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.

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.

Unexpected Diagnosis in an Adolescent With Bruises and Ecchymosis: Celiac Disease.

ABSTRACT: Acquired coagulopathy is a rare but challenging diagnosis for pediatric emergency physicians. Although the coagulopathy usually presents with mild skin and mucosal hemorrhages, it also can lead to life-threatening events. Thus, accurate interpretation of hints obtained from a detailed history, physical examination, and laboratory findings is essential for the prompt diagnosis and management. This case demonstrates an uncommon cause of coagulopathy; celiac disease that presented with spontaneous bruises and ecchymosis in an adolescent.

Integration of Physical Examination, Old and New Biomarkers, and Ultrasonography by Using Neural Networks for Pediatric Appendicitis.

OBJECTIVE: The objective of this study was to evaluate physical examinations, imaging, and laboratory analyses individually and combined using innovative statistical analysis methods for the accurate diagnosis of pediatric appendicitis. METHODS: Patients admitted to hospital with symptoms of abdominal pain whose pediatric appendicitis scores greater than 3 were included in the study. Clinical, radiologic, and laboratory findings and as a new biomarker calprotectin (CPT) concentrations were evaluated individually and combined using artificial neural networks (ANNs), which revealed latent relationships for a definitive diagnosis. RESULTS: Three hundred twenty patients were evaluated (190 appendicitis [43 perforated] vs 130 no appendicitis). The mean ± SD age was 11.3 ± 3.6 years and 63% were male. Pediatric appendicitis scores, white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP) level, procalcitonin (PCT) and CPT concentrations were higher in the appendicitis group; however, only WBC and ANC were higher in first 24 hours of pain. White blood cells and CRP were diagnostic markers in patients whose appendix could not be visualized using ultrasonography (US). On classic receiver operating characteristic (ROC) analysis, the areas under the curve (AUCs) were not strong enough for differential diagnosis (WBC, 0.73; ANC, 0.72; CRP, 0.65; PCT and CPT, 0.61). However, when the physical examination, US, and laboratory findings were analyzed in a multivariate model and the ROC analysis obtained from the variables with ANN, an ROC curve could be obtained with 0.91 AUC, 89.8% sensitivity, and 81.2% specificity. C-reactive protein and PCT were diagnostic for perforated appendicitis with 0.83 and 0.75 AUC on ROC. CONCLUSIONS: Although none of the biomarkers were sufficient for an accurate diagnosis of appendicitis individually, a combination of physical examination and laboratory and US was a good diagnostic tool for pediatric appendicitis.

High-mobility Group Box 1 Protein in Pediatric Trauma Patients With Acute Traumatic Coagulopathy or Disseminated Intravascular Coagulation.

OBJECTIVES: Trauma can induce the release of high-mobility group box 1 (HMGB1), which plays an important role in the activation of coagulation. In this study, we aimed to evaluate the role of HMGB1 in the early diagnosis of acute traumatic coagulopathy (ATC), disseminated intravascular coagulation, and clinical course. MATERIALS AND METHODS: One hundred pediatric trauma patients and 50 healthy controls were enrolled. Demographic data, physical examination results, trauma scores, International Society on Thrombosis and Hemostasis score, laboratory values, transfusion requirements, and needs for mechanical ventilation were recorded. Blood samples for HMGB1 were assessed by an enzyme-linked immunosorbent assay. RESULTS: Thirty-five patients had ATC and 3 patients had overt disseminated intravascular coagulation. In trauma patients, HMGB1 levels were statistically higher than those in the control group (P<0.001). There was a positive correlation between HMGB1 levels and D-dimer levels (r=0.589, P<0.001). ATC patients had higher plasma HMGB1 levels than those without ATC (P=0.008). High HMGB1 levels were associated with the duration of mechanical ventilation, need for intensive care unit observation, length of hospital stay, and mortality. CONCLUSION: This study showed the early increase of HMGB1 in pediatric trauma cases and demonstrated the significant association of high HMGB1 levels with the development of ATC, disseminated intravascular coagulation, trauma severity, clinical outcome, and mortality.

Is Ischemia-Modified Albumin a Reliable Marker in Accurate Diagnosis of Appendicitis in Children?

BACKGROUND: Acute appendicitis is one of the most common abdominal emergencies. Despite all improvements in diagnostic techniques, there are still ongoing problems as proper diagnosis, misdiagnosis and perforated appendicitis. The aim of this study is to demonstrate the clinical value of IMA in patients with appendicitis and to determine the accurate diagnosis of appendicitis in clinically suspected patients. METHODS: Pediatric patients with acute abdominal pain who had the Pediatric Appendicitis Score (PAS) ≥ 7 (n = 109) and a control group of 35 patients were included in this prospective case-control study. Patients were divided into two groups: patients with appendicitis (pathologically confirmed) (n = 78) and no appendicitis (n = 31). No appendicitis included observation patients and negative appendectomy. Serum samples were collected for routine laboratory parameters and IMA before surgery. RESULTS: Patients with appendicitis had significantly higher IMA levels than no appendicitis and control groups (p = 0.001 and p < 0.001; respectively). Moreover, patients with negative appendectomy had significantly lower IMA levels than patients with appendicitis (p = 0.009). IMA and PAS were used together, and in the ROC analysis, we obtained 0.81 AUC for PAS and 0.89 AUC for PAS and IMA. CONCLUSION: The current study indicated that IMA is a reliable marker for accurate diagnosis of appendicitis. The combination of IMA with PAS score has been shown to facilitate the diagnosis of appendicitis.

Pediatric emergency department visit characteristics of the patients on the ketogenic diet.

BACKGROUND: The ketogenic diet (KD) has been frequently used for the patients with drug-resistant epilepsy in recent years. The management of these patients in emergency departments (EDs) has some difficulties due to the special needs of KD. We aimed to determine the characteristics and the management of the patients on the KD in the pediatric ED setting. METHODS: Patients who were on the KD and admitted to the ED were included in the study. Demographic, clinical, and laboratory data of all patients were retrospectively reviewed and recorded. RESULTS: There were 105 emergency admissions of 27 patients. The median age of all patients was 55.0 (IQR: 29.0-91.0) months. The most common symptom was vomiting (43.8%). Four patients had upper gastrointestinal bleeding, and one patient had hyperammonemic acute hepatic failure while receiving KD. Of the patients, 41.9% had seizure-related ED admission. Infections were present in 41.9% of the ED visits. The frequency of status epilepticus was significantly lower in the patients who were on the KD for more than 6 months (p < 0.01). In 42.9% of all ED admissions, dextrose containing maintenance fluids was administered mistakenly; although ketosis rate was lower, no seizure was observed in this group. CONCLUSION: The patients on the KD can be admitted to EDs with intercurrent illnesses or adverse effects of the KD. For accurate management, emergency physicians must be aware of the common reasons for ED admission of these patients and the effects of the KD.

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.

Are clinical features and cardiac biomarkers at admission related to severity in pediatric acute myocarditis?: Clinical features and cardiac biomarkers in pediatric acute myocarditis.

OBJECTIVES: To evaluate the factors associated with intensive care requirement and mortality in pediatric myocarditis. METHODS: Children aged 28 days to 18 years who were diagnosed with acute myocarditis in a pediatric emergency department between January 2010 and September 2020 were enrolled in the study retrospectively. Demographic and clinical features, cardiac biomarkers, and imaging findings were evaluated. Length of hospital stay, need for hospitalization in the pediatric intensive care unit (PICU), treatments, and survival outcomes were recorded. To define the severity of disease, three groups were created and the data were compared in terms of clinical, laboratory, and imaging findings. The patients treated in the pediatric ward were compared with those hospitalized in the PICU. Ventricular dysfunction was defined in patients with a left ventricular ejection fraction (LVEF) of <50% and these patients were compared with those who had an LVEF of >50%. Also, survivor and non-survivor patients were compared. RESULTS: A total number of 62 patients with a median age of 8 years were included. Chest pain and tachycardia were the most common findings on physical examination. The mean LVEF was 59.3 ± 13.0% at admission. Of the patients, 17 were hospitalized in the PICU (27.4%). Chest pain was more common in patients hospitalized in the pediatric ward (p<0.001), and hypotension, vomiting, arrhythmia, were more common and LVEF was lower in patients in the PICU (p = 0.017, p = 0.008, p = 0.006, and p = 0.025, respectively). The children treated in the PICU were younger than those in the pediatric ward (p = 0.009). Troponin I levels were significantly higher in the pediatric ward (p = 0.035), and brain natriuretic peptide (BNP) levels were higher in patients in the PICU (p = 0.012). Death occurred in four patients. Hypotension and vomiting were significantly more common in non-survivors (p = 0.020 and 0.004, respectively). Inotropes and intravenous immunoglobulin (IVIG) were more commonly used in non-survivors (p = 0.001 and p = 0.015, respectively). BNP levels were higher in non-survivors (p = 0.008), and troponin I levels were not different between survivors and non-survivors (p = 0.260). CONCLUSION: In pediatric acute myocarditis, lower LVEF, increased BNP, as well as the presence of hypotension and arrhythmia were found to be related to intensive care requirement. Hypotension and vomiting were found to be more common in non-survivors. Due to the possibility of rapidly worsening disease, physicians should be alert to the presence of these findings.

The effect of early midazolam infusion on the duration of pediatric status epilepticus patients.

PURPOSE: Status epilepticus is one of the most common neurological emergencies in pediatric emergency departments. Although there are different approaches to treatment in the literature, early control of seizure activity is the most important factor determining prognosis. The purpose of this study was to evaluate the effect of early midazolam infusion on seizure duration. METHOD: This retrospective study included 150 episodes of 135 patients aged one month to 18 years old with status epilepticus. All patients were treated according to the local hospital protocol for SE, which included early midazolam infusion. Demographic data, medical history, applied treatments during SE, and seizure durations were recorded. RESULTS: The median age of the patients (58.7% male) was 2.7 years (1.0-6.0 years). The most common identified etiologies were remote symptomatic etiologies, and generalized tonic-clonic seizure was the most common seizure type. The pediatricians had selected intravenous midazolam for 130 patients (86.7%) as the first-line therapy in emergency services. In 55 patients given continuous midazolam infusion, the cumulative bolus of midazolam was 0.5 mg/kg (0.4-0.7 mg/kg), and the median peak rate of midazolam infusion was 0.2 mg/kg/h (0.2-0.4 mg/kg/h). The median duration between the start of midazolam infusion and the complete cessation of SE was 15.0 min (9.0-25.0 min). The early-midazolam infusion group had shorter seizure duration after initiation of midazolam infusion (p = 0.020). CONCLUSION: The current study shows that aggressive management of SE with early initiation of midazolam infusion was associated with a shorter seizure duration in SE patients.