Rochester Criteria and Yale Observation Scale Score to Evaluate Febrile Neonates with Invasive Bacterial Infection.

BACKGROUND: Febrile neonates undergo lumbar puncture (LP), empiric antibiotic administration, and admission for increased risk of invasive bacterial infection (IBI), defined as bacteremia and meningitis. OBJECTIVE: Measure IBI prevalence in febrile neonates, and operating characteristics of Rochester Criteria (RC), Yale Observation Scale (YOS) score, and demographics as a low-risk screening tool. METHODS: Secondary analysis of healthy febrile infants < 60 days old presenting to any of 26 emergency departments in the Pediatric Emergency Care Applied Research Network between December 2008 and May 2013. Of 7334 infants, 1524 met our inclusion criteria of age ≤ 28 days. All had fevers and underwent evaluation for IBI. Receiver operator characteristic (ROC) curve and transparent decision tree analysis were used to determine the applicability of reassuring RC, YOS, and age parameters as an IBI low-risk screening tool. RESULTS: Of 1524 neonates, 2.9% had bacteremia and 1.5% had meningitis. After applying RC and YOS, 15 neonates were incorrectly identified as low risk for IBI (10 bacteremia, 4 meningitis, 1 bacteremia, and meningitis). Age ≤ 18 days was a statistically significant variable ROC (area under curve 0.63, p < 0.05). Incorporating age > 18 days as low-risk criteria with reassuring RC and YOS misclassified 7 IBI patients (6 bacteremia, 1 meningitis). CONCLUSION: Thirty percent of febrile neonates met low-risk criteria, age > 18 days, reassuring RC and YOS, and could avoid LP and empiric antibiotics. Our low-risk guidelines may improve patient safety and reduce health care costs by decreasing lab testing for cerebrospinal fluid, empiric antibiotic administration, and prolonged hospitalization. These results are hypothesis-generating and should be verified with a randomized prospective study.

Pediatric Emergency Medicine Fellowship Education on Adolescent Sexual Health Care.

OBJECTIVES: Many adolescents use the emergency department as their sole resource for primary care and sexual health care. This provides an opportunity to prevent sexually transmitted infections and unintended pregnancy as well as to educate teenagers about their bodies and sexual health. There is no standard curriculum on sexual health as part of pediatric emergency medicine (PEM) fellowship education. Our goal is to evaluate what is taught in PEM fellowship about adolescent sexual health. METHODS: We administered an anonymous questionnaire to both PEM fellows and program directors (PDs). The questionnaire was distributed through the PEM Program Director Survey Committee. The questionnaire was sent to 88 PDs and 305 fellows total. An introductory email explaining the purpose of the study and a link to the online questionnaire was sent. The questionnaire was created using SurveyMonkey (www.surveymonkey.com). Data were analyzed using descriptive statistics. RESULTS: We achieved a 43% survey response rate from PDs (38 of 88) and a 24% survey response rate from fellows (73 of 305). The PD respondents included 61% females, and almost all (86%) are between ages 35 and 54 years. Seventy-three percent of the fellows are female, and they are all between 25 to 44 years old. There was a great deal of variability in the amount of adolescent sexual health education PDs provide their fellows in the form of lectures and bedside teaching cases. A majority of survey respondents (86% of fellows and 66% of the PDs) agreed that there should be a standard PEM curriculum to teach about adolescent sexual health. More than half (53% of PDs and 56% of fellows) are not satisfied with the number of training opportunities for adolescent sexual health. CONCLUSIONS: We found variability in adolescent sexual health training during PEM fellowship, although fellows and PDs agree that there should be a standardized curriculum. We recommend that the American Board of Pediatrics form a committee to decrease variability in the training of PEM fellows on adolescent sexual health.

Diagnostic modalities to determine ventriculoperitoneal shunt malfunction: A systematic review and meta-analysis.

BACKGROUND: Ventriculoperitoneal (VP) shunt malfunction is an emergency. Timely diagnosis can be challenging because shunt malfunction often presents with symptoms mimicking other common pediatric conditions. METHODS: We performed a systematic review and meta-analysis to determine which commonly used imaging modalities; Magnetic resonance imaging (MRI), Computed Tomography (CT), X-ray Shunt series or Optic Nerve Sheath Diameter (ONSD) ultrasound, are superior in evaluating shunt malfunction. INCLUSION CRITERIA: patients less than 21 years old with symptoms of shunt malfunction. We calculated the pooled sensitivity, specificity, Likelihood Ratios (LR+, LR-) using a random-effects model. RESULTS: Eight studies were included encompassing 1906 patients with a prevalence of VP shunt malfunction of (29.3%). Shunt series: sensitivity (14%-53%), specificity (99%), LR+ (23.2), and LR- (0.47-0.87). CT scan: sensitivity (53%-100%), specificity (27%-98%), LR+ (1.34-22.87), LR- (0.37). MRI: sensitivity (57%), specificity (93%), LR+ (7.66), and LR- (0.49). ONSD: sensitivity (64%), specificity (22%-68%), LR+ (4.4-8.7), LR- (0.93). A positive shunt series, CT scan, MRI, or ONSD has a post-test probability of (23%-84%). A normal shunt series, CT scan, MRI, or ONSD results in a post-test probability of (7%-31%). A positive shunt series results in a post-test probability of 80%, which is equivalent to the post-test probability of CT scan (23-84%) and MRI (83%). CONCLUSION: Despite the low sensitivity, a positive shunt series obviates the need for further imaging studies. Prompt referral for neurosurgical intervention is recommended. A negative shunt series or any result (positive or negative) from CT, MRI, or ONSD will still require an emergent neurosurgical referral.

Flank pain and hematuria is not always a kidney stone.

BACKGROUND: Patients with flank pain and hematuria are common emergency department presentations of nephrolithiasis. We may anchor on this etiology and potentially miss other less common differentials. We present a case of a patient with hematuria and flank pain typical of nephrolithiasis who was diagnosed with a Page kidney causing secondary hypertension. A 50 year-old male with no significant past medical history presented to the Emergency Department with severe left-sided flank pain, vomiting, and blood-tinged urine. We pursued a diagnosis of nephrolithiasis and found a left renal subcapsular hematoma on non-contrast CT. A CTA was done with no active hemorrhage found. The patient had no history of recent trauma and was found to be hypertensive on evaluation. Urology was consulted and management for the patient's hypertension was initiated. He was diagnosed with Page Kidney and admitted to medicine for observation and hypertension management with an angiotensin-converting enzyme inhibitor. Page Kidney is a diagnosis that describes compression of the renal parenchyma by a hematoma or mass causing secondary hypertension through the activation of the renin-angiotensin-aldosterone system. Causes may include traumatic subcapsular hematoma, renal cyst rupture, tumor, hemorrhage, arteriovenous malformation, among others. Treatment may involve conservative measures including hypertension management, or more invasive measures like evacuation or nephrectomy. We describe the case of a patient presumed to have nephrolithiasis presenting with typical left-sided flank pain, diagnosed with Page kidney, and treated conservatively.

The prevalence of serious bacterial infections in neutropenic immunocompetent febrile children.

CONTEXT: Febrile neutropenic immunocompromised children are at a high risk of Serious Bacterial Infections (SBI). OBJECTIVE: This systematic review and meta-analysis report the prevalence of SBI in healthy children with febrile neutropenia. DATA SOURCE: PubMed, EMBASE, and Web of Science from their inception to August 2020. STUDY SELECTION: Patients with an Absolute Neutrophil Count (ANC) <1000 cells/mm3 up to 18 years of age presenting to the ED with a chief complaint of fever (temperature > 38°C) and who had a workup for SBI as defined by each study. DATA ABSTRACTION: Data from individual studies was abstracted by a subset of the authors and checked independently by the senior author. Any discrepancies were adjudicated by the joint agreement of all the authors. We calculated the prevalence of SBI by using the number of SBI's as the numerator and the total number of febrile events in patients as the denominator. Bias in our studies was quantified by the Newcastle Ottawa Scale. RESULTS: We identified 2066 citations of which five studies (1693 patients) our inclusion criteria. None of our reviewed studies consistently tested every included patient for SBI. Spectrum bias in every study resulted in a wide range of the SBI prevalence of 1.9% (<0.01% - 11%) similar to non-neutropenic children. LIMITATIONS: All of our studies were retrospective and many did not consistently screen all subjects for SBI. CONCLUSION: If the clinical suspicion is low, the risk for SBI is similar between febrile healthy neutropenic and non-neutropenic children.

Iatrogenic Pulmonary Air Embolism with Rapid Resolution: A Case Report.

BACKGROUND: Iatrogenic pulmonary air embolism is a fairly common and sometimes deadly complication of i.v. contrast injection. CASE REPORT: We present the case of a 33-year-old man with a symptomatic iatrogenic injection air embolism and resolution within 5 h. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the importance of computed tomography imaging in emergency medicine, clinicians should be aware of the risk for injection air embolism from i.v. contrast injection.

The Utility of the Focused Assessment With Sonography in Trauma Examination in Pediatric Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the utility of the Point of Care Ultrasound (POCUS) Focused Assessment with Sonography for Trauma (FAST) examination for diagnosis of intra-abdominal injury (IAI) in children presenting with blunt abdominal trauma. METHODS: We searched medical literature from January 1966 to March 2018 in PubMed, EMBASE, and Web of Science. Prospective studies of POCUS FAST examinations in diagnosing IAI in pediatric trauma were included. Sensitivity, specificity, and likelihood ratios (LR) were calculated using a random-effects model (95% confidence interval). Study quality and bias risk were assessed, and test-treatment threshold estimates were performed. RESULTS: Eight prospective studies were included encompassing 2135 patients with a weighted prevalence of IAI of 13.5%. Studies had variable quality, with most at risk for partial and differential verification bias. The results from POCUS FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR- of 0.64. A positive POCUS FAST posttest probability for IAI (63%) exceeds the upper limit (57%) of our test-treatment threshold model for computed tomography of the abdomen with contrast. A negative POCUS FAST posttest probability for IAI (9%) does not cross the lower limit (0.23%) of our test-treatment threshold model. CONCLUSIONS: In a hemodynamically stable child presenting with blunt abdominal trauma, a positive POCUS FAST examination result means that IAI is likely, but a negative examination result alone cannot preclude further diagnostic workup for IAI. The need for computed tomography scan may be obviated in a subset of low-risk pediatric blunt abdominal trauma patients presenting with a Glasgow Coma Scale of 14 to 15, a normal abdominal examination result, and a negative POCUS FAST result.

Prevalence of Bacteremia in Febrile Patients With Sickle Cell Disease: Meta-Analysis of Observational Studies.

OBJECTIVE: Pneumococcal vaccination has decreased the bacteremia rate in both the general pediatric and sickle cell disease (SCD) populations. Despite this decrease, and an increasing concern for antibiotic resistance, it remains standard practice to obtain blood cultures and administer antibiotics in all febrile (>38.5°C) patients with SCD. We conducted a systematic review and meta-analysis of the available studies of the prevalence of bacteremia in febrile patients with SCD. METHODS: We searched the medical literature up to November 2018 in PUBMED, EMBASE, and Web of Science with terms epidemiology, prevalence, bacteremia, and sickle cell anemia. We only included studies with patients after 2000, when the pneumococcal 7-valent conjugate (PCV7) vaccine became widely available. The prevalence of bacteremia [95% confidence interval (CI)] was calculated by dividing the number of positive blood cultures by the number of febrile episodes. The I2 statistic measured heterogeneity between prevalence estimates. Bias in our studies was quantified by the Newcastle-Ottawa Quality Assessment Scale. RESULTS: Our search identified 228 citations with 10 studies meeting our inclusion/exclusion criteria. The weighted prevalence of bacteremia across all studies was 1.9% (95% CI, 1.22%-2.73%), and for Streptococcus pneumoniae bacteremia, it was 0.31% (95% CI, 0.16%-0.50%). Risks for bacteremia except central lines could not be determined because of the low prevalence of the outcome. CONCLUSIONS: There appears to be a need to develop a risk stratification strategy to guide physicians to manage febrile patients with SCD based on factors including, but not limited to, history and clinical examination, vaccination status, use of prophylactic antibiotics, laboratory values, likely source of infection, and accessibility to health care.

The Utility of Ultrasound in Detecting Skull Fractures After Pediatric Blunt Head Trauma: Systematic Review and Meta-Analysis.

BACKGROUND: Head trauma is a common reason for evaluation in the emergency department. The evaluation for traumatic brain injury involves computed tomography, exposing children to ionizing radiation. Skull fractures are associated with intracranial bleed. Point-of-care ultrasound (POCUS) can diagnose skull fractures. OBJECTIVES: We performed a systematic review/meta-analysis to determine operating characteristics of POCUS skull studies in the diagnosis of fractures in pediatric head trauma patients. METHODS: We searched PubMed, EMBASE, and Web of Science for studies of emergency department pediatric head trauma patients. Quality Assessment Tool for Diagnostic Accuracy Studies 2 was used to evaluate risk of bias. Point-of-care ultrasound skull study operating characteristics were calculated and pooled using Meta-DiSc. RESULTS: Six studies of 393 patients were selected with a weighted prevalence of 30.84%. Most studies were at low risk of bias. The pooled sensitivity (91%) and specificity (96%) resulted in pooled positive likelihood ratio (14.4) and negative likelihood ratio (0.14). Using the weighted prevalence of skull fractures across the studies as a pretest probability (31%), a positive skull ultrasound would increase the probability to 87%, whereas a negative test would decrease the probability of a skull fracture to 6%. To achieve a posttest probability of a skull fracture of ~2% would require a negative skull ultrasound in a patient with only a pretest probability of ~15%. CONCLUSIONS: A POCUS skull study significantly increases the probability of skull fracture, whereas a negative study markedly decreases the probability if the pretest probability is very low.

Pharmacologic cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis.

AIMS: We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF). METHODS AND RESULTS: We searched MEDLINE, Embase, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with AF ≤ 48 h and compared antidysrhythmic agents, placebo, or control. We determined these outcomes prior to data extraction: (i) rate of conversion to sinus rhythm within 24 h, (ii) time to cardioversion to sinus rhythm, (iii) rate of significant adverse events, and (iv) rate of thromboembolism within 30 days. We extracted data according to PRISMA-NMA and appraised selected trials using the Cochrane review handbook. The systematic review initially identified 640 studies; 30 met inclusion criteria. Twenty-one trials that randomized 2785 patients provided efficacy data for the conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that ranolazine + amiodarone intravenous (IV) [odds ratio (OR) 39.8, 95% credible interval (CrI) 8.3-203.1], vernakalant (OR 22.9, 95% CrI 3.7-146.3), flecainide (OR 16.9, 95% CrI 4.1-73.3), amiodarone oral (OR 10.2, 95% CrI 3.1-36.0), ibutilide (OR 7.9, 95% CrI 1.2-52.5), amiodarone IV (OR 5.4, 95% CrI 2.1-14.6), and propafenone (OR 4.1, 95% CrI 1.7-10.5) were associated with significantly increased likelihood of conversion within 24 h when compared to placebo/control. Overall quality was low, and the network exhibited inconsistency. Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low. CONCLUSION: For pharmacologic cardioversion of recent-onset AF within 24 h, there is insufficient evidence to determine which treatment is superior. Vernakalant and flecainide may be relatively more efficacious agents. Propafenone and IV amiodarone may be relatively less efficacious. Further high-quality study is necessary.

Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: A Systematic Review and Network Meta-analysis.

STUDY OBJECTIVE: We conduct a systematic review and Bayesian network meta-analysis to indirectly compare and rank antidysrhythmic drugs for pharmacologic cardioversion of recent-onset atrial fibrillation and atrial flutter in the emergency department (ED). METHODS: We searched MEDLINE, EMBASE, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with recent-onset atrial fibrillation or atrial flutter and compared antidysrhythmic agents, placebo, or control. We determined these outcomes before data extraction: rate of conversion to sinus rhythm within 4 hours, time to cardioversion, rate of significant adverse events, and rate of thromboembolism within 30 days. We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses network meta-analysis and appraised selected trials with the Cochrane review handbook. RESULTS: The systematic review initially identified 640 studies; 19 met inclusion criteria. Eighteen trials that randomized 2,069 atrial fibrillation patients provided data for atrial fibrillation conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that antazoline (odds ratio [OR] 24.9; 95% credible interval [CrI] 7.4 to 107.8), tedisamil (OR 12.0; 95% CrI 4.3 to 43.8), vernakalant (OR 7.5; 95% CrI 3.1 to 18.6), propafenone (OR 6.8; 95% CrI 3.6 to 13.8), flecainide (OR 6.1; 95% CrI 2.9 to 13.2), and ibutilide (OR 4.1; 95% CrI 1.8 to 9.6) were associated with increased likelihood of conversion within 4 hours compared with placebo or control. Overall quality was low, and the network exhibited inconsistency. CONCLUSION: For pharmacologic cardioversion of recent-onset atrial fibrillation within a 4-hour ED visit, there is insufficient evidence to determine which treatment is superior. Several agents are associated with increased likelihood of conversion within 4 hours compared with placebo or control. Limited data preclude any recommendation for cardioversion of recent-onset atrial flutter. Further high-quality study is necessary.

Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis.

INTRODUCTION: Emergency department (ED) overcrowding is linked to poor outcome and decreases patient satisfaction. Strategies to control Emergency department (ED) overcrowding has been subject of research. STUDY OBJECTIVES: The objective of this systematic review and meta-analysis was to investigate the impact of triage liaison providers (TLPs) on the ED throughput. METHODS: We searched PubMed, EMBASE, and Web of Science up to April 2019 for studies done in the United States. Primary outcomes were number of patients left without being seen (LWBS) and patients' emergency department length of stay (ED-LOS). ED-LOS data was pooled using mean difference with random effect model. Risk Ratio (RRs) for LWBS was calculated with random effect model with 95% confidence interval (95% CI). RESULTS: Twelve studies encompassing 329,340patients were included in the meta-analysis. Implementation of the TLP system using attending physicians was associated with a decrease in risk of LWBS 0.62 (95% CI 0.54, 0.71), The change in ED-LOS after implementation of TLP was too heterogeneous to pool the data with the mean ΔED-LOS ranging from -82 to +20 min. Stratification of studies by disposition, admitted versus discharged, did not decrease the heterogeneity. CONCLUSION: Implementation of TLP can decrease the rate of LWBS however this review is inconclusive about the effect of TLP on ED-LOS due to the high heterogeneity observed in the literature.

Toxic shock-like syndrome and COVID-19: Multisystem inflammatory syndrome in children (MIS-C).

Early reports of COVID-19 in pediatric populations emphasized a mild course of disease with severe cases disproportionately affecting infant and comorbid pediatric patients. After the peak of the epidemic in New York City, in late April to early May, cases of severe illness associated with COVID-19 were reported among mostly previously healthy children ages 5-19. Many of these cases feature a toxic shock-like syndrome or Kawasaki-like syndrome in the setting of SARS-CoV-2 positive diagnostic testing and the CDC has termed this presentation Multisystem Inflammatory Syndrome (MIS-C). It is essential to disseminate information among the medical community regarding severe and atypical presentations of COVID-19 as prior knowledge can help communities with increasing caseloads prepare to quickly identify and treat these patients as they present in the emergency department. We describe a case of MIS-C in a child who presented to our Emergency Department (ED) twice and on the second visit was found to have signs of distributive shock, multi-organ injury and systemic inflammation associated with COVID-19. The case describes two ED visits by an 11- year-old SARS-CoV-2-positive female who initially presented with fever, rash and pharyngitis and returned within 48 hours with evidence of cardiac and renal dysfunction and fluid-refractory hypotension requiring vasopressors and PICU admission.

Impact of Provider-In-Triage in a Safety-Net Hospital.

BACKGROUND: Increasing emergency department (ED) utilization has contributed to ED overcrowding, with longer ED length of stay (EDLOS) and more patients leaving without being seen (LWBS), and is associated with higher morbidity and mortality rates. Previous studies of provider in triage (PIT) have shown decreased LWBS, but variable improvements in EDLOS. OBJECTIVES: We evaluated the impact of PIT implementation in an urban safety-net hospital on commonly reported ED throughput metrics. METHODS: This before-and-after study was performed at an academic urban safety hospital. We implemented a PIT team that screened ambulatory ED patients for early discharge or expedited workup. The PIT intervention was implemented 3 days a week from January through April 2019. As controls, we compared throughput metrics from when PIT was unavailable (Group 2) and from 1 year prior (Group 3). RESULTS: There were significantly (p < 0.001) lower rates of LWBS in Group 1 (4.8%, 95% confidence interval [CI] 4.1-5.8%) compared with 2 (7.3%, 95% CI 5.5-9.7%) and 3 (7.8%, 95% CI 6.9-9.0%). Door-to-doctor times were significantly (p < 0.001) lower for Group 1 (148 min, interquartile range [IQR] 88, 226 min) compared with 2 (187 min, IQR 95.5, 266 min) and 3 (215 min, IQR 131, 290 min). EDLOS was significantly (p < 0.001) shorter for Group 1 (337 min, IQR 215, 468 min) compared with 2 (385 min, IQR 271, 516 min) and 3 (413 min, IQR 299, 538 min). CONCLUSIONS: We found significantly lower LWBS rates, shorter EDLOS, and shorter door-to-doctor times after PIT implementation. Compared with previous studies in a variety of settings, we found that PIT significantly improved LWBS and all throughput metrics in a safety net setting.

New Test, Old Disease: A Case Series of Diabetic Ketoalkalosis.

BACKGROUND: Diabetic ketoalkalosis (DKAlk) was first described in 1967 as a rare complication of diabetic ketoacidosis with normal or elevated pH/bicarbonate and elevated anion gap (AG) from high ß-hydroxybutyrate (BHB). OBJECTIVE: We report a case series of patients with DKAlk to show how venous blood gas (VBG) electrolytes alone may misdiagnose these patients. METHODS: This was a case series of DKAlk patients with concomitant VBG and basic metabolic panel (BMP) electrolytes who met the following criteria for DKAlk: BMP hyperglycemia (glucose >250 mg/dL), elevated AG (>15 mEq/L), elevated BHB (>1.2 mmol/L), and high Delta (Δ) gap (>6 mEq/L [bicarbonate gap (BG): measured bicarbonate - 24] - [AG - 12]). Data are reported as median with interquartile range (IQR) (25%, 75%) and group comparisons utilized Mann-Whitney U test (two-tailed, α = 0.05). RESULTS: We found 10 patients with DKAlk in 2 months. Patients ranged in age from 13 to 77 years, 50% were male, and all were African American. Most patients (8 of 10) were vomiting with hyperglycemia (350 to >600 mg/dL). DKAlk BMP AG ranged from 18 to 34 mmol/L and BHB from 1.74 to 9.09 mmol/L. For bicarbonate, we found no significant difference between VBG (24 mmol/L) and BMP (22 mmol/L) (p = 0.796). VBG chloride (98 mmol/L) was significantly higher than BMP chloride (88 mmol/L) (p < 0.005). This falsely elevated VBG chloride resulted in undervaluing of all VBG AGs, missing almost all of the patients with DKAlk. CONCLUSIONS: We found that DKAlk is more common than previously reported. We recommend screening with BMP electrolytes and BHB levels for hyperglycemic ED patients who are vomiting or suspected of hypovolemia.

Prevalence and Risk Factors for Burnout in Pediatric Emergency Medicine Fellows.

Burnout among emergency medicine (EM) physicians (57%) is significantly greater than among pediatricians (39%). Pediatric EM (PEM) providers are a unique population in that the majority first complete a pediatric residency and then a fellowship in pediatric emergency medicine. We sought to evaluate the prevalence and risk factors for burnout in PEM fellows. METHODS: An e-mail survey that included the Maslach Burnout Inventory (MBI) Health Services Survey was sent to fellows in PEM programs. Anonymous surveys were scored using the MBI subscales of emotional exhaustion and depersonalization. Fellows with scores of moderate to high in both emotional exhaustion and depersonalization were considered to have burnout. The data were compared with demographic information, including fellowship year, sex, and relationship status. Participants were also asked to list items in their life they felt were burnout contributors. The burnout rate was reported as a percentage with 95% confidence intervals (95% CI), based on the Agresti-Coull method. Associations between categorical variables and burnout were tested with Fisher exact test, alpha = 0.05 (2 tails). RESULTS: Of 463 PEM fellows, 146 responses were received (30% response rate), and 139 surveys were scored. Over half (65%) of the respondents were female. The burnout prevalence of PEM fellows was 30.9% (95% CI, 24%-39%). The burnout rate was significantly (P = 0.002) lower for men (13%) (95% CI, 6%-26%) than for women (39.8%) (95% CI, 30%-50%). Fellows who were single (50%) or divorced (66.7%) had significantly (P = 0.008) higher rates of burnout compared with married (27%) fellows. Current training year was not a significant burnout risk. Major contributors to burnout were work environment (52.5%), academic responsibilities of fellowship (36%), schedule (35.3%), work-life balance (33.8%), and career / occupational stress (33.1%). CONCLUSIONS: Pediatric emergency medicine fellows had a 30.9% prevalence of burnout. Risk factors for burnout were similar for PEM fellows and EM physicians. Women were more likely to suffer from burnout, as well as fellows who were single or divorced.

Elevated Liver Enzymes as a Manifestation of Haff Disease.

BACKGROUND: Haff disease is a rare syndrome of rhabdomyolysis thought to be caused by a heat-stable toxin associated with the consumption of seafood from fresh or brackish water. CASE REPORT: We present the case of a patient with Haff disease who presented to the emergency department with nausea/vomiting, diarrhea, and myalgias after a seafood buffet. Initially, he was treated with i.v. fluids and antiemetics for presumed gastroenteritis, but his symptoms did not improve. He was found to have elevated aspartate aminotransferase and alanine aminotransferase, normal point-of-care ultrasound, urinalysis with large blood and no red blood cells, and an elevated creatine phosphokinase (CPK). He was admitted to the hospital to receive ongoing fluid resuscitation for rhabdomyolysis presumed to be from fish. Liver enzymes and CPK downtrended, and patient was discharged on hospital day 3. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Undiagnosed Haff disease has important clinical implications, including multi-organ failure and death. Always maintain a high level of suspicion for Haff disease in patients with symptoms suggestive of gastroenteritis, but complicated by minor liver function test elevations and dipstick positivity for heme, without significant numbers of red blood cells per high-power field, in the setting of recent seafood ingestion.

Serial Sonographic Assessment of Pulmonary Edema in Patients With Hypertensive Acute Heart Failure.

OBJECTIVES: Objective measures of clinical improvement in patients with acute heart failure (AHF) are lacking. The aim of this study was to determine whether repeated lung sonography could semiquantitatively capture changes in pulmonary edema (B-lines) in patients with hypertensive AHF early in the course of treatment. METHODS: We conducted a feasibility study in a cohort of adults with acute onset of dyspnea, severe hypertension in the field or at triage (systolic blood pressure ≥ 180 mm Hg), and a presumptive diagnosis of AHF. Patients underwent repeated dyspnea and lung sonographic assessments using a 10-cm visual analog scale (VAS) and an 8-zone scanning protocol. Lung sonographic assessments were performed at the time of triage, initial VAS improvement, and disposition from the emergency department. Sonographic pulmonary edema was independently scored offline in a randomized and blinded fashion by using a scoring method that accounted for both the sum of discrete B-lines and degree of B-line fusion. RESULTS: Sonographic pulmonary edema scores decreased significantly from initial to final sonographic assessments (P < .001). The median percentage decrease among the 20 included patient encounters was 81% (interquartile range, 55%-91%). Although sonographic pulmonary edema scores correlated with VAS scores (ρ = 0.64; P < .001), the magnitude of the change in these scores did not correlate with each other (ρ = -0.04; P = .89). CONCLUSIONS: Changes in sonographic pulmonary edema can be semiquantitatively measured by serial 8-zone lung sonography using a scoring method that accounts for B-line fusion. Sonographic pulmonary edema improves in patients with hypertensive AHF during the initial hours of treatment.

Comparison of UTI antibiograms stratified by ED patient disposition.

OBJECTIVE: Institutional antibiograms guide Emergency Department (ED) clinicians' empiric antibiotic selection. For this study, we created and compared antibiograms of ED patients stratified by disposition (admitted or discharged). METHODS: We conducted a cross-sectional study at two hospitals for 2014, comparing antibiograms limited to Escherichia coli urinary tract infections. Study-Specific Antibiograms, created for the study, excluded polymicrobial samples and multiple cultures from the same patient. Study-Specific Antibiograms were arranged by patient disposition: admitted (IP-Only) vs discharged from the ED (ED-Only). Antibiogram data were presented as average antibiotic sensitivities with 95% confidence intervals and demographic data as medians with interquartile ranges. Sensitivities between Study-Specific Antibiograms were compared by Fisher's Exact Test, alpha=0.05, 2 tails. RESULTS: For Hospital A, 13 antibiotics were compared between Study-Specific ED-Only (n=313) vs IP-Only (n=244). We found that sensitivities to all four antibiotics appropriate for empiric outpatient therapy by Infectious Disease Society of America guidelines were significantly (p<0.0001) higher in the ED-Only compared to IP-Only groups: ciprofloxacin 80% (76-90%) vs 60% (53-69%), levofloxacin 81% (77-91%) vs 63% (57-72%), nitrofurantoin 75% (70-84%) vs 51% (44-58%), and trimethoprim/sulfamethoxazole 73% (68-82%) vs 58% (52-67%). For Hospital B, 14 antibiotics were compared between Study-Specific ED-Only (n=256) and IP-Only (n=168). Two out of the five appropriate empiric outpatient antibiotics had significantly (p<0.0001) higher sensitivities for ED-Only compared to IP-Only: ciprofloxacin 87% (83-91%) vs 71% (64-78%) and levofloxacin 86% (82-91%) vs 71% (65-78%). CONCLUSIONS: We found higher antibiotic sensitivities in ED-Only than the IP-Only Study-Specific Antibiograms. Our Study-Specific Antibiograms offer an alternative guide for antibiotic selection in the ED.

Predicting Flow in the Pediatric Emergency Department: Are Holidays Lighter?

OBJECTIVE: The aim of this study was to determine whether patient volume in an urban pediatric emergency department (ED) can be predicted based on holidays and thus aid in staffing and resource allocation. METHODS: Log-in dates and times were obtained for all patients seen in an urban pediatric ED between July 1, 2006, and June 30, 2013. Visits were coded for the day of the week, tour (ie, shift), and season and whether they occurred on a holiday or nonholiday. Comparisons between the median number of patient visits on holidays versus nonholidays by day of the week, tour, and season were performed. Additional comparisons on 5 Monday holidays as well as New Year's Day, Thanksgiving, and Christmas Day were also performed. Data were presented as medians with interquartile ranges. Group comparisons were performed via using Mann-Whitney U tests and Kruskal-Wallis tests (α = 0.05, 2 tailed). RESULTS: There were 223,677 total patient visits, with a mean yearly census of 31,954. The median daily volume was 85, peaking on Mondays (median, 99). The summer season demonstrated the fewest number of patient visits (median, 74) relative to the other seasons (medians, 89-91). Compared with nonholidays, there were fewer patient visits on Thanksgiving and Christmas Day and in the late afternoon and evening on other individual holidays. CONCLUSIONS: Fewer patient visits on Thanksgiving and Christmas Days, as well as during the late afternoon/evening on several other holidays, point to the possibility of small adjustments to staffing in ways that can more efficiently balance demand with available resources.