Central Line Repair in Pediatric Patients in the Pediatric Emergency Department by Emergency Physicians-A Single-Center Experience.

INTRODUCTION: Central venous catheters are more common with advanced treatments for a variety of conditions. These catheters may need to be repaired after local damage. This has been performed by those more involved with catheter placement such as pediatric surgeons and interventional radiologists. Gastroenterologists who treat many of these patients have also been involved with catheter repair. Repair by pediatric emergency physicians has not been explored. Such repairs by the emergency physician may be time saving and avoid unnecessary admissions. METHODS: This was a retrospective study of a single center's experience with catheter repair. The performers and outcomes were compared. RESULTS: During the study period, 52 catheter repairs were performed on 7 children. Forty of the repairs were performed by a pediatric emergency physician, 5 by pediatric surgeons, and 5 by interventional radiology. All but 1 repair was successful. Infectious complications were reported in 3 cases. None required catheter removal. The length of stay was significantly shorter for repair by emergency physician. CONCLUSIONS: Central line catheter repair can be performed successfully by pediatric emergency physician with minimal complications. A dedicated process of repair tutoring is required and may avoid infectious complications.

Nighttime Sedations in the Pediatric Emergency Department: A Single-Center Experience.

INTRODUCTION: Procedural sedation and analgesia (PSA) is the standard of care for many procedures in the pediatric emergency department (PED). Although generally performed by skilled PED physicians, in Israeli PEDs, during nighttime hours, it is mainly performed by pediatric residents. The safety of PSA by residents is considered comparable yet has not been evaluated regarding nighttime performance. METHODS: A retrospective study review of PSA performed in the PED at night (1:00 a . m .-7:00 a . m .). To evaluate these events, we compared each case of nighttime PSA to 2 daytime PSA cases from 2017 to 2019. Adverse events were evaluated using the Quebec criteria. RESULTS: The study included 451 sedations performed on 438 children from January 2017 to January 2019. Adverse events (AEs) occurred in 29 (6.4%) of the sedations. Serious AEs were uncommon. This included mostly bag-valve-mask ventilation used in 13 (2.9%) of the cases. Of these, 12 were daytime sedations. There was a clear association between abscess drainage during daytime hours and AEs. CONCLUSIONS: Sedations performed during nighttime hours by pediatric residents seem safe and effective. This should strengthen the empowerment of residents to perform sedations when necessary even at late hours of the night. Recognizing cases at higher risk may avoid possible AEs.

Leukocytosis and C-Reactive Protein Levels as Indicators of Infection in Children With Diabetic Ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is one of the serious complications of type 1 diabetes mellitus and may be aggravated by infection. Diagnosing an infection in a patient with DKA is often complicated because of the overlap of symptoms and the presence of leukocytosis in both conditions. Reliable indicators for the diagnosis of bacterial infection in DKA may reduce unnecessary use of antibiotics and enable closer monitoring of patients at risk. METHODS: This is a retrospective study. The study cohort included 180 children and adolescents with type 1 diabetes mellitus who were admitted to the Pediatric Emergency Department at Shaare Zedek Medical Center and had blood test results. We compared white blood cell count, C-reactive protein (CRP) levels, blood glucose levels, pH, the degree of acidosis, and the incidence of infection in patients with and without DKA. RESULTS: The incidence of probable bacterial infection in the entire cohort was 13.9%: 15.7% in the DKA group and 7.5% in the non-DKA group ( P = 0.65). The incidence of leukocytosis was significantly higher in patients with DKA ( P = 0.0003), although this was not related to bacterial infection. The CRP levels were higher in the DKA group with infection than without infection, and this was statistically significant ( P = 0.008). CONCLUSIONS: Our findings suggest that leukocytosis in DKA is not a reliable indicator of concomitant bacterial infection. In contrast, CRP levels were not related to the DKA or degree of acidosis and were significantly higher in patients with infection within the DKA group, and are therefore a more reliable indicator of concomitant infection in these patients.

Antibiotics for Clinical Dysentery in the Pediatric Emergency Department.

BACKGROUND: Clinical dysentery causes hundreds of thousands of deaths annually worldwide. However, current recommendations reserve antibiotics for those either clinically sick or with highly suspected cases of shigellosis. This treatment stems from rising antibiotic resistance. Children diagnosed with clinical dysentery in the pediatric emergency department (PED) are regarded more cautiously. OBJECTIVES: To explore the use of antibiotics in children diagnosed with clinical dysentery in the PED. METHODS: A retrospective case study of children with clinical dysentery at a single PED during the years 2015 and 2018. Demographics as well as clinical findings were compared to culture results and antibiotic treatment. RESULTS: The study included 281 children who were diagnosed with clinical dysentery during the study period; 234 (83%) were treated with antibiotics. However, cultures were positive in only 162 cases (58%). Only 32% were Shigella spp. Younger age, fever, and leukocytosis were related to antibiotic treatment. CONCLUSIONS: The diagnosis of clinical dysentery is misgiven commonly in the PED leading to widespread use of antibiotics when not indicated. This treatment may impact antibiotic resistance patterns. Further studies and interventions are necessary to create clear guidelines in the PED setting.

Pediatric Hospitalizations After School Reopening During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Alpha (B.1.1.7) Variant Spread: A Multicenter Cross-sectional Study in Israel.

This multicenter, cross-sectional study provides evidence on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated emergency department visits and hospitalizations in pediatric wards and intensive care units after school reopening during the SARS-CoV-2 Alpha (B.1.1.7) variant spread in Israel. Study findings suggest that school reopening was not followed by an increase in SARS-CoV-2-related pediatric morbidity.

Management of intraorbital infections in the pediatric emergency department.

Intraorbital infections may lead to severe complications, necessitating rapid diagnosis and intervention. The decision process regarding the need for emergent imaging and possible surgical intervention is unclear in the literature. This retrospective cohort study included two major pediatric emergency departments in Israel between 2010 and 2020. Patients arriving at the emergency department with an admission diagnosis of intraorbital infection and at least one high-risk symptom for orbital involvement were included in the study. The main outcome measures were the computerized tomography (CT) timing and results, whether the case was managed surgically or conservatively and whether the patient returned to the same hospital with significant complications. Ninety-five patients were included; 70 underwent a CT scan in the first 24 h, and of those 21 were managed surgically; 16 were treated based on clinical findings alone, with no imaging performed. When comparing groups based on management, we found no significant differences based on presenting symptoms, duration of complaints, or severity of CT findings. However, having three or more high-risk presenting symptoms was associated with a greater likelihood of surgical intervention (multivariate logistic regression p = 0.069, odds ratio 1.73, 95% confidence interval 0.96-3.11; one-way ANOVA and Fisher's exact test p < 0.05). CONCLUSION: The decision to treat intraorbital infections at our institutions appears to be based on clinical impression of disease severity rather than radiologic findings. This suggests a need for further interdisciplinary studies to clarify optimal management. WHAT IS KNOWN: • Orbital c ellulitis is associated with significant potential complications, necessitating rapid diagnosis and treatment. • Present literature provides insufficiently clear guidance on emergency department management. WHAT IS NEW: • Consideration of all relevant factors (clinical features, laboratory findings, timing of imaging, and conservative vs. surgical management) in a single retrospective cohort. • Our findings suggest that decision-making in practice may be guided by clinical impression rather than imaging.

Triage performance in adolescent patients with SARS-CoV-2 infection in Israel.

OBJECTIVE: The aim of this study was to assess the performance of the Pediatric Canadian Triage and Acuity Scale (PaedCTAS) in adolescent patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: A time-series study was conducted in the Emergency Departments (EDs) of 17 public hospitals during the Delta (B.1.617.2) variant spread in Israel. Data were collected prospectively from June 11, 2021 to August 15, 2021. Multivariate regression analyses were performed to identify independent variables associated with hospital admission and with admission to an Intensive Care Unit (ICU). RESULTS: During the study period, 305 SARS-CoV-2 patients ages 12-18 years presenting to the ED were included, and 267 (87.5%) were unvaccinated. Sixty-seven (22.0%) and 12 (3.9%) patients were admitted to pediatric wards and ICUs, respectively. PaedCTAS level 1-2 and the presence of chronic disease increased the odds of hospital admission (adjusted odds ratio (aOR) 5.74, 95% CI, 2.30-14.35, p < 0.0001), and (aOR 2.9, 95% CI, 1.48-5.67, p < 0.02), respectively. PaedCTAS level 1-2 and respiratory symptoms on presentation to ED increased the odds of ICU admission (aOR 27.79; 95% CI, 3.85-176.91, p < 0.001), and (aOR 26.10; 95% CI, 4.47-172.63, p < 0.0001), respectively. PaedCTAS level 3-5 was found in 217/226 (96%) of the patients who were discharged home from the ED. CONCLUSIONS: The findings suggest that PaedCTAS level 1-2 was the strongest factor associated with hospital and ICU admission. Almost all the patients who were discharged home had PaedCTAS level 3-5. Study findings suggest good performance of the PaedCTAS in this cohort.

Can parental simulation improve neonatal CPR performance? A pilot study.

Basic life support training and instruction is recommended for parents of premature infants discharged from the hospital. In order to assess the short-term efficacy of basic life support simulation, in addition to the institutional training, a prospective single-blinded randomized interventional study was performed. The study group received, besides the institutional training, an additional simulation training. The control group had only traditional training. A test assessment was followed approximately a week later and evaluated by two investigators. Fifty parents participated. Nineteen (38%) were in the study group. The study group showed a significant improvement in all the parameters assessed.Conclusion: The addition of a simulation encounter before discharge may improve short-term parental performance of basic life support. What is Known: • Parents of newborns at risk receive institutional training in basic life support. • The retention of knowledge from this training is a point of concern for parents. What is New: • A single simulation encounter for parents improved resuscitation performance. • Simulation for parents may be an important and useful tool to improve the efficacy of basic life support training.

Tickborne Relapsing Fever, Jerusalem, Israel, 2004-2018.

To compare tickborne relapsing fever (TBRF) in children and adults in Jerusalem, Israel, we collected data from the medical records of all 92 patients with TBRF during 2004-2018. The 30 children with TBRF had more episodes of fever and lower inflammatory markers than adult patients.

The molluscum contagiosum BOTE sign-Infected or inflamed?

BACKGROUND: Molluscum contagiosum (MC) is a common skin infection in the pediatric age group. The infection is self-limited and manifests as discrete, umbilicated skin-colored papules on any skin surface of the body. At times, complications such as local dermatitis and swelling, erythema, and pus formation may appear. These signs of inflammation are commonly presumed to represent bacterial infection. METHODS: This multicenter study was a retrospective analysis of data collected on all patients diagnosed with inflamed lesions secondary to MC and treated at the Hadassah Medical Centers and Shaare Zedek Medical Center in Jerusalem, Israel, from 1/1/2008 to 1/07/2018. Characteristics of children with positive cultures were compared to those with negative cultures and those with contaminants. RESULTS: A total of 56 cases were reviewed; the mean age at presentation was 4.6 years. Fever was reported in 12.5%, and 62.5% received systemic antibiotics because of their inflamed MC prior to admission. Fifty-five percent had sterile cultures or cultures growing only contaminants. Only seven had positive cultures with the common cutaneous pathogens. No statistical difference was observed between the patients with pathogenic isolates and patients with sterile or non-pathogenic cultures in terms of demographics, lesion characteristics, inflammatory markers, or length of hospitalization. CONCLUSION: The findings suggest that most cases of suspected MC-related secondary infection can be attributed to inflammation rather than to bacterial infection. However, in some cases, true bacterial infection should be suspected and treated accordingly.

Sedation Provided for Consultations in the Pediatric Emergency Department: Another Perspective.

BACKGROUND: Many procedures requiring sedation in the pediatric emergency department are performed by consultants from outside the department. This team usually includes orthopedic surgeons and general surgeons. As sedation is now a standard of care in such cases, we evaluated consultants' views on sedation. OBJECTIVES: To evaluate consultants' views on sedation. METHODS: A questionnaire with both open-ended questions and Likert-type scores was distributed to all orthopedic surgeons and general surgeons performing procedures during the study period. The questionnaire was presented at three medical centers. RESULTS: The questionnaire was completed by 31 orthopedic surgeons and 16 general surgeons. Although the vast majority (93-100%) considered sedation important, a high percentage (64-75%) would still perform such procedures without sedation if not readily available. CONCLUSIONS: Sedation is very important for patients and although consultants understand its importance, the emergency department staff must be vigilant in both being available and not allowing procedures to "escape" the use of sedation.

Stress Hyperglycemia in a Pediatric Emergency Department Setting and its Relationship to the Underlying Disease and Outcome.

BACKGROUND: Stress hyperglycemia (SH) is a common finding in patients in pediatric emergency departments (PED) and has been related to increased morbidity and mortality. OBJECTIVES: To assess the incidence of SH among children visiting the PED. To identify which diseases predispose patients to SH and whether they indicate a worse outcome. METHODS: Data were collected retrospectively from the medical records of all children aged 0-18 years who visited the PED during the years 2010-2014 and who had a glucose level of ≥ 150 mg/dl. Data collected included age, gender, weight, blood glucose level, presence or absence of a pre-existing or a new diagnosis of diabetes mellitus, and previous treatment with medications affecting blood glucose levels or with intravenous fluids containing dextrose. Data were collected regarding hospitalization, duration of hospitalization, discharge diagnosis, and survival status. RESULTS: The study population included 1245 children with SH, which comprised 2.6% of all patients whose blood glucose level was measured in the PED during the study period. The mean age of children with SH was 49 months; 709 (56.9%) were male. The mean blood glucose level was 184 mg/dl. The rate of hospitalization was 57.8%. The mean duration of hospital stay was 5.6 days and mortality rate was 0.96%. The majority were diagnosed with a respiratory illness. CONCLUSIONS: SH is a common phenomenon among children evaluated in the PED and is associated with a high incidence of hospitalization. It may serve as an additional clinical indicator of disease severity.

Disaster zones-should we be clowning around?

Medical clowns have an important role in helping patients cope with their pain and distress. This is especially true in the pediatric population. However, their activity in a disaster area is unheard of. Following the Nepal earthquake in 2015, the Israeli field hospital set up in Kathmandu, Nepal was joined by five volunteer medical clowns. They were active in all parts of the field hospital. Following the hospital's activity, an online questionnaire was sent to the field hospital members to assess the impact of medical clowning on the hospital in general and its members' individual performance. Physicians and nurses found that medical clowning had a positive impact both generally and personally. (65.4 and 78.3% respectively on general impact.) Personnel that were not previously exposed to medical clowning also found them to have a positive impact; however, they were less likely to view it as impacting their personal performance. CONCLUSION: Medical teams in disaster areas may benefit from the presence of medical clowns. What is known about this topic: • Medical clowns are used for alleviation and distraction in painful and distressful medical procedures and treatments. Its positive effect on patients, and their families are well established. WHAT THIS STUDY ADDS: • This is the first description of medical clowning in a disaster area. In addition, the impact of medical clowning on the medical staff working in a disaster area is evaluated. No previous studies have explored the impact of medical clowns on the medical staff.

Challenges in Implementing International Standards for the Field Hospital Emergency Department in a Disaster Zone: The Israeli Experience.

BACKGROUND: Medical response to world disasters has too often been poorly coordinated and nonprofessional. To improve this, several agencies, led by the World Health Organization (WHO), have developed guidelines to provide accreditation for Foreign Medical Teams (FMTs). There are three levels, with the highest known as FMT Type-3 providing outpatient as well as inpatient surgical emergency care in addition to inpatient referral care. In November 2016, the WHO certified the Israel Defense Forces Field Hospital as the first FMT Type-3. OBJECTIVES: The objectives of this article are to describe the challenges in implementing these international standards for the field hospital emergency department in a disaster zone. DISCUSSION: There are general standards for all levels of FMTs, as well as specific requirements for the FMT-3. These include a mechanism of appropriate triage, two operating suites, 40 regular beds, four to six intensive care unit beds, radiology facilities, and various staff specialties. Despite the sophistication of the field hospital, there are many challenges. Logistical challenges include constructing the hospital in a disaster zone and equipment issues. There are staff challenges such as becoming oriented to a new and difficult environment. Patient challenges include cultural differences, language barriers, and issues of follow-up. There are often ethical challenges unique to the disaster zone. CONCLUSION: By presenting the experience and challenges of the first FMT Type-3, we hope that more countries can join this initiative and improve disaster care throughout the world.

Success rate of pneumatic reduction of intussusception with and without sedation.

BACKGROUND: Pneumatic reduction of ileocolic intussusception is often performed without sedation. The aim of this study was to evaluate the success rate of pneumatic reduction of intussusception with and without sedation. METHODS: We conducted a retrospective cohort study in Israel in two tertiary care centers using a similar protocol for pneumatic reduction of intussusception. In one center, patients had pneumatic reduction of intussusception under propofol-based sedation, while in the other, patients had pneumatic reduction of intussusception without any sedation. Children aged 3 months to 8 years who were diagnosed with ileocolic intussusception between January 1, 2008 and July 31, 2015 were included in the study. Multivariable regression was used to adjust for the possible confounders of age, gender, number of cases of intussusception prior to the study period, time period from the beginning of symptoms to emergency department admission (<12 h, >12 h), and time period from emergency department admission to the beginning of pneumatic reduction of intussusception. Secondary outcomes of the study included the proportion of bowel perforations during the procedure, and the proportion of early (within 48 h) recurrence of intussusception. RESULTS: The sedation and nonsedation cohorts included 124 and 90 patients, respectively. The cohorts were comparable with regard to demographic characteristics, hemodynamic vital signs on admission to the emergency department, blood gases tests during emergency department stay, and time variables prior to reduction of intussusception. Multivariable regression revealed reduction of intussusception success rates of 89.5% and 83.3% for the sedation group and nonsedation group, respectively, with an adjusted odds ratio of 1.2, 95% CI 1.1-5.3. Three sedated patients and 0 nonsedated patients developed bowel perforations during the procedure. Rates of early recurrence of intussusception of sedated patients and nonsedated patients were 5.1% (6/117) and 1.3% (1/79), respectively (P = 0.15, RR = 3.9, 95% CI: 0.47 to 31.81). CONCLUSION: The findings suggest that the pneumatic reduction of intussusception under propofol-based sedation had a slightly higher success rate than the pneumatic reduction of intussusception without sedation; however, the safety of this practice is yet to be determined.

High-dose adenosine for refractory supraventricular tachycardia: a case report and literature review.

Supraventricular tachycardia is the most common significant arrhythmia in children. If prolonged, it may cause heart failure and progress to cardiogenic shock warranting prompt treatment. The recommended interventions following vagal manoeuvres are intravenous adenosine and in the unstable patient electrical cardioversion. We present an infant with an unstable supraventricular tachycardia that was resistant to electrical cardioversion and recommended doses of adenosine. He reverted to sinus rhythm with a higher dose of adenosine, suggesting that such doses may be required in refractory supraventricular tachycardia.

Procedural sedation and analgesia in the emergency room of a field hospital after the Nepal earthquake.

Procedural sedation and analgesia (PSA) should be a priority in the emergency care of injured children. This humanistic approach is particularly important in paediatric victims of disaster, because these patients are prone to psychological distress secondary to the traumatic event. Following the Nepal earthquake, an Israeli field hospital (IFH) was deployed in Kathmandu. We report our experience with PSA in the emergency room (ER) of the IFH. 22 children underwent surgery in the operating room and 10 underwent PSA in the ER by paediatric emergency physicians: 6 had wound debridement, 2 had fracture reduction and 2 had laceration repair. All the procedures were successfully completed in the ER and no patient required intubation or admission to the intensive care unit due to an adverse event. The present study is the first report of the practice of paediatric PSA by non-anaesthesiologists in a field hospital.

Occult Bacteremia: Should We Look for the Needle in the Haystack?

BACKGROUND: Once a well-recognized entity, occult bacteremia (OB) is no longer a significant or serious bacterial infection. First following the introduction of the Haemophilus influenzae type B vaccine and now with the implementation of the conjugate pneumococcal vaccine (PCV), the number of cases has declined significantly. This has led to a change in many published guidelines to avoid taking blood cultures in fully vaccinated children presenting with fever. In Israel, the introduction of the PCV13 is now widespread. OBJECTIVES: To assess the incidence and outcome of OB, specifically by Streptococcus pneumoniae, in a single large pediatric medical center. METHODS: We conducted a retrospective review of all cases of pneumococcal bacteremias in the years 2008-2013 and specifically those considered occult. RESULTS: Of 355 cases of bacteremia diagnosed during the study period, 164 were caused by S. pneumoniae and 20 (12.8%) were considered occult. None of the OB cases had any complications. OB was not found in children over the age of 36 months. There was a change in the serotypes involving pneumococcal OB. CONCLUSIONS: OB is uncommon in the PCV-vaccinated population and the serotypes involved have changed.