Clinical decision-making training using the Script Concordance Test and simulation: A pilot study for pediatric residents.

BACKGROUND: Each year, new pediatric residents begin their shifts in the pediatric emergency room. While technical skills are often acquired during workshops, non-technical skills such as communication, professionalism, situational awareness, or decision-making are rarely tested. Simulation enables non-technical skills to be developed in situations frequently encountered in pediatric emergencies. Adopting an innovative approach, we combined two pedagogical methods: the Script Concordance Test (SCT) and simulation to improve clinical reasoning and non-technical skills of first-year pediatric residents in dealing with clinical situations involving febrile seizures. The aim of this work is to report the feasibility of such a combined training. METHODS: The first-year pediatric residents participated in a training session on how to manage a child attending the emergency department with a febrile seizure. At the beginning of the session, the trainees had to complete the SCT (seven clinical situations) and then participated in three simulation scenarios. Student satisfaction was assessed by means of a questionnaire at the end of the session. RESULTS: In this pilot study, 20 residents participated in the training. The SCT scores for the first-year pediatric residents were lower and more widely distributed than those of the experts with better concordance for diagnostic items compared to investigation or treatment items. All were satisfied with the teaching methods employed. Further sessions on additional topics relating to the management of pediatric emergency cases were requested. CONCLUSION: Although limited by the small size of our study, this combination of teaching methods was possible and seemed promising for the development of non-technical skills of pediatric residents. These methods are in line with the changes being made to the third cycle of medical studies in France and can be adapted to other situations and other specialties.

An unusual route of non-intentional intoxication by ecstasy in a toddler.

We report a pediatric case of ecstasy intoxication via an unusual route. A mother called the emergency services after her daughter had inserted an ecstasy pill into her nose. During transportation, the child developed hypertension, tachycardia, and tachypnea. She was admitted to the nearest regional hospital, where a physical examination revealed psychomotor agitation, mydriasis, hypertension, tachycardia, and no hyperthermia. Blood tests showed no abnormalities. She was subsequently transferred to a tertiary-level pediatric hospital. During transportation, she was described as being intensely agitated with persistent mydriasis, tachycardia, and high blood pressure. Urinary toxicological screening confirmed the presence of MDMA. She was discharged after 24 h.

[Diagnosis of a pediatric inflammatory multisystemic syndrome associated with COVID-19]. / Diagnostic d'un syndrome inflammatoire multi-systémique pédiatrique associé à la COVID-19.

Following the spread of the 2019 coronavirus (COVID-19) pandemic, a new disease entity has emerged, defined as Pediatric Inflammatory Multisystemic Syndrome temporally associated with COVID-19 (PIMS-TS), or Multisystem Inflammatory Syndrome in Children (MIS-C). The purpose of this article is to detail the approach to establishing the diagnosis of pediatric multisystemic inflammatory syndrome (PIMS). PIMS is a rare and serious condition. This condition needs to be detected early to initiate emergency hospital management. PIMS should be considered in a child presenting with the following warning signs: high fever with marked deterioration in general condition and digestive signs. This syndrome should be considered in children with features of Kawasaki disease (typical or atypical) or toxic shock syndrome or in cases of acute heart failure/acute myocarditis. As this area is rapidly evolving, changes in the coming months are possible; as the pandemic progresses.

[Management of the Sars-Cov2 pandemic in France - Benefit-risk balance at the collective versus individual level individual scale in children]. / Gestion de la pandémie à Sars-Cov2 en France ­ Balance bénéfice-risque à l'échelle collective versus à l'échelle individuelle chez les enfants.

According to the precautionary principle and facing the initial uncertainty of the potential seriousness of Covid-19, France has adopted collective measures understood as acceptable despite the deprivation of liberty and the known risks of long confinement on mental health. Such measures should be applied proportionately and cause the least possible harm. Among these, the closure of schools was decided by declination of those appearing in response plans to viral pandemics where children play a major role in the transmission of the disease (e.g. flu). In an unprecedented way, measures and constraints have been taken against the interests of children and to protect a vulnerable group other than the children themselves. From the perspective of children's health, the relationship between health gains from these measures and negative consequences has been unbalanced. The reduction in instruction time has reduced overall academic performance and has had adverse consequences for the socialization and development of children. Confinement has generated more serious domestic accidents, an increase in intra-family violence and marked collateral effects in terms of the mental health of adolescents. Very early on, the various Covid19-related publications showed that children were not the driving force behind this pandemic - If the initial application of collective measures was legitimate, the adaptation of measures at the individual level was out of step with the already known repercussions followed by those observed on the health of the child.

The psychological effects of COVID-19-related containment in children: The E-COCCON French study.

The first containment of the Sars-Cov2 pandemic had the potential to generate posttraumatic stress (PTS) symptoms in children. OBJECTIVE: The main objective of the study was to determine the prevalence of PTS symptoms within 6 weeks of the end of lockdown, in children contained between March 17, 2020 and May 11, 2020 in France. MATERIAL AND METHODS: This was a French prospective cross-sectional study between May 15 and July 2, 2020 conducted via telephone survey. Parents of children aged between 8 and 15 years were eligible. The invitation to participate was proposed through social networks (Instagram and Facebook), various local and national media, and by e-mail to the staff of our University Hospital Center. The PTS symptoms were assessed using the CRIES-13. A score of 30 and over has been confirmed as the cut-off for screening cases. RESULTS: During the study period, 379 children (male, n = 207) were included, their mean age was 10.8±2.1 years. Symptoms of PTSD were identified in 17% of the children (girls 20.5%, boys 13.5%). These children were younger (p = 0.04), lacked access to a private outdoor space (p < 0.0001; OR: 7.8), had parents whose profession exposed them more to the coronavirus, and had parents who were more afraid of COVID-19. CONCLUSION: After the first lockdown related to the pandemic crisis, children developed PTSD symptoms. The onset of such symptoms is correlated with gender, age, lockdown conditions, and parental perceptions. These last considerations were worse for pink- or blue-collar families, attesting to the subsequent intensification of health inequalities.

Description of a migrant pediatric population visiting the Toulouse Children's Hospital emergency department.

BACKGROUND: Today, one in eight migrants and one in two refugees are children. Since this population has been less studied than the adult population, there is little data available on the state of health of this pediatric migrant population and the reasons they seek care. OBJECTIVE: The objective of this study was to describe the sociodemographic and medical characteristics of a pediatric migrant population visiting an emergency department in order to better understand their specific needs. MATERIALS AND METHODS: This was a retrospective observational study using data from medical records and social surveys of migrant children who had visited the Toulouse pediatric emergency department between 1 January 2018 and 31 December 2018. RESULTS: A total of 203 migrant children, i.e., 344 emergency visits, were analyzed. The average age of the children was 3.3 years old. More than half (58.1%) of the children were from Eastern Europe; 71% visited due to infectious pathologies. The severity of the reasons for visiting (90% of the reasons for visiting had a CCMU (Clinical Classification of Emergency Patients) of 1 or 2) and the hospitalization rate (9%) were not higher in the pediatric migrant population than in the general pediatric population. We discovered associated diagnoses (e.g., scabies, anemia, oral and dental disorders) in connection with migration and/or the resulting vulnerability. There was a language barrier in 78% of the visits analyzed with underuse of professional interpreting (7%). CONCLUSION: Because of the journey they make, migrant children are likely to have specific health needs and require dedicated care.

Lyme neuroborreliosis in pediatrics: A retrospective, descriptive study in southwest France.

BACKGROUND: The neurological effects of Lyme borreliosis in children are varied and their clinical progression is not widely reported in the French literature. We carried out a retrospective study to describe the clinical characteristics of Lyme neuroborreliosis in children in southwest France and their clinical progression at 6 months. METHODS: This study was carried out at Toulouse University Hospital during the period 2006-2017 using patient records. Case definition was based on the combined French clinical and laboratory diagnostic criteria. RESULTS: In total, 26 children were included. The median age was 8 years (4-14 years). The different neurological symptoms reported were: meningoradiculitis (62%), which was usually associated with facial palsy (54%); isolated facial palsy (15%); isolated meningitis (8%); polyradiculoneuritis (4%); benign intracranial hypertension (4%) and myelomeningoradiculitis (4%). The most common functional symptoms were headaches (54%), the perception of asthenia (42%), neck pain (27%), and a loss of appetite (19%). Patients with laboratory meningitis (84%) often had no signs of meningism or headaches (38%). CONCLUSION: The majority of the cases involved meningoradiculitis but other, less common, neurological conditions have been described. The clinical signs suggestive of meningitis are not very marked and might delay the diagnosis.

Pediatric ocular trauma: Characteristics and outcomes among a French cohort (2007-2016).

Pediatric ocular trauma is a major cause of acquired monocular blindness. Post-traumatic visual impairment can lead to significant handicap. In France, recent data on the epidemiology of pediatric ocular trauma are lacking. AIM: To describe the characteristics of a pediatric cohort with ocular trauma and to analyse patient outcomes. MATERIAL AND METHODS: This was a retrospective observational study of pediatric ocular trauma (age<15 years) presenting to pediatric and ophthalmology emergency units of our tertiary university hospital between January 1, 2007 and December 31, 2016. Data were collected on: age, sex, time and circumstances of trauma, injury type and location, trauma mechanism, other associated injuries, hospitalisation rate and length of stay, treatment, and sequelae (visual impairment). Ocular traumas were classified according to the Birmingham Eye Trauma Terminology (BETT) system and the Ocular Trauma Score (OTS). RESULTS: A total of 337 children were included (247 males). The global mean age was 8.4±4.1 years (range 6 months to 14.9 years). The trauma occurred at home (51%) or in a public area (21%). Blunt objects (22%) and direct trauma (17%) were the main mechanisms. According to the BETT, 23% of ocular traumas were open-globe traumas (OGT): penetrating (n=39), perforating (n=12), with intraocular foreign body (n=24). Among closed-globe injuries (CGT), hyphema was the most frequent lesion (22%). Associated injuries were recorded in 32 patients. In all, 63% of patients had an OTS of 5 (good visual prognosis) while 39 children (12%) had an OTS of ≤3. In 47 patients, there was an initial surgery; 62% of children were hospitalised. By the end of the ophthalmic follow-up, 32 patients (9.5%) had sequelae. Children aged between 2 and 5 years had the greatest proportion of sequelae (15%). Compared with female patients, male patients were older (P=0.0007) and were more frequently injured by projectiles (P=0.036). Compared with CGT, OGT were more frequent among younger children (P=0.0015). Ocular injuries secondary to a projectile and spring-summer accidents were associated more frequently with a poor visual prognosis (OTS ≤3; P=0.036, OR=2.5 [1.1-5.8] and P<0.0001, OR=5.8 [3.2-10.7] respectively). COMMENTS: The annual admission for pediatric ocular trauma was stable during the study period (200 cases per 100,000 annual trauma admissions in the first period [2007-2011] and 195 cases per 100,000 during the most recent period [2012-2016]). Projectiles such as Airsoft gun bullets and paintball are still the cause of severe injuries while reports on ocular injuries secondary to blaster or Nerf guns use are starting to be published. CONCLUSION: The great majority of ocular traumas could be prevented, especially by wearing protective goggles during at-risk activities. French legislation should be stricter about the sale of any Airsoft gun to children under 18 years old. Parents must repeat educational warnings to their children handling sharp objects. The social and psychological burden of relative visual impairment is of importance: One in ten children will have a permanent visual defect.

Assessing the management of pediatric bone and joint infections according to French guidelines.

BACKGROUND: Short treatments for acute bone and joint infections (BJI) are recommended. We implemented a protocol in 2009 to improve diagnosis and bacteriological documentation, and to shorten antibiotic therapies as per French guidelines (French Pediatric Infectious Disease Group, GPIP). METHODS: To assess the impact of the new clinical protocol for BJI, we conducted a retrospective study from January 1st, 2006 to August 31st, 2012. Two successive cohorts were compared, before and after protocol implementation. All children suspected of community-acquired BJI were included. Confirmed osteomyelitis and septic arthritis required a positive bacterial isolate; otherwise, cases were considered probable. We compared clinical, biological, and radiological data; duration of antibiotic therapy and hospital length of stay; and complications and sequelae. RESULTS: A total of 377 children with suspected BJI were included. The bacteriological identification improved from 32% to 44% when patients were completely evaluated. Isolated bacteria were Staphylococcus aureus (53%), Kingella kingae (17%), Streptococcus pyogenes (15%), and Streptococcus pneumoniae (8%). Before protocol implementation, 70% of patients had a central venous line versus 9% after implementation. Mean duration of IV antibiotics (11 days versus 6 days), mean duration of total antibiotic therapy (45 days versus 32 days) and mean hospital length of stay (13 days versus 7 days) had significantly improved. CONCLUSION: Improvement in bacteriological diagnosis and shorter antibiotic regimens lead to shorter hospital length of stays with no additional morbidity. Simplifying the protocol and better diffusion among health professionals should contribute to shortening BJI treatment duration.

Sudden death by arrythmia in a 4-year-old boy.

Cardiac arrhythmia with sudden death is rare in children but mainly due to ventricular tachycardia. In case of pulseless ventricular tachycardia, prehospital treatment is crucial with immediate cardiopulmonary resuscitation and external electrical cardioversion. We report the case of pulseless ventricular tachycardia in a child with no past medical history. Sinus rhythm was obtained after 12min of cardiorespiratory resuscitation and three external electrical shocks. An exhaustive diagnostic approach allow us to find its origin. The clinical progression was marked by a severe encephalopathy. The authors discuss different etiologies and treatment of arrhythmia in children, reviewing the pediatric algorithm for shockable rhythm.

Purpura of the chin: Two consecutive cases.

Two healthy children, a 10-year-old boy and a 13-year-old girl, both with no previous medical history, unrelated, presented with pinpoint purpura of the chin and the upper lip. It had appeared 2 days before and extended from the chin to the lower lip. Neither had fever or recent trauma, nor had they taken any medication. Their vital parameters and physical examination were normal. Their peripheral blood cell counts and coagulation parameters were normal. A week later, upon the follow-up consultation, the purpuric lesions had disappeared and both children reported they had played the glass game.

[Management of unintentional pediatric female genital trauma]. / Prise en charge des traumatismes du périnée accidentels chez la jeune fille.

INTRODUCTION: Unintentional pediatric female genital trauma is frequent in the daily practice of emergency wards. However, scientific data are rare in the literature, leading to variability in their management. The aim of this study was to evaluate our practice in order to obtain epidemiological data and define clinical guidelines. MATERIAL AND METHODS: We conducted a retrospective study from March 2013 to January 2015 and identified all emergency visits for this pathology. Data were extracted from the patients' charts and a statistical analysis was performed. RESULTS: One hundred and eighteen patients were admitted during the study period, with an average age of 5.9years. Straddle injuries accounted for 73 % of the injury mechanisms. Most wounds involved the majora and minora labia. Sixty-five patients did not require stitches (55.9 %); 29 patients were examined with Meopa® but 43 % required a more precise surgical exploration in the OR, due to the lack of compliance. Forty-six patients were sutured in the OR. Associated lesions (undiagnosed in the emergency department) were diagnosed during surgical exploration in 13 patients (22 %) with two urethral wounds. Significant wound size differences were observed in 69 % of patients between the pre- and intraoperative assessments. CONCLUSION: Surgical exploration under general anesthesia should be proposed for all unintentional female genital trauma unless the patient is older than 8 and allows complete examination at the emergency department consultation.

[Hallucinations: Etiological analysis of children admitted to a pediatric emergency department]. / Hallucinations : analyse étiologique chez des enfants admis en service d'accueil des urgences.

Children's hallucinations pose the dual challenge of diagnosing a possible medical emergency and a possible psychiatric disorder. PURPOSE: The main objective was to analyze the causes of such hallucinations in children presenting to a pediatric emergency department. MATERIAL AND METHODS: We conducted a single-center, observational, retrospective study including all children aged less than 15 years experiencing hallucinations and admitted to our tertiary level pediatric emergency department between 1 January 2007 and 31 December 2015. The data collected were demographic; medical: previous medical or psychiatric history, current medications, associated clinical or psychiatric symptoms, type and character of hallucinations, length and recurrence of hallucinatory phenomena; and other biological, radiological and neurological explorations. RESULTS: Sixty-eight patients were included (29 boys). The mean age was 9.1±3 years (range, 2-14 years and 10 months; median, 9.2 years). Admissions were seasonal with a bimodal distribution (a peak during springtime and another one during fall). Hallucinations were mainly visual (90%), acute (77%) and complex (63%). Visual hallucinations were associated with other types of hallucinations: auditory (n=17), somatosensory (n=7). Fifteen children had a psychiatric history and had already experienced hallucinatory phenomena (93%). Among 47 patients (69%), these hallucinations were associated with other symptoms: agitation (41%), headaches (28%), hyperthermia (21%) and negative symptoms of the schizophrenia spectrum (15%). On admission, 20 patients (29%) had one or more treatments under way (34 drugs, 41% known for hallucinogenic adverse effects). Neurological explorations were undertaken in half of the cases. Toxicological analysis prescribed in 19 children was positive in five cases (26%). Fifty-three percent of patients were hospitalized and 51 children received a specialized follow-up (by a neurologist and/or a psychiatrist). A nonpsychiatric origin of these hallucinations was diagnosed in 29 patients (43%): neurological causes (n=10), infectious diseases (n=10), intoxications (n=5) and a medication side effect (n=4). CONCLUSION: Hallucinations with a suspected underlying psychiatric cause differed on several factors: chronic duration (p=0.02), an onset after 10 years of age (p=0.004), previous identical episodes (p=0.014) and a parental psychiatric history (p=0.036), auditory hallucinations (p=0.0009), absence of fever (p=0.005), headaches (p=0.036) and the presence of negative symptoms of the schizophrenic spectrum (p=0.02).

[Conservative management of tracheal injuries in children: Clinical case and literature review]. / Prise en charge conservatrice d'un traumatisme trachéal : cas clinique et revue de la littérature.

Tracheal injuries are a rare but potentially lethal entity, most particularly in pediatrics. While standardized management allows quick therapeutic decisions in adults, based on the results of the initial bronchoscopy, the use of diagnostic exams remains unclear during childhood. We describe the case of a 6-year-old patient with a posterior tracheal wall injury due to a car accident, which was managed without tracheal endoscopy. Based on our experience and on a literature review, we suggest clarifying the management of tracheal injury in children, defining the place of computerized tomodensitometry and endoscopy in the decision process.

[Pediatric brucellosis : A case report and literature review]. / Brucellose : revue de la littérature à propos d'un cas pédiatrique.

Brucellosis is an overlooked infection of widespread geographic distribution. This disease is rarely evoked when assessing unexplained pediatric fever, and only 20-30 cases (children and adults) are confirmed per year. Risk factors for contracting brucellosis are exposure to bodily fluids and consumption of unpasteurized dairy products from infected animals. Most cases of brucellosis are associated with traveling to or importing contaminated goods from endemic areas. Here, we report a case of brucellosis in a 16-month-old patient hospitalized for an acute febrile illness in a French general pediatric ward. An antibiotic regimen of rifampicin and co-trimoxazole given over 6 weeks led to successful cure without relapse. The child had eaten a cake made from unpasteurized goat's milk and imported from Oran, a region in Algeria. His mother had consumed the same cake and was hospitalized for brucellosis 15 days later. Clinicians should suspect brucellosis when encountering febrile patients who have traveled to endemic areas, been exposed to body fluids or products of abortion of farm animals, or consumed unpasteurized products.

A pseudoencephalitis presentation of a pediatric non-intentional intoxication.

UNLABELLED: We report a case of a pseudo encephalitis presentation of pediatric intoxication - Case report - a 7 year-old girl was admitted to our pediatric emergency unit after she developed sudden agitation, visual and tactile hallucinations. She was febrile (38.3 °C). She had not experienced any recent head trauma, infection or toxic ingestion; she did not take any medication for ADD. Her physical exam revealed tachycardia, normal pupils, reflexes and normal plantar responses. Laboratory investigations (complete blood count, basic metabolic panel, plasma lactate level, ammonia level) produced normal results. Lumbar puncture and computed tomography of the brain were normal. A serum and urine drug screening (benzodiazepines, barbiturates, cocaine, cannabis, amphetamines, methadone, ethanol) was negative. An electroencephalogram, performed during an episode of hallucinations, was compatible with benzodiazepine intoxication. A larger toxic detection by liquid chromatography/diode array detector (LC-DAD) detected promethazine and its metabolites. Symptoms lasted 20 h and she finally said she drank syrup from an over-the-counter cough suppressant medication. Comments - Anticholinergic syndrome is not well recognized or evoked in children presenting hallucinations. Promethazine is still present in several over-the-counter medications, alone or in combination with acetaminophen, carbocisteine or opiates. CONCLUSION: Medications containing promethazine should not be prescribed in children. Such intoxication can mimic encephalitis.

Hyperglycemia is a risk factor for high-grade envenomations after European viper bites (Vipera spp.) in children.

CONTEXT: Hyperglycemia has been described in severe scorpion envenomation, we wanted to analyze if it was applicable to viper bites in children. AIM: To describe clinical, biological, and therapeutic characteristics of 83 children bitten by European viper (Vipera spp.) and to confirm that hyperglycemia is a risk factor for high-grade envenomation. MATERIAL AND METHODS: A retrospective study was conducted between 2001 and 2014 in the pediatric emergency department of a tertiary level children's hospital. Collected data were: age and sex of children; day and time of admission; day, time and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; laboratory abnormalities, use of specific immunotherapy, associated treatments; length of stay; hospital course. RESULTS: Eighty-three children were included (62 boys, 21 girls). The mean age was 7.4 ± 3.9 years. Bites were most often located on the lower extremities (66%). The classification of envenomation was: 83% low grade (absent or minor envenomation) and 17% high grade (moderate to severe envenomation). All high-grade envenomations received specific immunotherapy (Viperfav(TM), (Aventis Pasteur, MSD, Lyon, France). Being bitten on an upper extremity (odds ratio [OR] 51.1 95% class interval [CI] [6.1-424], p < 0.0001), during the afternoon (OR 13.4 95% CI [1.7-107.9], p = 0.015), feeling violent pain (OR 4.2 95% CI [1.1-16.5], p = 0.023), and high initial plasma glucose level (6.5 ± 1.7 mmol/L versus 5.0 ± 0.9 mmol/L, p = 0.027) were associated with a significant risk of high-grade envenomation. CONCLUSION: We have confirmed a potential link between initial hyperglycemia and the risk of progression to high-grade envenomation as well as its association with other published predictive factors.

[Choking games among 2nd and 3rd graders]. / Jeux d'asphyxie chez les élèves de CE1 et CE2.

UNLABELLED: It is suspected that elementary school age children engage in "the choking game" or other asphyxial practices, but the prevalence is unknown. OBJECTIVE: This study was conducted to determine the prevalence among 2nd and 3rd graders. METHODS: Twenty-five schools in a region in Southeastern France were sampled on the following criteria: school size, rural/urban location, underprivileged neighborhood or not, and private/public school. Second and third grade classes were randomly sampled in each school. Another sample of 25 schools was selected in case a school refused to participate. A self-administered questionnaire, previously validated in two nonsampled schools, was administered in selected classes by the pediatrician leading the project. RESULTS: A total of 1125 questionnaires were distributed and 95% were completed. The mean (SD) age of children was 8.3 (0.7) years. Forty percent of children reported they had already played choking games. Among all the declared players (n=401), the male to female ratio was 1.4; 13% of them played this game every day or several times a day (91% were male). This prevalence varied between schools (16-75%) and games and was significantly higher among children schooled in underprivileged neighborhoods. Seventy-six percent of non-players and 48% of players were aware of the potential life-threatening risk. CONCLUSIONS: The mean prevalence in elementary school (40%) appears to be higher compared to middle and high schools (5-10%). Motivation differs in elementary school children compared to older children and teenagers. Prevention of choking games should start at elementary school and determinants leading to the continuation of such practices from elementary school to high school need to be explored.