Sedoanalgesia With Ketamine in the Emergency Department: Factors Associated With Unsatisfactory Effectiveness.

OBJECTIVE: Ketamine is a safe and widely used sedative and analgesic in children. The purpose of this study is to evaluate the response to sedoanalgesia for painful procedures in the pediatric emergency department. METHODS: A retrospective study was conducted in children younger than 16 years who underwent painful procedures with intravenous/intranasal ketamine between January 2016 and December 2022. We collected demographic variables, effectiveness, route of administration, indication, dose, sedation strategy, duration of procedure, and associated adverse effects. RESULTS: A total of 671 ketamine sedation procedures (411 males/260 females) were included, with a mean age of 7.2 years. Closed reduction was the most common painful procedure (53.8%), followed by burn healing (24.6%). Ketamine was administered intravenously in 93.4% of procedures and intranasally in 6.6%. The result of sedoanalgesia was satisfactory in 84.9% and unsatisfactory in 15.1%. The percentage of cases with unsatisfactory analgesia was higher with intranasal administration (36.4%; P < 0.001). In the intravenous group, the percentage of cases with unsatisfactory effectiveness (28.7%) was higher for patients younger than 2 years of age ( P < 0.001). Arthrocentesis procedures were associated with the highest percentage of unsatisfactory sedoanalgesia failures among patients receiving intravenous ketamine (39.3%; P < 0.001). Intranasal ketamine patients who received a dose between 3.6 and 4 mg/kg had a significantly higher percentage of unsatisfactory sedoanalgesia (66.7%; P = 0.048). Patients receiving intravenous ketamine had significantly higher rates of unsatisfactory sedoanalgesia when the initial dose interval was 1.6 to 2 mg/kg (11.8%; P = 0.002) and when the final total dose was also 1.6 to 2 mg/kg (17.6%; P = 0.002). CONCLUSIONS: This study concludes that intravenous/intranasal ketamine can provide safe and successful analgesia in pediatric patients in the ED. At intravenous doses of 1-1.5 mg/kg, good effectiveness was achieved in almost 90% of cases. Arthrocentesis had the highest percentage of unsatisfactory results. Repeat dosing should be considered for procedures longer than 20 minutes.

Pediatric Emergency Department Management of C1 Inhibitor Deficiency.

INTRODUCTION: C1 inhibitor deficiency is a rare, potentially life-threatening syndrome. Acute attacks of angioedema may occur at any time, so the emergency department (ED) constitutes an indispensable component of its care. AIM: To describe the reasons for consultation by children with C1 inhibitor deficiency at the ED, as well as its management and complications. PATIENTS AND METHODS: This is a longitudinal retrospective study conducted in a pediatric ED of a tertiary care hospital in Madrid. The study includes children with C1 inhibitor deficiency, aged 0 to 16 years, who had consulted the ED for whatever reason, over a span of 9 years (2011-2020). Analyzed data include the following: age, sex, type of disease, reason for query, complementary examinations, established diagnosis, treatment, number of visits to the ED, length of ED stay, and admissions. RESULTS: Sixteen patients, amounting a total of 83 ED visits, were analyzed. Fifty-six percent were boys, and the median age was 6.9 years (5 months to 15.9 years). The median and mean of number of visits to the ED per patient was 2 (1-22) and 5.2 ± 6.11, respectively. There were 85.5% of the ED visits initially attributed to acute angioedema attacks. Additional tests were conducted in 30.1%, and 31.3% required C1 inhibitor concentrate. Three episodes required hospital admission (3.6%), and there were no complications. The stay in the ED was longer for patients who needed specific intravenous treatment. CONCLUSIONS: C1 inhibitor deficiency is a rare disease that may require ED care. The main reasons for ED visits were respiratory problems, and the main location of the acute attacks of angioedema were abdominal and cutaneous. Almost one third of the ED visits needed specific treatment, resulting in longer stays. A proper management in the ED and the specific treatment with C1 inhibitor concentrate were effective in 96.2% of the acute attacks of angioedema. Knowledge of this disease in the ED is key to prevent complications.

Characteristics of Upper Limb Osteoarticular Infections at the Emergency Department of a Tertiary University Hospital in Spain.

OBJECTIVES: Osteoarticular infections are infrequent in pediatric patients, although their incidence seems to be increasing. They usually affect children younger than 5 years and tend to localize in the lower limbs. Because of their nonspecific symptoms, especially at onset, a timely diagnosis is difficult to achieve, with the subsequent risk of a delay in treatment. We hereby report the management of osteoarticular infections in our pediatric emergency department. METHODS: This is a retrospective descriptive study of patients diagnosed with osteoarticular upper limb infection in the pediatric emergency department of a tertiary hospital from January 2011 to December 2016. RESULTS: From an initial global sample of 170 patients diagnosed with osteomyelitis or septic arthritis at any location at the pediatric emergency department, 32 children (18.82%) with upper limb involvement were included in the study. Of them, 22 were male and the mean age at diagnosis was 14.5 months (interquartile range, 2-106). Eighteen patients (56%) were diagnosed with septic arthritis, and 14 (44%) had a diagnosis of osteomyelitis.The most frequent symptom was pain (50%). More than one third of patients (11) had received a different diagnosis in a previous hospital visit. A traumatic etiology was suspected in 7 cases (21%).Regarding acute phase reactants, the mean value for C-reactive protein was 21.3 mg/L, and erythrocyte sedimentation rate was elevated in 27 cases (84%). In 28 patients, blood cultures were obtained, 24 of which came back negative. All children received antibiotic treatment and achieved a full recovery. CONCLUSIONS: One third of patients were misdiagnosed at the first consultation, which stresses the importance of a high clinical suspicion to avoid delays in diagnosis and treatment of osteoarticular infections. This study also shows a lower mean age of children with upper limb infection as compared with those with lower limb infection. All patients recovered fully with oral antibiotics.

Handlebar Hernia: An Uncommon Traumatic Abdominal Hernia.

ABSTRACT: Handlebar hernia is a type of traumatic abdominal wall hernia caused by the impact of a bicycle handlebar against the abdominal wall. A good anamnesis and physical examination are important for the correct diagnosis, and ultrasonography is an accessible tool in the emergency department for imaging confirmation. We describe a case of an 11-year-old girl who presented to the emergency department after an abdominal trauma caused by a handlebar. Ultrasonography revealed an abdominal wall defect with herniation of omentum and bowel loops. Conservative management was initially established, followed by surgical treatment due to persistent symptoms.

Coccygodynia Due to a Sacrococcygeal Anomaly: A Rare Cause of Constipation.

ABSTRACT: We report a case of an uncommon sacrococcygeal anomaly in a healthy girl initially presenting to the emergency department with coccygodynia and a past history of longstanding constipation. The clinical evolution was satisfactory once the bony anomaly was removed (coccygectomy). This unusual case exemplifies the importance of the medical history and physical examination to make an accurate diagnosis. An inadequate intervention may result in persistent pain, worsening longstanding constipation, and psychosocial and medical consequences.

Staphylococcal toxic shock syndrome in a child with interleukin-17 inhibitor treatment for psoriasis.

A 6-year-old girl presented with fever, skin rash, anuria, and conjunctivitis that rapidly progressed to toxic shock syndrome. Following hospital discharge, she developed a staphylococcal abscess on the lower extremity. She had recently received the first two doses of the interleukin-17 (IL-17) inhibitor secukinumab for resistant plaque psoriasis. IL-17 is known to be essential in host defense against Staphylococcus aureus. To our knowledge, this is the first reported case of staphylococcal toxic shock syndrome (STSS) associated with an IL-17 inhibitor.

Retrospective study of acute mastoiditis in children in Spain attended in a Pediatric Emergency department.

OBJECTIVE: To analyze the cases of acute mastoiditis, characteristics, management and complications in children attended in the emergency department. METHODS: Retrospective study of acute mastoiditis in a Spanish tertiary hospital over a 6-year period (2018-2023). RESULTS: One hundred two episodes of acute mastoiditis were analyzed (54% males, median age 1.8 years). Microorganisms were isolated in one third of cases, mainly Streptococcus pyogenes (64% of ear secretion cultures). Complications occurred in 27.5%, primarily subperiosteal abscess. A younger age, absence of vaccination schedule, previous history of otitis, cochlear implant carriers or white blood cell counts and C-reactive protein levels were not associated with complications. Complicated cases had longer hospitalizations. Treatment included antibiotics, corticosteroids, and surgery in 50% of cases. CONCLUSIONS: This study shows an increase of acute mastoiditis during 2023, with a relevant role of S. pyogenes. A younger age, absence of vaccination, personal history of otitis or cochlear implant, blood cell counts and C-reactive protein levels were not associated with complications.

Multicentric Pediatric Stroke Code: Insight to the first years after implementation.

BACKGROUND: The development of unicentric pediatric acute stroke protocols has improved stroke diagnosis and treatment. The impact of the implementation of a multicentric Pediatric Stroke Code (PSC) remains unknown. AIM: to describe the characteristics of the PSC activations and identify clinical features associated with stroke compared to stroke mimics in children in whom a multicentric PSC had been activated and compare them to reported monocentric PSC results. METHODS: Observational, retrospective, case and control multicentric study, performed in the Pediatric Emergency Department (PED) of the three Primary Pediatric Stroke Centers (PPSCs) in Madrid (Spain). Study population corresponded to children between 28 days and 16 years old in whom PSC was activated that consulted or were referred to any of the PPSC PED between March 2019 and June 2022. The main outcome was to compare the characteristics of patients with final diagnosis of stroke versus stroke mimics, among all patients for which PSC had been activated. Logistic regression modeling was used to investigate associations between independent variables and stroke diagnosis. Odds ratio (ORs) and 95 % confidence intervals (95%CIs) were estimated. RESULTS: PSC was activated in 196 patients. Stroke was confirmed in 39 patients (19.9 %): 20 (10.2 %) had an ischemic stroke and 19 (9.7 %) a hemorrhagic stroke. Stroke mimics represented 80.1 % of the PSC activations. Migraine was the most frequent stroke mimic (38.3 %). Time from symptom onset to brain imaging was 233.00 min (IQR 153.00-373.00) when patients self-presented at the PPSC compared to 231.00 min (IQR 129.00-400.00) when PSC was triggered at other settings (p0.580). Five patients (25.3 %) were eligible for hyperacute recanalization treatment. Low level of consciousness (OR4.373, 95%IC 0.247-0.652, p < 0.001), sensory disruption/motor disability of face/limbs (OR3.633, 95%IC 0.103-0.349, p < 0.001), aphasia (OR2.311, 95%IC 0.023-0.284, p0.022) and altered mental status (OR2.517, 95%IC 0.043-0.357, p0.013) were associated with an increased probability of stroke. CONCLUSION: multicentric PSC achieved similar results to previously reported unicentric PSCs, showing the feasibility of such an organization.

Laboratory interpretative comments and guidance: clinical and operative outcomes on moderate to severe hyponatraemia patient management.

AIMS: Hyponatraemia is the most common body fluid disorders but often goes unnoticed. Our laboratory incorporated a standardised procedure to help clinicians detect moderate/severe hyponatraemia. The study aims were to evaluate the outcomes on patient care and clinicians' satisfaction. METHODS: The study, observational and retrospective, included 1839 cases, adult and paediatric patients, with sodium concentration <130 mmol/L. The procedure consisted of interpretative comments in the emergency and core laboratories report and the point-of-care testing blood gas network report. We evaluated hyponatraemia length in two equal periods: before and after the implementation. We conducted a survey addressed to the staff of the clinical settings involved to know their satisfaction. RESULTS: The median hyponatraemia length decreased significantly from 4.95 hours (2.08-16.57) in the first period to 2.17 hours (1.06-5.39) in the second period. The lack of hyponatraemia patients follow-up was significantly less after the procedure implementation. The survey was answered by 92 (60 senior specialists and 32 residents) out of 110 clinicians surveyed. Ninety of them (98%) answered positively. CONCLUSIONS: We have demonstrated the reduction in the time for diagnosing and management by physicians, the higher uniformity in the time required to solve hyponatraemia episodes following our laboratory procedure and the clinicians' satisfaction.

Recommendation document on rapid intravenous rehydration in acute gastroenteritis.

INTRODUCTION: The efficacy and safety of the Rapid Intravenous Rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice. OBJECTIVE: To prepare a document with evidence-based recommendations about RIR in paediatric population. METHODS: The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of "relevant outcomes"; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security). RESULTS: 16 recommendations were set up, from which we can highlight as the main ones: 1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation, moderate evidence). 2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong, high). 3) Isotonic fluids are recommended (strong, high), suggesting saline fluid as the first option (light, low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong, moderate). 4) A rhythm of 20cc/kg/h is recommended (strong, high) during 1-4 h (strong, moderate). CONCLUSIONS: This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting.

Child sexual abuse detection in the pediatric emergency room.

BACKGROUND: Children who report sexual abuse are often first evaluated in a Pediatric Emergency Room (ER). OBJECTIVE: This study aims to describe clinical characteristics and management among these children. PARTICIPANTS AND METHODS: A retrospective review of child sexual abuse (CSA) cases in the ER of a tertiary hospital in Madrid over a 9-year period (January 2011 to April 2020) was conducted. 213 children up to 16 years old were included. Descriptive statistics were performed. RESULTS: An 83% of victims were girls, of whom 97.7% reported physical contact. The mean age was 8.5 ± 4.4 years, with two peaks of incidence at ages of 3 and 13. Aggressors were known by the victim in 77.8% of cases. Anogenital lesions were present in 39.9% of children who described physical contact, of which 31.7% were suspicious or specific of CSA. We obtained positive microbiological samples in 41 patients, with 14.6% specific findings for sexually transmitted infections (STIs). 23,9% received prophylaxis for bacterial STIs and 13.6% against HIV. 59.6% were followed-up in outpatient clinics. Since our protocol renovation in 2019, we observe a statistically significant increase in microbiological detection (p < .005) and outpatient follow-up (p < .001). CONCLUSIONS: STIs screening should always be done when physical contact is reported for eventual treatment and perpetrator prosecution, as physical lesions are frequently not found. The optimal treatment of CSA requires the use of renewed specific protocols and the involvement of multidisciplinary trained teams to ensure adequate medical and personal care.

Urgent Bordetella PCR in infants under 3 months, a useful tool in the Pediatric Emergency Department. / PCR urgente de Bordetella en lactantes menores de 3 meses, una herramienta útil en el Servicio de Urgencias Pediátricas.

INTRODUCTION: Whooping cough in patients aged under 3 months has higher rates of morbimortality. Hospitalization and treatment with azithromycin is generally recommended. Many patients with cough without other signs of alarm, are admitted and started antibiotic therapy until a result of Bordetella-PCR is available. This technique, when performed urgently, can provide the diagnosis in a few hours. The objective of this study is to determine if its generalisation in the Emergency Department allows to improve patient management. METHODS: Retrospective cohort study of patients aged under 3 months who underwent Bordetella-PCR testing from upper respiratory tract secretions since March 2011 to December 2017. From December 2015 the test was performed urgently. RESULTS: One hundred and fifty-eight PCR were performed, 16 (10%) were positive for B. pertussis. Negative results (142; 90%) were divided in 2 cohorts: conventional-PCR, with 74 cases, and urgent-PCR, with 68 cases. The 2 groups were homogeneous in terms of clinical and analytical characteristics. In the urgent-PCR group there was 18% reduction in chest X-rays performed (P=.008). There were 33 (48.5%) patients admitted in the urgent-PCR group, compared to 49 (66.2%) in the conventional-PCR (P=.042). Antibiotic treatment was initiated in 32% of the patients in the urgent-PCR group compared to 67% in the conventional-PCR group (P=.000047), without observing any significant increase in the number of visits to the Emergency Department or worse clinical performance. CONCLUSIONS: The introduction of urgent PCR in the Emergency Department is a useful tool in the management of infants under 3 months of age with suspected pertussis, since it can avoid unnecessary admissions, diagnostic tests and antibiotic treatments.

Think of the Children: Evaluation of SARS-CoV-2 Rapid Antigen Test in Pediatric Population.

BACKGROUND: Real-time reverse transcription-quantitative polymerase chain reaction (RT-qPCR) is the reference laboratory method to diagnose SARS-CoV-2 infection then requires equipment and is time-consuming. There is a crucial demand for rapid techniques such as antigen detection test. Considering the different diagnostic accuracy of tests with other respiratory viruses in adults and children, SARS-CoV-2 antigen test must be evaluated specifically in children. METHODS: The purpose of this study was to evaluate the performance of Panbio COVID-19 Ag Rapid Test Device (Abbott) as a point-of-care test for diagnosis of SARS-CoV-2 in comparison to RT-qPCR in a pediatric population. RESULTS: Four hundred forty nasopharyngeal swabs were tested. Amongst the 18 positive RT-qPCR samples, 14 were detected by the rapid antigen test, given an overall sensitivity of 77.7%. All the samples detected positive with the antigen rapid test were also positive with RT-qPCR. CONCLUSION: The sensitivity of Panbio COVID-19 Ag Rapid Test Device is lower in children than in adults. Nevertheless, considering the good values of specificity, negative and positive predictive values this test could be used as a frontline test to obtain quick results, although the negative values with COVID-19 high clinical suspicion should be confirmed using RT-qPCR.

[Recommendation document on rapid intravenous rehydration in acute gastroenteritis]. / Documento de recomendaciones sobre la rehidratación intravenosa rápida en gastroenteritis aguda.

INTRODUCTION: The efficacy and safety of the rapid intravenous rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice. OBJECTIVE: To prepare a document with evidence-based recommendations about RIR in paediatric population. METHODS: The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of «relevant outcomes¼; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security). RESULTS: Sixteen recommendations were set up, from which we can highlight as the main ones: (1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation and moderate evidence). (2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong and high). (3) Isotonic fluids are recommended (strong and high), suggesting saline fluid as the first option (light and low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong and moderate). (4) A rhythm of 20 cc/kg/h is recommended (strong and high) during 1-4 h (strong and moderate). CONCLUSIONS: This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting.

[Impact of the COVID-19 pandemic on emergency department: Early findings from a hospital in Madrid]. / Impacto de la pandemia COVID-19 en urgencias: primeros hallazgos en un hospital de Madrid.

INTRODUCTION: SARS-CoV-2, coronavirus that causes coronavirus disease 2019 (COVID-19), was first detected in Spain on 31 January 2020. On 14 March 2020, a state of emergency was declared in Spain in a bid to control the spread of the COVID-19 pandemic in the country. The aim of our study is to analyse the impact on emergency medicine attendance after the national lockdown, as well as the clinical presentation and the management of patients with suspected COVID-19 in the Paediatric Emergency Department. PATIENTS AND METHODS: This retrospective observational study included children and adolescents under the age of 18, attended in our Paediatric Emergency Department during the period March 14 to April 17, 2020. RESULTS: A total of 1,666 patients were attended during the study period, 65.4% less than in the same period of 2019. Just over half (51.2%) were males, and mean age was 5.4 years. In triage, 39.9% were high priority levels, 6.5% more than 2019. Most frequent reasons for consultation at the Paediatric Emergency Department were fever (26.5%), respiratory symptoms (16.1%), and trauma (15.2%). A total of 218 patients (13%) received a diagnosis of possible COVID-19, with SARS-CoV-2 infection confirmed in 18.4%, and 23.8% (52/218) were hospitalised. At discharge, 44% (96/218) were diagnosed with lower, and 33.9% (74/218) with upper respiratory infection. CONCLUSIONS: During the SARS-CoV-2 outbreak, the demand for urgent paediatric care decreased, with the proportion of cases with high priority triage levels increasing. Most of the patients with suspected or microbiological confirmation of COVID-19 had mild respiratory symptoms.

Impact of the COVID-19 pandemic on emergency department: Early findings from a hospital in Madrid.

INTRODUCTION: SARS-CoV-2, coronavirus that causes coronavirus disease 2019 (COVID-19), was first detected in Spain on 31 January 2020. On 14 March 2020, a state of emergency was declared in Spain in a bid to control the spread of the COVID-19 pandemic in the country. The aim of our study is to analyze the impact on emergency medicine attendance after the national lockdown, as well as the clinical presentation and the management of patients with suspected COVID-19 in the Paediatric Emergency Department. PATIENTS AND METHODS: This retrospective observational study included children and adolescents under the age of 18, attended in our Paediatric Emergency Department during the period March 14 to April 17, 2020. RESULTS: A total of 1666 patients were attended during the study period, 65.4% less than in the same period of 2019. Just over half (51.2%) were males, and mean age was 5.4 years. In triage, 39.9% were high priority levels, 6.5% more than 2019. Most frequent reasons for consultation at the Paediatric Emergency Department were fever (26.5%), respiratory symptoms (16.1%), and trauma (15.2%). A total of 218 patients (13%) received a diagnosis of possible COVID-19, with SARS-CoV-2 infection confirmed in 18.4%, and 23.8% (52/218) were hospitalised. At discharge, 44% (96/218) were diagnosed with lower, and 33.9% (74/218) with upper respiratory infection. CONCLUSIONS: During the SARS-CoV-2 outbreak, the demand for urgent paediatric care decreased, with the proportion of cases with high priority triage levels increasing. Most of the patients with suspected or microbiological confirmation of COVID-19 had mild respiratory symptoms.

INTRODUCCIÓN: SARS-CoV-2, responsable de la enfermedad por coronavirus 2019 (COVID-19), fue detectado por primera vez en España el 31 de enero de 2020. El 14 de marzo fue declarado el estado de alarma con el objetivo de controlar la pandemia. El objetivo de este estudio es analizar las consecuencias de esta crisis sanitaria sobre el patrón de demanda asistencial, así como el manejo y las características de los pacientes con sospecha de COVID-19 en el Servicio de Urgencias Pediátricas. PACIENTES Y MÉTODOS: Estudio retrospectivo observacional en niños y adolescentes menores de 18 años, atendidos en nuestro Servicio de Urgencias Pediátricas durante el periodo comprendido desde el 14 de marzo hasta el 17 de abril de 2020. RESULTADOS: Durante el periodo de estudio se atendieron 1.666 pacientes, un 65,4% menos que en el mismo periodo de 2019. La edad media fue de 5,4 años y el 51,2% eran varones. El 39,9% fueron clasificados con niveles de alta prioridad, un 6,5% más que en 2019. Los principales motivos de consulta fueron fiebre (26,5%), síntomas respiratorios (16,1%) y traumatismos (15,2%). Un total de 218 pacientes (13%) fueron diagnosticados de posible COVID-19, confirmándose la infección en el 18,4%. El 44% (96/218) fueron diagnosticados de infección respiratoria inferior y el 33,9% (74/218), superior. El 23,8% (52/218) fueron hospitalizados. CONCLUSIONES: Durante el brote epidémico SARS-CoV-2 disminuyó la demanda de asistencia pediátrica urgente, aumentando la proporción de casos con niveles de triaje de alta prioridad. La mayoría de los pacientes con sospecha o confirmación microbiológica de COVID-19 cursaron con clínica respiratoria leve.