Case Report of a Child with Colocolic Intussusception with a Primary Lead Point.

Intussusception is the telescoping of bowel into an adjacent segment of bowel and has an associated risk for bowel ischemia and perforation. The classic triad of abdominal pain, blood in stool, and an abdominal mass is present in less than 40% of pediatric cases and is less common in older children.1 Ultrasound has a high sensitivity and specificity for the diagnosis of intussusception, and once diagnosed, treatment modalities include reduction by either ultrasound or fluoroscopic guided air or hydrostatic enema. The risk of recurrence after successful reduction occurs in up to 12% of pediatric patients and occurs more frequently in older children and children with a pathologic lead point.2 We present a case of a 6-year-old child with colocolic intussusception that was successfully reduced and recurred within five days due to a large colonic polyp. Topics: Intussusception, lead point, pediatrics.

Emergency Department Volumes After State-Wide Lockdown Orders Across the United States During the COVID-19 Pandemic: COVID-19 lockdown and emergency volume.

OBJECTIVE: The objective of this study was to describe changes in emergency department volumes after statewide lockdown in a network of hospitals across the United States during the COVID-19 global pandemic. METHODS: A retrospective study was performed utilizing data on daily volumes across multiple emergency departments from a centralized data warehouse from a private for-profit hospital system during the COVID-19 pandemic. The mean daily volumes of 148 emergency departments were evaluated across 16 states in relation to each state's governmental statewide lockdown orders. Comparisons of the same period in the prior year were evaluated for percent changes in volumes. We also compared pre-lockdown to post-lockdown volumes. A separate analysis was made for the pediatric ED volumes. RESULTS: The 2020 post-lockdown volumes compared to the same 2019 dates revealed a mean percent change of -43.09%. The overall post-lockdown volumes compared to the pre-lockdown volumes had a mean percent change of -45.00%. The pediatric data revealed a greater mean percentage change in volumes of -71.52% (post-lockdown compared to 2019) and -69.03% (post-lockdown compared to pre-lockdown). CONCLUSIONS: This study found an overall decrease in volumes among 148 emergency departments across 16 states when compared to the comparable period pre-global pandemic.

Validation of a Clinical Prediction Rule for Distinguishing Bacterial and Aseptic Meningitis in Pediatric Patients.

Introduction The treatments and prognosis of bacterial meningitis differ greatly from those of aseptic meningitis, making early identification and differentiation essential. Several different clinical prediction rules have been developed to distinguish bacterial meningitis from aseptic meningitis. We sought to validate one clinical prediction rule for pediatric patients utilizing a centralized data warehouse that collects daily data from 184 hospitals across the United States. Methods We retrospectively collected data on all patients aged 29 days to 14 years who presented to Hospital Corporation of America (HCA) Healthcare hospitals from January 1, 2016, to May 31, 2021, with a diagnosis of meningitis. Our study replicated the original study of the meningitis score for emergencies (MSE) for the pediatric clinical prediction rule and assigned 3 points for procalcitonin (PCT) >1.2 ng/dL, 2 points for CSF protein >80 mg/dL, and 1 point for each of the other variables of C-reactive protein (CRP) >40 mg/L and CSF absolute neutrophil count >1000 cells per mm3. Patients were categorized either as having bacterial or aseptic meningitis. Using the clinical prediction rule, a calculation of the sensitivity, specificity, positive predictive value, negative predictive value, and receiver operating characteristic (ROC) curve was performed. Results The optimum test characteristic was found to have a score of ≥ 3, showing a sensitivity of 92.86% (95% CI, 83.3-100), a specificity of 65.22% (95% CI, 51.5-79), a positive predictive value of 61.90% (95% CI, 47.2-76.6), and a negative predictive value of 93.75% (95% CI, 85.4-100). The ROC curve from this study showed an area under the curve (AUC) of 0.7892 (95% CI, 0.681-0.897). Conclusion Our study validated a high sensitivity for distinguishing bacterial meningitis from aseptic meningitis, suggesting the clinical prediction rule has clinical utility as a predictive screening tool. Although the original MSE advised a cutoff score of ≥1, our study suggests that a score ≥3 would give the best test performance.

Tibial Spine Fracture in an Adolescent Male After Minor Injury: A Case Report.

CASE PRESENTATION: A 13-year-old male presented with right knee pain and swelling from a basketball injury. The right knee exam demonstrated minimal swelling, decreased range of motion secondary to pain, and generalized tenderness. A radiograph of the right knee revealed a tibial spine fracture. DISCUSSION: Tibial spine fractures are avulsion fractures of the spine of the tibia at the insertion site of the anterior cruciate ligament. The incidence of avulsion fractures is higher in adolescents because the region of the apophyseal growth plate between the soft-tissue attachment site and the body of the bone is weaker in that age group. Tibial spine avulsion fractures are relatively uncommon and occur annually in approximately three per 100,000 children.

Neonatal hyperbilirubinemia: recommendations for diagnosis and management in the emergency department.

Hyperbilirubinemia is one the most common reasons for emergency department visits for the neonate. Most cases of unconjugated hyperbilirubinemia are benign. Although rare, unrecognized or untreated pathologic unconjugated hyperbilirubinemia can lead to the development of acute bilirubin encephalopathy and, ultimately, kernicterus. This issue reviews the emergency department evaluation and management of neonatal hyperbilirubinemia and discusses how to recognize acute bilirubin encephalopathy, with the goal of preventing kernicterus. Recommendations are provided for risk stratification and determining the need for phototherapy or exchange transfusion, using nomograms to plot total serum bilirubin levels and taking into consideration hyperbilirubinemia and neurotoxicity risk factors.

The Effect on Length of Stay After Implementation of Discharging Low Acuity Patients From Triage.

Introduction Overcrowding in the emergency department is a complex and challenging issue across the nation. The increasing number of patients seeking care in the emergency department leads to overcrowding and therefore decreased available rooms and slower throughput. As part of a quality improvement project to improve throughput, we implemented a policy encouraging the discharge of non-emergent patients directly from triage. Methods This was a retrospective pre- vs post-implementation analysis of a discharge process from triage to decrease emergency department length of stay. We implemented a policy that allowed the physician assistant to discharge lower acuity patients directly from triage. We collected daily length of stay metrics for a two-week period prior to and a two-week period after the implementation of the policy. Total and daily pre- and post-implementation length of stay means were compared and reported. Results There was a total of 1044 (pre-implementation) and 1063 (post-implementation) patients evaluated during the study period. There was a significant mean difference improvement in the overall length of stay post-implementation of 18.43 minutes (95% CI, 15.45 - 21.40). When comparing the differences for the day of the week, all days showed a statistically significant mean improvement in the length of stay of greater than 10%. Conclusion Discharging low acuity patients directly from triage can lead to a reduction in length of stay. Future studies are needed to determine the impact of different confounders on the length of stay of patients who are discharged from triage, as well as studies to evaluate the outcomes of patients that have been discharged from triage.

COVID-19 hospitalization rate in children across a private hospital network in the United States: COVID-19 hospitalization rate in children.

OBJECTIVES: There are limited studies with varying results evaluating the rate of hospitalizations of pediatric patients tested for COVID-19 in the United States. More information in the pediatric COVID-19 literature is needed. The objective of this study was to describe the rates of positive tests, hospitalization, severe disease, and mortality for COVID-19 in children. MATERIAL AND METHODS: We performed a retrospective analysis of data collected from a data warehouse from 184 hospitals across the United States. All cases of pediatric patients who were tested for COVID-19 were analyzed for test positivity, hospitalization, severe disease, and mortality. A separate subgroup analysis for ages < 1 year, 1-4 years, 5-8 years, 9-14 years, and 15-17 years was performed. RESULTS: Of 24,781 patient encounters, we found a test positivity rate of 11.15% (95% CI: 10.76-11.55). There were 142 admissions out of the 2,709 symptomatic patients, 5.24% (95% CI: 4.43-6.15) admission rate. Of those admitted, we found that 54.93% (78/142) were admitted to the PICU, but only 22 of the 142 admissions, 15.49% (95% CI: 9.97-22.51), were determined to have severe COVID-19 disease. One patient died during the study period giving an overall pediatric mortality rate of 0.04% (95% CI: 0.00-0.21). CONCLUSION: In our sample, we found a test positivity rate of 11.15%. We also report a 5.24% hospitalization rate with 15.49% of admitted patients with severe disease. Lastly, we also report a very low mortality rate of 0.04% of all patients who tested positive for COVID-19.

Investigation of a Peculiar Case of Childhood Lymphadenopathy.

Introduction: Lymphadenopathy is a common physical finding often associated with an infectious etiology. We present a case of a patient with generalized cervical and supraclavicular lymphadenopathy diagnosed with a rare malignancy. Health care providers should be aware of some uncommon historical or physical examination findings that warrant further investigation. Clinical Findings: A 16-year-old female presented to the emergency department with 3 days of a fever, congestion and sore throat with swelling around the jaw. Her physical examination findings included bilateral mandibular swelling and generalized cervical lymphadenopathy with palpable supraclavicular lymph nodes. Outcomes: Complete blood count showed pancytopenia with a white blood cell count of 4.4 × 10e3/uL, hemoglobin of 10.8 g/dL and platelets of 87 × 10e3/uL. CT scan of the neck with IV contrast revealed extensive cervical and mediastinal lymphadenopathy with suspicion of lymphoma. Biopsy results diagnosed a rare form of a hematologic malignancy called blastic plasmacytoid dendritic cell neoplasm. Conclusions: The presence of supraclavicular lymphadenopathy should raise concern for non-infectious etiologies, such as malignant processes.

Pediatric heat-related illness: recommendations for prevention and management

Infants, children, and adolescents are at increased risk for heat-related illness due to their inability to remove themselves from dangerous environments. Evidence shows that morbidity and mortality from heat illness is related to the length of time core temperature is elevated, so rapid reduction and accurate serial measurements are crucial to prevention of organ system damage and death. The primary methods of patient cooling are conduction (ice-water immersion, cold packs) and convection (moisture and moving air). The choice of method used may depend on availability of equipment, but there is evidence that can guide optimal use of resources. This issue presents evidence-based recommendations and best practices in heat-illness resuscitation, including managing children who are obese, have special needs or take medications, and advocacy for prevention strategies.

Os Odontoideum Discovered After Minor Cervical Trauma.

Minor cervical spine injury is a common cause of pediatric emergency department visits. We present a case of a 10-year-old boy with transient paresthesia after minor cervical trauma found to have a rare cervical spine abnormality requiring surgical fusion. We present and discuss the management options for os odontoideum.

Pediatric procedural sedation with propofol using a higher initial bolus dose.

OBJECTIVES: We sought to describe the doses of propofol used for sedation in our pediatric emergency department, along with the range of procedures performed under propofol sedation. We also planned to describe clinically important physiologic changes seen and physician satisfaction with propofol at the doses observed. METHODS: This was a prospective observational case series. Physicians completed a data collection form after the propofol sedation. The physicians were asked to report physiologic changes that occurred during sedation and rate their satisfaction with propofol as a sedation agent on a 100-mm visual analog scale. RESULTS: Eight hundred eighty-six sedation events were reported. The median initial dose of propofol given was 2.0 mg/kg and the median total dose was 3.6 mg/kg. Propofol was used for a wide range of procedures. The most common physiologic change was desaturation/hypoxia (desaturation to <90% in 7.2%). No deaths, unplanned intubations, or surgical airway placements were reported. Treating physicians reported a median satisfaction score of 97 mm. CONCLUSIONS: A 2-mg/kg initial bolus dose of propofol for pediatric sedation was well tolerated and useful for a wide range of procedures. Physicians should expect to find a high level of satisfaction with this dose.

Analysis of medication errors in simulated pediatric resuscitation by residents.

INTRODUCTION: The objective of our study was to estimate the incidence of prescribing medication errors specifically made by a trainee and identify factors associated with these errors during the simulated resuscitation of a critically ill child. METHODS: The results of the simulated resuscitation are described. We analyzed data from the simulated resuscitation for the occurrence of a prescribing medication error. We compared univariate analysis of each variable to medication error rate and performed a separate multiple logistic regression analysis on the significant univariate variables to assess the association between the selected variables. RESULTS: We reviewed 49 simulated resuscitations. The final medication error rate for the simulation was 26.5% (95% CI 13.7% - 39.3%). On univariate analysis, statistically significant findings for decreased prescribing medication error rates included senior residents in charge, presence of a pharmacist, sleeping greater than 8 hours prior to the simulation, and a visual analog scale score showing more confidence in caring for critically ill children. Multiple logistic regression analysis using the above significant variables showed only the presence of a pharmacist to remain significantly associated with decreased medication error, odds ratio of 0.09 (95% CI 0.01 - 0.64). CONCLUSION: Our results indicate that the presence of a clinical pharmacist during the resuscitation of a critically ill child reduces the medication errors made by resident physician trainees.

Evidence-based management of neonatal vomiting in the emergency department.

Vomiting accounts for up to 36% of neonatal visits to the emergency department. The causes of vomiting can range from benign to life-threatening. Evidence to guide the diagnosis and management of neonatal vomiting in the emergency department is limited. History and physical examination are extremely important in these cases, especially in identifying red flags such as bilious or projectile emesis. A thorough review is presented, discussing various imaging modalities, including plain abdominal radiography, upper gastrointestinal studies, ultrasonography, and contrast enema. A systematic approach in the emergency department, as outlined in this review, is required to identify the serious causes of vomiting in the neonate.

Emergency Department Management Of Upper Gastrointestinal Bleeding In Pediatric Patients.

Upper gastrointestinal bleeding is an uncommon problem in pediatric patients, accounting for 0.2% of complaints in children presenting to the emergency department. Managing children suspected of having an upper gastrointestinal bleed can be anxiety-provoking, as the differential diagnosis includes a range of benign to life-threatening conditions with the potential for significant morbidity and mortality if management is delayed. Common differential diagnoses of upper gastrointestinal bleeding will be reviewed, and the initial clinical evaluation and management of children with a suspected upper gastrointestinal bleed will be outlined.

Finger counting: an alternative method for estimating pediatric weights.

OBJECTIVES: We compared the accuracy of a conceptually simple pediatric weight estimation technique, the finger counting method, with other commonly used methods. METHODS: We prospectively collected cross-sectional data on a convenience sample of 207 children aged 1 to 9 presenting to our pediatric emergency department. Bland-Altman plots were constructed to compare the finger counting method to the Broselow tape method, parental estimate, the Luscombe formula, and the advanced pediatric life support (APLS) formula. Proportions within 10% and 20% of measured weight were compared. RESULTS: Mean difference and range of agreement in kilograms for Bland-Altman plots were as follows: -1.8 (95% confidence interval [CI], -2.3 to -1.3) and 15.4 (95% CI, 13.6-17.2) for the finger counting method; -1.4 (95% CI, -2.0 to -0.9) and 15.8 (95% CI, 13.9-17.6) for the Broselow method; -0.02 (95% CI, -0.53 to 0.49) and 14.8 (95% CI, 13-16.6) for parental estimate; 0.2 (95% CI, -0.33 to 0.72) and 15.3 (95% CI, 13.5-17.2) for the Luscombe formula; and -3.8 (95% CI, -4.4 to -3.2) and 17.2 (95% CI, 15.2-19.2) for the APLS formula. The finger counting method estimated weights within 10% in 59% of children (95% CI, 52%-65%) and within 20% in 87% of children (95% CI, 81%-91%). Proportions within 10% were similar for all methods, except the APLS method, which was lower. CONCLUSIONS: The finger counting method is an acceptable alternative to the Broselow method for weight estimation in children aged 1 to 9 years. It outperforms the traditional APLS method but underestimates weights compared with parental estimate and the Luscombe formula.

Incidence of serious bacterial infections in febrile children with sickle cell disease.

OBJECTIVE: To determine the incidence of serious bacterial infections in febrile children with sickle cell disease and to describe the outcomes of children discharged from the pediatric emergency department. METHODS: We conducted a retrospective chart review of 188 febrile patients with sickle cell disease presenting to our pediatric emergency department over a 10-year period. Serious bacterial infection was defined as bacteremia, meningitis, urinary tract infection, osteomyelitis, or pneumonia. RESULTS: Our overall incidence rate for serious bacterial infections was 16.0% (95% confidence interval [CI] = 10.8% to 21.2%). Pneumonia had the highest incidence rate of 13.8% (95% CI = 8.8% to 18.8%). This was followed by bacteremia and urinary tract infections, both with incidence rates of 1.1% (95% CI = 0.0% to 2.5%). We had no cases of meningitis or osteomyelitis in our study group. CONCLUSION: We had an incidence of 16.0% for serious bacterial infections in febrile children with sickle cell disease, with the majority of patients diagnosed with pneumonia.

Avulsion fracture of the lesser trochanter: an unusual cause of hip pain in an adolescent.

Sports injuries involving the hip and groin are common. Special consideration must be given to musculoskeletal injuries in children and adolescents as their immature skeletons have growth plates that are relatively weaker than the tendons and ossified bone to which they connect. We present a case of an adolescent athlete with acute-onset groin pain who was found to have an avulsion fracture of the lesser trochanter.

Pediatric emergency department census during major sporting events.

OBJECTIVES: Our study attempted to evaluate the effects of major sporting events on the census of a pediatric emergency department (ED) in the United States specifically related to the National Football League Super Bowl, National Basketball Association (NBA) Finals, and Major League Baseball World Series. METHODS: We performed a retrospective data analysis of our pediatric ED census on the number of visits during major sporting events over a 5-year period. Data during the same period 1 week after the major sporting event were collected for comparison as the control. We evaluated the medians of 2-hour increments around the event start time. Subgroup analysis was performed for games involving the local sporting teams. RESULTS: Our results showed no significant difference in ED census during the sporting events, except in the post 6 to 8 hours of the NBA finals. Subgroup analysis of the Los Angeles Lakers showed the same significant findings in the post 6 to 8 hours of the NBA finals. CONCLUSIONS: No major difference in pediatric ED census is observed during the most major sporting events in the United States.

Incidence of Serious Bacterial Infections in Ex-premature Infants with a Postconceptional Age Less Than 48 Weeks Presenting to a Pediatric Emergency Department.

OBJECTIVES: Premature infants are at higher risk of developing serious bacterial infections (SBI). However, the incidence of SBI in ex-premature infants presenting to the emergency department (ED) remains undetermined. The objective of this study is to examine the incidence of SBI in ex-premature infants with a postconceptional age of less than 48 weeks presenting to a pediatric ED. METHODS: A retrospective medical record review was conducted on 141 ex-premature infants with a postconceptional age of less than 48 weeks who had a full or partial septic work up completed in a pediatric ED between January 1, 1998 and March 31, 2005. RESULTS: The overall median gestational age at birth was 35 weeks (IQR 33-36 week) and the overall median postconceptional age at ED presentation was 40 weeks (IQR 37-42 weeks). Thirteen (9.2%) infants were found to have a SBI. Five subjects had pneumonia, four with bacteremia, two with pyelonephritis, and two with a concomitant infection of meningitis/pneumonia and bacteremia/pyelonephritis. CONCLUSION: The results of this study reveal that the incidence of SBI in ex-premature infants with a postconceptional age of less than 48 weeks is similar to in-term infants (9.2%) and is consistent with previously published incidence rates in-term infants (10%).