Pathogens in Pediatric Septic Arthritis: A Multi-Center Study in Turkiye (PEDSART Study).

OBJECTIVES: Septic arthritis (SA) is a serious bacterial infection that must be treated efficiently and timely. The large number of culture-negative cases makes local epidemiological data important. Accordingly, this study aimed to evaluate the etiology, clinical characteristics, and therapeutic approach of SA in children in Turkiye, emphasizing the role of real-time polymerase chain reaction (PCR) techniques in the diagnosis. METHODS: In this multi-center, prospective study, children hospitalized due to SA between February 2018 and July 2020 in 23 hospitals in 14 cities in Turkiye were included. Clinical, demographic, laboratory, and radiological findings were assessed, and real-time PCR was performed using synovial fluid samples. RESULTS: Seventy-five children aged between 3 and 204 months diagnosed with acute SA were enrolled. Joint pain was the main complaint at admission, and the most commonly involved joints were the knees in 58 patients (77.4%). The combination of synovial fluid culture and real-time PCR detected causative bacteria in 33 patients (44%). In 14 (18.7%) patients, the etiological agent was demonstrated using only PCR. The most commonly isolated etiologic agent was Staphylococcus aureus, which was detected in 22 (29.3%) patients, while Streptococcus pyogenes was found in 4 (5.3%) patients and Kingella kingae in 3 (4%) patients. Streptococcus pyogenes and Kingella kingae were detected using only PCR. Most patients (81.3%) received combination therapy with multiple agents, and the most commonly used combination was glycopeptides plus third-generation cephalosporin. CONCLUSIONS: Staphylococcus aureus is the main pathogen in pediatric SA, and with the use of advanced diagnostic approaches, such as real-time PCR, the chance of diagnosis increases, especially in cases due to Kingella kingae and Streptococcus pyogenes.

Intravenous Magnesium Sulfate for Acute Bronchiolitis: Evaluation of the Effect on Clinical Course and Outcomes.

The aim of the present study was to assess the efficacy of intravenous (IV) magnesium sulfate (MgSO4) for children with bronchiolitis. A retrospective cohort study was performed at a pediatric emergency department. Aged between 1 and 24 months, children with moderate/severe bronchiolitis according to the Modified Respiratory Distress Assessment Instrument (mRDAI) score were included. Patients who received 40 mg/kg/dose of IV MgSO4 (group 1, n: 74) or not (group 2, n: 33) were compared. Respiratory rate and mRDAI score significantly decreased at the second hour of MgSO4 treatment and the decrease was observed for 4th, 8th, and 12th hours, compared with group 2. Patients in group 2 had a higher rate of requirement and an earlier start high-flow nasal cannula oxygen therapy and a longer hospital stay than group 1. Intravenous MgSO4 provided significant improvement on clinical severity, need for respiratory support, length of hospital stay, and outcomes.

Traumatic asphyxia with a 'masque ecchymotique' in a 14-year-old adolescent.

Traumatic asphyxia, which is manifested by facial edema, cyanosis, subconjunctival hemorrhage, and petechiae on the upper chest and abdomen, is a very rare clinical syndrome in children. In adults, the incidence of traumatic asphyxia was reported as 1 case/18,500 accidents, but the actual incidence is not known for pediatric population. Traumatic asphyxia is a mechanical cause of hypoxia resulting from sudden compression of the thoracic-abdominal region and the valsalva maneuver is necessary for the development of this syn-drome. Here, we describe a case of traumatic asphyxia with an ecchymotic mask in a 14-year-old boy who was referred to our pediatric emergency department.

What is the safe observation period for seizure recurrence in pediatric emergency departments?

BACKGROUND: Afebrile seizures are the common causes of emergency department (ED) admissions in childhood, and there is limited data on the observation period in emergency service follow-up of these patients in terms of seizure recurrence in the literature. This study aims to determine the seizure recurrence time in afebrile seizures and the risk factors that determine it. METHODS: Patients aged between 1 month and 18 years with afebrile seizures were included in the study. Seizure recurrence times, demographic data, diagnosis of epilepsy, use of antiseizure medications, Electroencephalography (EEG) and imaging results, structural abnormalities, hospitalizations, and treatments were recorded. RESULTS: The median age of 623 patients included in the study was 42 months (16.0-94.0 months) and 59.9% were male. Epilepsy was diagnosed in 372 (59.7%) of the patients. Short-acting benzodiazepine was administered in 249 of the cases. The mean observation time of the patients was 36 hours (24-98 hours). Electroencephalography (EEG) was applied in 437 (70.1%) of the patients and abnormality was detected in 53.5%. Seizure recurrence was observed in 149 patients (23.9%). The median time of seizure recurrence was 1.0 hour (0.5-4.0 hours). Eighty-six percent of the seizure recurrences (n = 129) occurred within the first six hours and 95.3% (n = 142) within the first 12 hours. Risk factors included a history of febrile seizures (p = 0.001, OR = 2.7), not receiving short-acting benzodiazepine therapy (p = 0.026, OR 1.7), previous structural abnormalities (p = 0.018, OR 1.8), and cluster seizures (p = 0.001, OR 6.7) for all patients and also EEG abnormalities in pediatric ED for first seizure (p = 0.012, OR 2.4). CONCLUSION: Patients with a history of febrile seizure, previous structural abnormalities, cluster seizures, EEG abnormalities in pediatric ED, and patients who didn't receive BZD treatment were at risk for seizure recurrence in the early period. Since most seizure recurrences occur within the first 6 hours, this period is the most critical time for recurrence risk.

The Role of Ultrasound in Pediatric Skull Fractures: Determination of Fracture and Optic Nerve Sheath Diameter Measurements.

BACKGROUND: The aim of the present study was to determine the accuracy of point-of-care ultrasound (POCUS) for detecting skull fractures and to evaluate sonographic measurements of optic nerve sheath diameter (ONSD) and ONSD/eyeball vertical diameter (EVD) ratios in children with head trauma. METHODS: Children who presented with local signs of head trauma and underwent cranial computed tomography (CT) were enrolled. The suspected area was examined by POCUS to identify a skull fracture, and then the ONSD at 3 mm posterior to the globe and the EVD were measured. Ratios of ONSD measurement at 3 mm/EVD were reported. All ONSD measurements and ratios were calculated from cranial CT images. RESULTS: There were 112 children enrolled in the study. The sensitivity and specificity of POCUS for skull fractures was 93.7% (95% confidence interval [CI], 82.8-98.6) and 96.8% (95% CI, 89.1-99.6), whereas the positive predictive value was 95.7% (95% CI, 85.1-98.8), and the negative predictive value was 95.3% (95% CI, 87.3-98.4). There was high agreement between POCUS and CT for identifying skull fractures (κ, 0.90 [±0.04]). In the group without elevated intracranial pressure findings on CT, patients with space-occupying lesions (SOLs) had higher sonographic ONSD measurements and ratios (P < 0.001) compared with cases without SOLs. CONCLUSIONS: When used with clinical decision rules to minimize the risk for clinically important traumatic brain injury, POCUS seems to be a promising tool to detect skull fractures and calculate ONSD measurements and rates to predict the risk for SOLs and perform further risk stratification of children with minor head trauma.

Roles of Vitamin-K-dependent Factors Protein S and GAS6 With TAM Receptors and HMGB1 in Pediatric COVID-19 Disease.

OBJECTIVE: This study was designed to evaluate serum high-mobility group box 1 (HMGB1), protein S (PS), growth arrest-specific gene 6 (GAS6), and TAM receptor (TYRO3, AXL, and MERTK) levels in children with COVID-19 disease. METHODS: A prospective case-control study was conducted in our pediatric emergency department and 57 patients with SARS-CoV-2 polymerase chain reaction (PCR) positivity, 6 patients with multisystem inflammatory syndrome in children (MIS-C), and 17 healthy children were included. Demographic data, clinical findings, laboratory and radiologic data, the need for hospitalization, and prognosis were recorded. Serum HMGB1, PS, GAS6, and TAM receptor levels were studied by enzyme-linked immunosorbent assay method. RESULTS: While SARS-CoV-2 PCR-positive patients and healthy controls were similar in terms of gender and age, GAS6 and MERTK levels were significantly lower in SARS-CoV-2 PCR-positive patients compared with healthy controls. Among SARS-CoV-2 PCR-positive patients, no difference was found in terms of serum markers in those with and without gastrointestinal or respiratory system symptoms. However, in patients with respiratory distress at admission, PS and TYRO3 levels were significantly lower. AXL levels were lower in patients diagnosed with MIS-C compared with healthy controls. Activated partial thromboplastin time was negatively correlated with HMGB1, PS, GAS6, and AXL levels. CONCLUSION: Our results suggest that such measurements may be informative and warranted in children with COVID-19 who show evidence of coagulopathy and respiratory distress. Further studies are needed to clarify the roles of these markers in diagnosis, to predict clinical severity, and to evaluate their roles in treatment approaches for COVID-19 disease.

Return visit characteristics of SARS-CoV-2 PCR-positive cases in a pediatric emergency department.

BACKGROUND: The aim of this study was to evaluate return visits to the pediatric emergency department (ED) for children who were detected to be positive for SARS-CoV-2 by polymerase chain reaction (PCR). METHODS: Between April 2, 2020, and January 20, 2021, children aged 0 to 18 years who were detected to be SARS-CoV-2 PCR-positive and discharged from the ED were evaluated. Among them, patients who returned to the ED within 14 days of quarantine were included in the study. For the first presentation and return visit, demographics, clinical findings, laboratory and radiologic investigations, and ward/pediatric intensive care unit (PICU) admissions were recorded. Patients were divided into 5 groups according to clinical severity. RESULTS: Among 575 children who were confirmed to be SARS-CoV-2 PCR-positive, 50 (8.6%) of them [median age: 10.4 years (IQR: 4.8-15.2); 26 females] had returned. There was no difference for age, sex, underlying diseases, or symptoms for patients who returned or did not for the first presentation, but the percentage of those from whom laboratory tests were obtained was higher in cases of return visits. For symptomatic cases on the first presentation, the most common reason for return was having additional symptoms. The most common symptoms at the return visit were fever, cough, and sore throat. There was no severe/critical case in terms of clinical severity. Among all cases, 36 (72.0%) patients were discharged from the ED, 13 (26.0%) were observed for 6-8 h and then discharged, and 1 (2.0%) was admitted to the ward; there was no PICU admission or death, respectively.

Distribution of Viral Respiratory Pathogens During the COVID-19 Pandemic: A Single-Center Pediatric Study from Turkey.

OBJECTIVE: To evaluate the distribution and characteristics of respiratory viral pathogens and to assess the epidemiological data, clinical features, and prognoses of infected children in a pediatric emergency department during the COVID-19 pandemic. MATERIALS AND METHODS: Between September 1, 2020, and April 30, 2021, patients aged between 0 and 18 years arrived at the pediatric emergency department and were tested by nasopharyngeal/tracheal specimen polymerase chain reaction for both SARS-CoV-2 and other viral respiratory pathogens. Demographics, symptoms, laboratory and radiologic investigations, respiratory viruses detected by PCR, presence of co-infection and co-infecting viruses, need for respiratory support, hospitalization, length of hospital stay, and prognosis were recorded. RESULTS: There were 327 patients for whom PCR tests were performed and 118 (36.0%) of them had positive results for SARS-CoV-2 and/or other respiratory viruses. Rhinovirus was the most commonly detected pathogen with 74 (62.7%) cases, followed by enterovirus with 38 (32.2%) and adenovirus with 20 (16.9%) cases. There was no detection of influenza virus or respiratory syncytial. SARS-CoV-2 PCR results were positive in 14 (11.9%) cases and there was only 1 coinfection of SARS-CoV-2 occurring together with rhinovirus. For 43 (36.4%) patients, there was co-infection, and among co-infections, the most common was that of rhinovirus and enterovirus, seen in 37 (86.0%) cases. CONCLUSION: A decrease was observed in the positivity rate of respiratory viral pathogens, while no cases of influenza virus or respiratory syncytial virus were observed in our study. Circulating viruses may change due to multifactorial approaches during the COVID-19 pandemic.

COVID-19 Disease in Presenting to the Pediatric Emergency Department: A Multicenter Study of 8886 Cases.

BACKGROUND: The aim was to evaluate the epidemiological, clinical, laboratory, and radiologic data of children with SARS-CoV-2 positivity by polymerase chain reaction (PCR) together with treatment strategies and clinical outcomes and to evaluate cases of multisystem inflammatory syndrome in children (MIS-C) in this population. METHODS: This was a multicenter retrospective observational cohort study performed in the pediatric emergency departments of 19 tertiary hospitals. From March 11, 2020, to May 31, 2021, children who were diagnosed with confirmed nasopharyngeal/tracheal specimen SARS-CoV-2 PCR positivity or positivity for serum-specific antibodies against SARS-CoV-2 were included. Demographics, presence of chronic illness, symptoms, history of contact with SARS-CoV-2 PCR-positive individuals, laboratory and radiologic investigations, clinical severity, hospital admissions, and prognosis were recorded. RESULTS: A total of 8886 cases were included. While 8799 (99.0%) cases resulted in a diagnosis of SARS-CoV-2 with PCR positivity, 87 (1.0%) patients were diagnosed with MIS-C. Among SARS-CoV-2 PCR-positive patients, 51.0% were male and 8.5% had chronic illnesses. The median age was 11.6 years (IQR: 5.0-15.4) and 737 (8.4%) patients were aged <1 year. Of the patients, 15.5% were asymptomatic. The most common symptoms were fever (48.5%) and cough (30.7%) for all age groups. There was a decrease in the rate of fever as age increased (p < 0.001); the most common age group for this symptom was <1 year with the rate of 69.6%. There was known contact with a SARS-CoV-2 PCR-positive individual in 67.3% of the cases, with household contacts in 71.3% of those cases. In terms of clinical severity, 83 (0.9%) patients were in the severe-critical group. There was hospital admission in 1269 (14.4%) cases, with 106 (1.2%) of those patients being admitted to the pediatric intensive care unit (PICU). Among patients with MIS-C, 60.9% were male and the median age was 6.4 years (IQR: 3.9-10.4). Twelve (13.7%) patients presented with shock. There was hospital admission in 89.7% of these cases, with 29.9% of the patients with MIS-C being admitted to the PICU. CONCLUSION: Most SARS-CoV-2 PCR-positive patients presented with a mild clinical course. Although rare, MIS-C emerges as a serious consequence with frequent PICU admission. Further understanding of the characteristics of COVID-19 disease could provide insights and guide the development of therapeutic strategies for target groups.

Uncommon presentation of Meckel's diverticulum in a child with decompensated hypovolemic shock.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and may cause serious complications such as intestinal obstruction, gastrointestinal hemorrhage, or inflammation with/without perforation, which can present with non-spe-cific symptoms and signs. We report on the case of a 2.5-year-old boy admitted to our emergency department in poor condition, with compatible signs of decompensated hypovolemic shock. This case finally resulted in intestinal volvulus and internal hernia, a very rare combination of two complications of MD, as determined in the operating room.

Determinants of mortality and intensive care requirement in pediatric thoracoabdominal injuries.

BACKGROUND: Thoracoabdominal injuries (TAI) are an important cause of trauma-related morbidity in children. Early and correct intervention is essential to reduce mortality. We aimed to determine factors associated with mortality and the need for intensive care in TAI. METHODS: The children admitted to the pediatric emergency department of a tertiary care hospital with TAI in a 6-year-period were enrolled. Demographic data; mechanism of injuries; clinical, laboratory and imaging findings; length of hospital and intensive care unit (ICU) stay; invasive procedures and medical treatments; surgical interventions; and survival outcomes were recorded. RESULTS: The median age of the 136 children was 9 (IQR: 5-14) years and 72.8% were male. The vast majority of injuries were caused by blunt trauma (92.7%). Pulmonary contusion, pneumothorax, splenic, and liver injuries were the most common diagnoses. Motor vehicle accidents were seen in more than half of the cases (52.2%). The median length of hospital stay was 5 (IQR: 2-8) days; 21 patients were hospitalized in the ICU (15.4%). The need for intensive care was higher in patients with lower Glasgow Coma Scale (GCS) scores and lower Pediatric Trauma Scores (PTSs), in the presence of multiple injuries, pulmonary contusion, and pneumothorax (p<0.001). Mortality was seen in nine patients, eight of whom had multiple injuries. The mortality rate was higher in patients with pulmonary contusion and pneumothorax (p=0.002 and p=0.003, respectively). The PTS and GCS were found to be lower in patients who died in hospital (p<0.001). Prolongation of coagulation parameters and hyperglycemia was more common in the non-survivor group (p=0.005 and p=0.004, respectively). CONCLUSION: Although thoracoabdominal trauma is not common in childhood, it is an important part of trauma-associated mortality. Multiple injuries, pulmonary contusion, pneumothorax, lower GCS, and PTSs can be a sign of serious injuries to which physicians must be alert.

The role of sonographic optic nerve sheath diameter measurements in pediatric head trauma.

PURPOSE: To determine the accuracy of bedside sonographic measurements of optic nerve sheath diameter (ONSD) and ONSD/eyeball transverse (ETD) diameter ratios to predict space-occupying lesions (SOLs) or elevated intracranial pressure (ICP) in pediatric head trauma. METHODS: Children who presented to the emergency department with head trauma and underwent cranial computed tomography (CT) were enrolled and examined by ocular ultrasonography (US), and the ONSD was measured at 3 mm posterior to the globe and ETD were measured. Ratios of ONSD at 3 mm/ETD were calculated. All ONSD measurements and ratios were calculated from cranial CT images. RESULTS: Subjects with elevated ICP had increased ONSD measurements and ratios. To predict elevated ICP, the AUC for ONSD at 3 mm was 0.956 (95% CI 0.896-1). At a cut-off level of 5.1 mm, the sensitivity and specificity of ONSD 3 mm values for elevated ICP were 92.9% and 94.0%. For the ONSD 3 mm/ETD ratio, it was 0.980 (95% CI 0.959-1). At a cut-off level of 0.22, the sensitivity and specificity were 100% sensitivity and 88.0%. All sonographic ONSD measurements and ratios were significantly correlated with readings calculated from cranial CT images. CONCLUSION: Sonographic ONSD measurements and ratios were found to be quite sensitive to detect elevated ICP on cranial CT images. Additionally, there was a significant correlation between measurements calculated by ocular US and cranial CT scans. Bedside ocular US seems to be a promising and useful tool to determine ICP in children with head trauma.

Point of care diaphragm ultrasound in mechanically ventilated children: A predictive tool to detect extubation failure.

BACKGROUND: Children should be weaned from the ventilator once their clinical condition improves. Extubation failure is associated with poorer clinical outcomes in children. Predictive indicators of successful extubation are needed. This study aims to evaluate the predictive value of ultrasonographic diaphragm imaging could help predict weaning success. METHODS: In this prospective, observational study conducted between March and December 2021, children between 1 month and 10 years of age who were mechanically ventilated for more than 48 h were included. Diaphragm ultrasound (DUS) examinations were performed at the end of 2-h extubation readiness test (ERT). The end-inspiratory thickness (DTi), end-expiratory thickness (DTe), diaphragmatic thickening fraction (DTF), diaphragmatic excursion (DE), inspiratory slope (IS), and expiratory slope (ES) were evaluated. RESULTS: Twenty-four (60%) patients were successfully extubated, while 16 (40%) required invasive or noninvasive mechanical ventilation support which were classified as failed extubation group. Three of the sixteen patients in the failed extubation group required reintubation. DTF was significantly greater in the successful weaning group (55.05 ± 23.75% vs. 30.9 ± 10.38%) (p < 0.001). DE was significantly greater in the successful weaning group (14 ± 4.4 mm vs. 11.05 ± 3.25 mm) (p < 0.001). DTF and DE were found to have a sensitivity and specificity of 91.67%, 87.50%, 83.33%, and 81.25%, respectively. CONCLUSION: Diaphragm ultrasound is a feasible and promising tool to guide physicians during weaning from invasive mechanical ventilation. Among all DUS measurements, the DE and DTF indexes showed better performance in extubation failure than other diaphragmatic parameters.

Early application of non-invasive ventilation for children with pulmonary edema after drowning.

BACKGROUND: The present study aimed to assess the efficacy of non-invasive ventilation (NIV) on the clinical course, oxygenation, need for invasive mechanical ventilation (IMV), and outcomes for children with pulmonary edema after drowning. METHODS: We conducted a retrospective chart review. Children who were referred to the pediatric emergency department due to drowning-related pulmonary edema and underwent NIV between May 2014 and October 2020 were included. Demographics, vital signs, clinical findings, and results of laboratory and radiologic investigations were recorded. Patients were divided into six groups using the Szpilman classification system. The need for IMV, the need for pediatric intensive care unit admission, and the length of NIV treatment and stay in the pediatric intensive care unit were recorded for each patient. RESULTS: Twenty-five patients were enrolled. According to the Szpilman classification, 13 (52.0%) patients were evaluated as grade 3 and 12 (48.0%) as grade 4. All patients were treated with bi-level positive airway pressure in the spontaneous / timed mode. A significant increase in oxygen saturation (SpO2) and SpO2/fraction of inspired oxygen ratios was observed from the beginning of NIV treatment and this increase was also observed for the second and fourth hours. There was a decrease in respiratory rate at the fourth hour of NIV treatment. No patient subsequently deteriorated to require IMV. CONCLUSIONS: We have reported a favorable clinical course of drowning patients who underwent early use of NIV in the pediatric emergency department. Management of drowning patients with pulmonary edema by NIV with close follow-up can be successfully applied in selected cases.

Which Device Is Favorable for Intubation Attempts of Pediatric Residents on Four Different Pediatric Airway Simulations?

OBJECTIVES: Endotracheal intubation is an essential skill for the pediatric airway management. Although direct laryngoscopy (DL) is the standard method, several videolaryngoscopes (VLs) have been recently enhanced as an alternative especially for difficult intubations. We aimed to compare McGrath MAC (McG) and Storz C-MAC PM (ST) VLs with DL in terms of intubation success rate, time to intubation (TTI), and duration of obtaining glottis view of intubation attempts performed by pediatric residents on different pediatric airway manikins. METHODS: The pediatric residents with no experience in videolaryngoscopy were included. After a brief demonstration, intubation attempts with 3 randomly handled different devices with 6 different blades were performed on a child manikin, an infant manikin, a Pierre-Robin sequence infant manikin, and a child manikin with cervical immobilization sequentially. RESULTS: Fifty pediatric residents were enrolled. The attempts of DL on child manikin and attempts of all devices on child with cervical immobilization simulation were completely successful. For the attempts on both infant manikin and Pierre-Robin sequence infant manikin, the success rate of McG was significantly lower than ST and DL (P = 0.011 and P = 0.001). In the child manikin, McG and ST had prolonged TTI compared with DL (P = 0.016 and P = 0.001). For the child with cervical immobilization simulation, TTI of DL was significantly shorter than McG and ST (P = 0.011 and P = 0.001). Time to intubation of McG was significantly longer than DL and ST for the attempts on both 2 infant manikins. The rate of Cormack-Lehane grade I glottis view was similar for the attempts on both 2 child airway simulations. For infant manikin and Pierre-Robin sequence infant simulation, the rate of Cormack-Lehane grade I of ST was higher than attempts of DL and McG. CONCLUSIONS: The attempts of pediatric residents on infant normal airway and Pierre-Robin sequence infant airway simulations resulted with enhanced glottis view by the utilization of Storz C-MAC PM, but both 2 VLs did not provide the improvement of intubation success rate and TTI compared with DL on these 4 different pediatric manikins. Further clinical studies of different VLs in different clinical courses are required for a reliable utilization in children.

Evaluation of Pediatric Maxillofacial Injury: Who Is Critical?

OBJECTIVE: Isolated facial injuries are less common among pediatric trauma patients. The literature has focused on, especially, fractures in facial injuries. There is a limited number of studies evaluating all facial injuries in childhood. The study aims to evaluate the clinical characteristics of maxillofacial injuries and to identify patients who require further intervention. METHODS: The data from pediatric patients with maxillofacial injury (<18 years) between January 2011 and December 2015 were collected. Demographic characteristics, trauma mechanisms, concomitant injuries, treatments, hospitalization, and follow-up results were recorded. RESULTS: The median age of the patients (N = 2926) was 5.0 years (2.0-10.0 years), and 63.1% were boys. Falls and motor vehicle accidents were the leading mechanism of injury. The most common injury types were lacerations (49.3%) and fractures (15.5%). One hundred thirty (0.4%) patients had concomitant injuries. Surgical treatment was performed in only 3.4% of the patients, and the mortality rate was 0.6%. Patients with concomitant injuries had more hospitalization rates, surgical treatment, and organ dysfunction. All patients who underwent cardiopulmonary resuscitation and resulted in mortality were in the concomitant injury group. CONCLUSIONS: Isolated facial injuries are unlikely to be life-threatening, and basic interventions are sufficient in most of the maxillofacial injuries. The primary issue in maxillofacial injuries is to recognize and manage concomitant injuries that can lead to organ dysfunction and mortality.

Pediatric trauma: Blood product transfusion characteristics in a pediatric emergency department, a single center experience.

AIM: To investigate clinical and laboratory data, management and outcomes of pediatric trauma patients who initially received blood product transfusions. METHODS: Between January 2011-January 2021, traumatic children who underwent blood product transfusions within 24 h of arrival at the emergency department were included. Demographics, clinical and laboratory data, Injury Severity Score (ISS), volume of transfused blood products and crystalloid boluses in 24 h were recorded. Massive transfusion (MT) was defined as transfusion of ≥40 mL/kg of all blood products in 24 h. RESULTS: Among 32 cases, 8 (25.0 %) patients met the MT threshold criterion. Length of pediatric intensive care unit (PICU) stay and mechanical ventilation (MV) were longer for patients who received MT although there was no difference for age, ISS, volume of crystalloid boluses, length of hospital stay, and 30-day mortality between those who received MT or not. Volume of crystalloid boluses was higher in patients who died than those who survived but the volume of blood products was similar for two groups. An APTT value of >37.5 s was identified as a predictor of 30-day mortality (OR = 48.000, 95 % CI: 3.704-621.998, p: 0.003). CONCLUSION: Children who received MT had longer durations of MV and PICU stay than those who did not receive, but there was no significance for ISS, volume of crystalloid boluses, hospital stay, or mortality between two groups. Volume of crystalloid boluses was higher in patients who died than those who survived. An APTT value of >37.5 s can be used to predict 30-day mortality.

The skills of defibrillation practice and certified life-support training in the healthcare providers in Turkey.

AIM OF THE STUDY: Successful cardiopulmonary resuscitation and early defibrillation are critical in survival after in- or out-of-hospital cardiopulmonary arrest. The scope of this multi-centre study is to (a) assess skills of paediatric healthcare providers (HCPs) concerning two domains: (1) recognising rhythm abnormalities and (2) the use of defibrillator devices, and (b) to evaluate the impact of certified basic-life-support (BLS) and advanced-life-support (ALS) training to offer solutions for quality of improvement in several paediatric emergency cares and intensive care settings of Turkey. METHODS: This cross-sectional and multi-centre survey study included several paediatric emergency care and intensive care settings from different regions of Turkey. RESULTS: A total of 716 HCPs participated in the study (physicians: 69.4%, healthcare staff: 30.6%). The median age was 29 (27-33) years. Certified BLS-ALS training was received in 61% (n = 303/497) of the physicians and 45.2% (n = 99/219) of the non-physician healthcare staff (P < .001). The length of professional experience had favourable outcome towards an increased self-confidence in the physicians (P < .01, P < .001). Both physicians and non-physician healthcare staff improved their theoretical knowledge in the practice of synchronised cardioversion defibrillation (P < .001, P < .001). Non-certified healthcare providers were less likely to manage the initial doses of synchronised cardioversion and defibrillation: the correct responses remained at 32.5% and 9.2% for synchronised cardioversion and 44.8% and 16.7% for defibrillation in the physicians and healthcare staff, respectively. The indications for defibrillation were correctly answered in the physicians who had acquired a certificate of BLS-ALS training (P = .047, P = .003). CONCLUSIONS: The professional experience is significant in the correct use of a defibrillator and related procedures. Given the importance of early defibrillation in survival, the importance and proper use of defibrillators should be emphasised in Certified BLS-ALS programmes. Certified BLS-ALS programmes increase the level of knowledge and self-confidence towards synchronised cardioversion-defibrillation procedures.

Evaluation of COVID-19 Disease and the Effect of Trends in Intervention Measures: The Pediatric Perspective from a Tertiary Care Hospital in Turkey.

BACKGROUND: COVID-19 is an emerging disease of global public health concern. AIMS: To evaluate the epidemiological, clinical, laboratory, and radiologic findings and the clinical outcomes of children who were diagnosed with SARS-CoV-2 by polymerase chain reaction (PCR), and to evaluate the effect of the trends in intervention measures. STUDY DESIGN: Between April 2, 2020 and January 16, 2021, children aged 0-18 years who had presented at the pediatric emergency department and were diagnosed with confirmed SARS-CoV-2 by PCR were enrolled. METHODS: Details on demographics, epidemiologic characteristics, clinical findings, laboratory data, and radiologic investigations, hospital admissions, and prognosis were recorded. According to clinical severity, patients were divided into 5 groups as asymptomatic, mild, moderate, severe, or critical. We classified the outbreak into 3 periods. The first was between April 2, 2020, the date when the first pediatric case of our hospital was detected, and June 1, 2020, when restrictive measures were relaxed. The second period was between June 1, 2020 and November 15, 2020, when restrictive measures were reimplemented. The third period was between November 15, 2020 and January 16, 2021. RESULTS: A total of 600 patients [median age: 10.3 years (IQR: 4.4-15.1); 304 females] were enrolled. Among them, 25.0% were asymptomatic, while the 3 most common symptoms among symptomatic cases were fever, cough, and fatigue. There was contact with a COVID-19 PCRpositive individual in 73.5% of the cases, with 76.6% of those being a household contact. There were 23 (3.9%) moderate, severe, or critical cases in terms of clinical severity. The presence of chronic disease, a pathological physical chest examination, and procalcitonin levels of >0.05 ng/mL were identified as predictors of being moderate, severe, or critical. Twenty-four (4.0%) patients were admitted to the hospital; 14 (2.3%) to the ward and 10 (1.6%) to the pediatric intensive care unit. In the second intervention period, we observed a rapidly increasing number of new cases daily, especially in August. From September, an increase was observed, being particularly marked from October to November 18. Since then, there was a decrease in the daily number of cases. CONCLUSION: The majority of the cases were asymptomatic or had a mild clinical presentation. The presence of chronic disease, a pathological physical chest examination, and procalcitonin levels of >0.05 ng/mL were identified as predictors of being moderate, severe, or critical in terms of clinical severity. Strict intervention measures seem to be effective in containing the spread of COVID-19.

Accuracy of point-of-care ultrasound for determining the adequacy of pediatric forearm fracture reductions.

BACKGROUND: The objective of the present study was to the determine the accuracy of point-of-care ultrasound (POCUS) in assessing closed reduction (CR) of pediatric forearm fractures in a pediatric emergency setting. METHODS: After determination of the need for CR using X-ray images by an orthopedic consultant, POCUS examinations were performed just before and after the reduction attempt. The transducer was positioned longitudinally over the dorsal, volar, and lateral surfaces of the radius and ulna to view the fracture site. The presence of angulation, displacement, or bayonetting of the fracture fragments was recorded. The adequacy of realignment according to the POCUS and the orthopedic consultant's final determination were recorded. RESULTS: Sixty-two patients were enrolled in the study and 96 bones were evaluated. The sensitivity and specificity of POCUS for adequacy of CR were 95.8% [95% confidence interval (CI): 88.3-99.1)] and 95.8% (95% CI: 78.8-99.8), the positive predictive value was 98.5% (95% CI: 91.0-99.7), and the negative predictive value was 88.4% (95% CI: 71.6-95.8). The corresponding positive and negative likelihood ratios were 23 (3.37-156.77) and 0.04 (0.01-0.12). There was high agreement between POCUS and X-ray images for predicting adequacy of CR [κ: 0.892 (±0.053)]. There was also a significant correlation between POCUS and X-ray measurements of angulation and displacement performed before and after CR, respectively (p < 0.001). CONCLUSION: Our study has reported the successful use of POCUS for the management of pediatric forearm fractures in a pediatric emergency department. Point-of-care ultrasound can minimize radiation exposure and appears to be an alternative and accurate tool for reduction attempts.