND: Appendicitis is uncommon in children <6 months old, with few observational studies reporting cases of children younger than 5 years old with the diagnosis. The classic periumbilical pain that migrates to the right lower quadrant, followed by the onset of fever and vomiting, is present in approximately 40% of pediatric patients under 12 years of age with appendicitis. CASE REPORT: A 4-month-old girl presented to the Emergency Department (ED) with acute onset of grunting, pallor, fussiness, emesis, and diarrhea. The patient was initially afebrile, tachycardic, and tachypneic with a soft, nondistended, nontender abdomen and active bowel sounds. The patient became febrile, with a maximum temperature of 39.3°C (102.7°F), and remained tachycardic despite receiving fluids and antipyretics. Laboratory studies were notable for mild dehydration and sterile pyuria. Chest x-ray study was negative for infectious etiologies. Initial abdominal ultrasound found no clear etiology of the patient's symptoms. The patient was admitted to inpatient pediatrics for dehydration, fever, and presumed pyelonephritis. Twenty-four hours later the patient's abdomen became distended and diffusely tender to palpation, with obstipation and increasing episodes of emesis. Abdominal x-ray study demonstrated mild gaseous distension of multiple bowel loops with repeat abdominal ultrasound notable for a focal 8-mm, noncompressible hyperemic structure in the right lower quadrant. The patient was taken to the operating room for a laparoscopic appendectomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Appendicitis is a potentially life-threatening condition. In the infant population it frequently presents without the features typically seen in older children.

Evaluation of child maltreatment in the emergency department setting: an overview for behavioral health providers.

Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.

Emerging concepts in pediatric emergency radiology.

Radiologic studies are a vital component in the workup and diagnosis of disease. An appropriate radiographic study will accurately rule in or rule out disease with the least possible harm. Special considerations are necessary for the imaging of children. Current trends in pediatric imaging support the increased use of ultrasound and magnetic resonance imaging to decrease radiation exposure. In this review, we highlight some of the emerging concepts in the radiographic workup of pediatric disease, with a focus on decreasing ionizing radiation, increasing ultrasound use, and using clinical decision rules to identify children who do not need imaging.

Emergency department evaluation of child abuse.

Child abuse presents commonly to emergency departments. Emergency providers are confronted with medical, social, and legal dilemmas with each case. A solid understanding of the definitions and risk factors of victims and perpetrators aids in identifying abuse cases. Forensic examination should be performed only after the child is medically stable. Emergency providers are mandatory reporters of a reasonable suspicion of abuse. The role of the emergency provider is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and to provide an ethical testimony if called to court.

The effects of resident level of training on the rate of pediatric prescription errors in an academic emergency department.

BACKGROUND: Medication errors are a leading cause of increased cost and iatrogenic injury in the pediatric population. In the academic setting, studies have suggested that these increased error rates are related primarily to resident inexperience, thus advocating a higher level of supervision. STUDY OBJECTIVE: We sought to identify the number of prescription errors in our institution's academic Emergency Department, how this varied between the beginning and end of the academic year and between practitioners at varying levels of training. METHODS: A retrospective review of computer-based outpatient prescriptions for children aged 0-12 years old was performed. Outpatient prescriptions were reviewed during a 2-week time block at the end of the academic year and beginning of the academic year (109 [June] and 111 [July] data sets, respectively). Prescriptions were retrieved electronically and reviewed for appropriate dosing. Errors were defined as those that varied>10% above or below recommended weight-based dosing. RESULTS: Twenty-nine (16.1%) of 180 written prescription orders were determined to be incorrectly written. Error rates were not significantly different between the beginning and end of the academic year. In both sampling periods, a higher percentage were found to be derived from senior level practitioners in both data sets (9/14 and 10/15; respectively), but few of these were considered high-grade prescription errors. CONCLUSIONS: Overall prescription error rates at our institution are comparable to nationally reported error rates in children. Error rates were not associated with newly matriculated residents. These findings dispute previously held opinion that physician level of training is a factor of prescription errors.