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Study objective To estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing abscess incision and drainage in the emergency department. Methods The Up-Down method was used to estimate the dose of intravenous ketamine infused over 5 seconds or less that provided effective sedation in 50% (ED50) and 95% (ED95) for healthy children aged 2 to 5 years and 6 to 11 years undergoing abscess incision and drainage. None were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was determined when patients reached a Modified Aldrete score of 10. Results We enrolled 20 children in each age group. The estimated ED50 was 0.9 and 0.6 mg/kg for the 2 to 5 years and 6 to 11 years' groups and the estimated ED95 was 1.1 mg/kg for both groups. The median time to full recovery for the 2 groups was 20.5 and 17.5 minutes when only 1 dose of ketamine was administered and 27.5 and 35 minutes when additional doses of ketamine were administered. No participants experienced serious adverse events. Conclusions We estimated ED50 and ED95 for rapidly infused ketamine for 2 age groups undergoing abscess incision and drainage. Further studies are needed to get a more precise estimate of ED95. The total sedation time with this technique in the abscess group was shorter than most previous studies and is consistent with our previous observations in patients undergoing fracture reduction.

Objective Few prospective studies have assessed the occurrence of radiographic pneumonia in young febrile infants. We analyzed factors associated with radiographic pneumonias in febrile infants 60 days or younger evaluated in pediatric emergency departments. Study design We conducted a planned secondary analysis of a prospective cohort study within 26 emergency departments in a pediatric research network from 2008 to 2013. Febrile (≥38°C) infants 60 days or younger who received chest radiographs were included. Chest radiograph reports were categorized as "no," "possible," or "definite" pneumonia. We compared demographics, Yale Observation Scale scores (>10 implying ill appearance), laboratory markers, blood cultures, and viral testing among groups. Results Of 4778 infants, 1724 (36.1%) had chest radiographs performed; 2.7% (n = 46) had definite pneumonias, and 3.9% (n = 67) had possible pneumonias. Patients with definite (13/46 [28.3%]) or possible (15/67 [22.7%]) pneumonias more frequently had Yale Observation Scale score >10 compared with those without pneumonias (210/1611 [13.2%], P = 0.002) in univariable and multivariable analyses. Median white blood cell count (WBC), absolute neutrophil count (ANC), and procalcitonin (PCT) were higher in the definite (WBC, 11.5 [interquartile range, 9.8-15.5]; ANC, 5.0 [3.2-7.6]; PCT, 0.4 [0.2-2.1]) versus no pneumonia (WBC, 10.0 [7.6-13.3]; ANC, 3.4 [2.1-5.4]; PCT, 0.2 [0.2-0.3]; WBC, P = 0.006; ANC, P = 0.002; PCT, P = 0.046) groups, but of unclear clinical significance. There were no cases of bacteremia in the definite pneumonia group. Viral infections were more frequent in groups with definite (25/38 [65.8%]) and possible (28/55 [50.9%]) pneumonias than no pneumonias (534/1185 [45.1%], P = 0.02). Conclusions Radiographic pneumonias were uncommon, often had viruses detected, and were associated with ill appearance, but few other predictors, in febrile infants 60 days or younger.

OBJECTIVE Adults presenting to pediatric emergency departments are transferred to general emergency departments in proportions between 20% and 60%. How illness severity is related to the decision to transfer is poorly understood. We compared the proportion of adults with emergent and nonemergent conditions with respect to their final disposition. We also determined characteristics associated with transfer. METHODS We conducted a retrospective review of the electronic medical record and identified all patients 25 years and older presenting to a large urban freestanding pediatric emergency department from 2008 to 2013. We collected demographic and clinical information and used a preexisting algorithm to classify visits as emergent or nonemergent. We created a multivariate logistical regression model to determine independent variables associated with transfer. RESULTS Among 246,694 encounters, 1182 (0.5%) patients were older than 25 years. We excluded 402 (34%) because they were not categorized. Of the 780 categorized, 32% had an emergent and 68% had a nonemergent condition. Only 22% were transferred. Compared with nonurgent patients, the proportion transferred was twice as high for emergent patients (36% vs 15%), but even for emergent patients, most (63%) were retained for definitive care and/or disposition. Emergent diagnosis, age 45 to 64 years, and higher triage acuity were independently associated with the decision to transfer. CONCLUSION Regardless of illness severity, a minority of adult patients were transferred away for definitive care. Factors independently associated with transfer were emergent condition, higher triage acuity, and older age.

OBJECTIVE This study aimed to compare prehospital spinal immobilization techniques applied to age-based cohorts of children with and without cervical spine injury (CSI) after blunt trauma. METHODS We compared prehospital spinal immobilization in 3 age-based cohorts of children with blunt trauma-related CSI transported to 1 of 17 participating hospitals. We also compared children younger than 2 years with CSI with those at risk for but without CSI after blunt trauma. We identified patients through query of billing and radiology databases. We compared immobilization methods using Fisher's exact test for homogeneity. RESULTS We identified 16 children younger than 2 years, 78 children 2 to 7 years old, and 221 children 8 to 15 years old with CSI, and 66 children younger than 2 years without CSI. There were no significant differences in spinal immobilization techniques applied to children younger than 2 years old with and without CSI (P = 0.34). Of the 82 children younger than 2 years, 34 (41%) were fully immobilized in a cervical collar and rigid long board. There was a significant difference between spinal immobilization techniques applied to children with CSI younger than 2 years and 8 to 15 years old (P < 0.01). Six (38%) children with CSI younger than 2 years were fully immobilized versus 49 (63%) children 2 to 7 years old and 175 (79%) children 8 to 15 years old. CONCLUSIONS In this retrospective, observational study involving several emergency departments and Emergency Medical Services systems, we found that full spinal immobilization is inconsistently applied to children younger than 2 years after blunt trauma regardless of the presence of CSI. Full spinal immobilization is applied more consistently to older children with CSI.

The objective of this study was to estimate the sensitivity of plain radiographs in identifying bony or ligamentous cervical spine injury in children.We identified a retrospective cohort of children younger than 16 years with blunt trauma-related bony or ligamentous cervical spine injury evaluated between 2000 and 2004 at 1 of 17 hospitals participating in the Pediatric Emergency Care Applied Research Network. We excluded children who had a single or undocumented number of radiographic views or one of the following injuries types: isolated spinal cord injury, spinal cord injury without radiographic abnormalities, or atlantoaxial rotary subluxation. Using consensus methods, study investigators reviewed the radiology reports and assigned a classification (definite, possible, or no cervical spine injury) as well as film adequacy. A pediatric neurosurgeon, blinded to the classification of the radiology reports, reviewed complete case histories and assigned final cervical spine injury type.We identified 206 children who met inclusion criteria, of which 127 had definite and 41 had possible cervical spine injury identified by plain radiograph. Of the 186 children with adequate cervical spine radiographs, 168 had definite or possible cervical spine injury identified by plain radiograph for a sensitivity of 90% (95% confidence interval, 85%-94%). Cervical spine radiographs did not identify the following cervical spine injuries: fracture (15 children) and ligamentous injury alone (3 children). Nine children with normal cervical spine radiographs presented with 1 or more of the following: endotracheal intubation (4 children), altered mental status (5 children), or focal neurologic findings (5 children).Plain radiographs had a high sensitivity for cervical spine injury in our pediatric cohort.

Objective: Evaluate the effectiveness of the 2005 National Pediatric Emergency Medicine Fellows' Conference in achieving predefined objectives in scholarship, leadership, and partnership. Methods: Preconference and postconference questionnaires measured knowledge, research-related confidence, beliefs about institutional support for emergency medical services for children (EMSC) research, and intentions to engage in 7 specific behaviors relating to scholarship, leadership, and partnership. Bivariate correlations among the variables were assessed. Repeated-measures analysis of variance measured change between preconference and postconference measures. Hierarchical multiple linear regression models identified predictors of postconference intentions to engage in each of the 7 specific behaviors controlling for preconference intentions. Results: Ninety-two pediatric emergency medicine fellows attended; more than 90% completed preconference and postconference questionnaires, and 88% completed both. Knowledge (P < 0.001) and confidence (P < 0.001) improved after the conference. Increases were observed in fellows' intentions to establish national mentoring relationships (P < 0.001), continue in EMSC research (P = 0.003), and participate in national collaborations (P = 0.022). Confidence and subjective norms correlated significantly (P < 0.05) with each of the behavioral intentions in bivariate tests. In the multivariable regression models, confidence correlated with 4 behavioral intentions (P < 0.02), and subjective norms correlated with one (P < 0.001). Forty-eight percent established a mentoring relationship with a faculty member; 25% planned to collaborate on research with other attendees. Conclusions: The 2005 National Pediatric Emergency Medicine Fellows' Conference resulted in positive, measurable outcomes relating to the professional development of attendees, including increased conference-specific knowledge, confidence, and intentions to continue in EMSC research, join national collaborative research networks, and establish national mentoring relationships.

Objective: We hypothesized that children with moderate acute asthma exacerbations receiving oral montelukast with standard therapy will have at least 12% greater forced expiratory volume in 1 second (FEV 1 ) improvement in 3 hours than those receiving standard therapy alone. Methods: In this randomized, double-blind, placebo-controlled study, we enrolled emergency patients aged 6 to 14 years with moderate acute asthma exacerbations (peak expiratory flow rate, 40%-70% predicted). Subjects received montelukast 5 mg or placebo orally then standard therapy. We measured FEV 1 before study medication administration and hourly for 3 hours. The primary outcome was FEV 1 % predicted change at 3 hours. Results: At the time of the planned interim analysis, we had enrolled 27 subjects; 23 (11 montelukast, 12 placebo) had a complete FEV 1 data. Both groups had similar mean FEV 1 increases at 3 hours (mean [SD]: montelukast = 16.8% [11.4%], placebo = 19.9% [12.1%]; 95% confidence interval for difference = -12.22% to 5.95%). Based on further analysis, we determined that enrollment of the planned sample was unlikely to significantly change the results. If our study hypothesis were true, the montelukast group mean FEV 1 increase should be 32% or greater. The probabilities were low that the montelukast sample could be drawn from a normally distributed population with a mean of 32% and that subsequently enrolled montelukast subjects would have sufficient FEV 1 improvements to attain a mean of greater than 32%. Conclusion: Based on these results, for children aged 6 to 14 years with moderate acute asthma exacerbations, oral montelukast (5 mg) added to standard therapy as in this design is unlikely to result in additional FEV 1 improvements in 3 hours.

Childhood injuries are a major source of morbidity and mortality in industrialized countries, and many injuries occur on playgrounds. Our purpose was to examine childhood playground injuries in a metropolitan center in Canada. All children injured on playground equipment who were seen in the emergency department (ED) at The Hospital for Sick Children between March 1990 and July 1991 and were entered in the Children's Hospital Injury Research and Prevention Project (CHIRPP) database were included. The type, body part, and mechanism of injury were determined as well as the type of equipment, location, and surface. Among the 289 children injured on playground equipment, the mean age was 5.9 years with 39%5 years (range: 1 to 18 years). The most common injuries included fractures (28%), lacerations (24%), and hematomas (14%). The head and neck were injured 43% of the time, the upper extremity 41%, lower extremity 10%, and the trunk 6%. Climbing apparatus injuries occurred in 29% of children5 years compared with 47% of those injured who wereor = 5 years (P = 0.002). Injuries related to slides occurred in 40% of children5 years compared to 26% of childrenor = 5 years (P = 0.033). Of children5 years, 58% had head and neck injuries compared to 32% of childrenor = 5 years (P = 0.0006). Of children5 years, 28% had upper extremity injuries compared to 49% of childrenor = 5 years (P = 0.0005). There were no fatalities and the overall hospitalization rate was 18%. Of those children hospitalized, 77% had fractures, compared to 16% of those not hospitalized (P = 0.00001). Of all children hospitalized, 62% were injured on climbing apparatus, compared to 37% of those not hospitalized (P = 0.0004). There were no significant differences between nonprotective and natural protective surfaces with respect to hospitalization. We conclude that: 1) upper extremity injuries, especially fractures, accounted for the majority of hospitalizations resulting from injuries on playground equipment; 2) climbing apparatus-related injuries accounted for nearly two thirds of hospitalizations; 3) older children sustained more injuries on climbing apparatus, where younger children sustained more injuries on slides; and 4) younger children sustained more head injuries on playground equipment than older children, but most of these were minor.

The epidemiology of bacterial meningitis in the United States has changed tremendously in the past 20 years. Since the introduction of the Haemophilus influenzae type b vaccine in 1988, the incidence of H. influenzae type b meningitis has declined by at least 97%, and Streptococcus pneumoniae has emerged as the most common etiologic agent. The PCV7 (7-valent pneumococcal conjugate vaccine [Prevnar]; Wyeth Pharmaceuticals) vaccine, which targets 7 pneumococcal serotypes, was introduced in 2000 and has had an enormous impact on both the incidence and epidemiology of bacterial meningitis. This article reviews the impact of the PCV7 vaccine and the most up-to-date evidence on diagnosis and empiric therapy of suspected bacterial meningitis in the current day.

OBJECTIVE: The aim of this study was to ascertain potential factors associated with cervical spine injuries in children injured during sports and recreational activities. METHODS: This is a secondary analysis of a multicenter retrospective case-control study involving children younger than 16 years who presented to emergency departments after blunt trauma and underwent cervical spine radiography. Cases had cervical spine injury from sports or recreational activities (n = 179). Comparison groups sustained (1) cervical spine injury from other mechanisms (n = 361) or (2) other injuries from sports and recreational activities but were free of cervical spine injury (n = 180). RESULTS: For children with sport and recreational activity-related cervical spine injuries, common injury patterns were subaxial (49%) and fractures (56%). These children were at increased odds of spinal cord injury without radiographic abnormalities compared with children with cervical spine injuries from other mechanisms (25% vs 6%). Children with sport and recreational activity-related trauma had increased odds of cervical spine injury if they had focal neurologic findings (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.5-9.4), had complaints of neck pain (OR, 3.1; 95% CI, 1.9-5.0), were injured diving (OR, 43.5; 95% CI, 5.9-321.3), or sustained axial loading impacts (OR, 2.2; 95% CI, 1.3-3.5). Football (22%), diving (20%), and bicycle crashes (11%) were the leading activities associated with cervical spine injury. CONCLUSIONS: In children injured during sports and recreational activities, focal neurologic findings, neck pain, axial loading impacts, and the possibility of spinal cord injury without radiographic abnormality should guide the diagnostic evaluation for potential cervical spine injuries. Certain activities have a considerable frequency of cervical spine injury, which may benefit from activity-specific preventive measures. Language: en

To evaluate the use of intravenous (IV) sedation in children during peritonsillar abscess (PTA) incision and drainage in the emergency department (ED).Retrospective review of medical records of children with a diagnosis of PTA.The ED of a large, urban, academic children's hospital.Consecutive patients 18 years or younger presenting from April 1995 to November 1998.Information was retrieved from a time-based sedation record that included age, sex, ASA classification, time since last liquid or solid, agent and dose, level of sedation (A=alert, V=response to voice, P=purposeful response to pain, U=unresponsive), vital signs, complications, recovery time, and disposition.Forty-two patients had incision and drainage performed with IV sedation in the ED. Mean age was 11.3 +/- 4.3 years (range 4-18 years); 57% were African-American, and 64% were female. Agents used included ketamine plus midazolam (K/M) (n = 36, 86%), morphine plus midazolam (n = 3, 7%), meperidine plus midazolam (n = 2, 5%), and nitrous oxide plus midazolam (n = 1, 2%). No cardiorespiratory complications, including laryngospasm, occurred. Vomiting occurred in 1 patient who received meperidine and midazolam. The deepest level of sedation reached included: 12% A, 64% V, and 24% P. No patient who had an abscess drained in the ED with IV sedation was admitted, and mean recovery time was 81.0 +/- 30.1 minutes.IV sedation in children for incision and drainage of PTA by skilled personnel in the ED may eliminate the need for admission and surgical drainage in the operating room. K/M was used most frequently, without adverse effect, and all patients were discharged from the ED. Because K/M may result in deep sedation, appropriate personnel and equipment must be present.

OBJECTIVE To test the hypothesis that gene expression analysis of circulating white blood cells and/or plasma cytokines could be used to improve diagnostic accuracy in children being evaluated for appendicitis. METHODS We recruited 28 children being evaluated for abdominal pain from a tertiary pediatric emergency department. Twenty patients were used as a training cohort and 8 patients as a validation cohort. After consent was obtained, blood was processed for plasma cytokine analysis and RNA gene expression. Alvarado and pediatric appendicitis scores were obtained. Principal components analysis was used to explore global differences in gene expression. The random forest method was used to classify patients into those with and without appendicitis in the prospective cohort. Comparisons were made evaluating clinical scoring systems, cytokine analysis, and gene expression analysis to accurately predict appendicitis. RESULTS The random forest method accurately predicted appendicitis in 4 of 5 patients in the prospective cohort. Cytokine analysis was not as accurate as gene expression analysis; however, it did accurately rule out all 3 patients in the prospective cohort. Pediatric appendicitis scores and Alvarado scores were not useful for predicting appendicitis. CONCLUSIONS Our findings provide proof of technical feasibility and support the diagnostic potential of plasma cytokines to rule out and riboleukograms to rule in the diagnosis of appendicitis.

Objective: Evaluate the effectiveness of the 2005 to 2007 National Pediatric Emergency Medicine (PEM) Fellows Conference series in achieving predefined objectives in the domains of scholarship, leadership, and partnership. Methods: Conference attendees included fellows in the existing PEM fellowship programs. Self-administered preconference and postconference questionnaires measured knowledge, research-related confidence, beliefs about institutional support for Emergency Medical Services for Children (EMSC) research, and intentions to engage in 7 specific behaviors relating to scholarship, leadership, and partnership. Pearson product-moment correlations measured relationships among continuous variables. Repeated-measures analysis of variance measured change between preconference and postconference measures. Hierarchical multiple linear regression models identified predictors of postconference intentions to engage in each of the 7 specific behaviors, controlling for preconference intention. Results: Approximately one third of all PEM fellows attended the conference each year. Preconference and postconference questionnaires were completed by at least 70% of attendees each year. Because several fellows attended more than one conference, data were analyzed from the first conference that a fellow attended. In each year, we observed significant increases in attendees' conference-specific knowledge, confidence, and intentions to continue in EMSC research, join national collaborative research networks, and establish national mentoring relationships. Conclusions: The National PEM Fellows' Conference is an effective means to increasing fellows' knowledge about scholarship, leadership, and partnership in EMSC and increasing their confidence and intentions to conduct research in EMSC.

In a retrospective study of children with abdominal pain in a pediatric emergency department, 371 children were identified during four seasonally diverse months. Half of the children were two to six years old, 32% were seven to 11 years old, and 19% were 12 to 16 years old. Forty-eight different diagnoses were made, but 10 diagnoses were given to 83% of the patients. We found an increased frequency of respiratory illnesses (12%) as compared to other studies. Appendicitis was the only surgical problem that occurred in more than one percent of the children. The diagnoses were classified as medical (64.4%), surgical (6.5%), and nonspecific (29.1%). chi 2 and multinomial logit analysis revealed that guarding and abdominal tenderness were the two symptoms which were most strongly associated with a surgical diagnosis. The goal of this work is to assist the busy emergency clinician with the difficult task of making expeditious and accurate diagnoses for children with abdominal pain.

OBJECTIVE: Injury and poisoning from metallic mercury has become a rare event. Review of the literature and a case report of pediatric metallic mercury injury are presented. DESIGN: A case report. SETTING: The Emergency Department at St. Louis Children's Hospital. PATIENTS OR PARTICIPANTS: A 15-year-old boy. INTERVENTIONS: None. MAIN OUTCOME MEASURES: None. RESULTS: The 15-year-old boy fell on a broken mercury thermometer. A subcutaneous abscess formed on his left forearm during the next five days. He had no signs or symptoms of mercury toxicity. His wound was debrided in the operating room and healed completely after several months. CONCLUSIONS: This case shows elemental mercury from a thermometer as a potential, if unusual, source of mercury toxicity. Language: en

Intraperitoneal rupture of an infected urachal cyst is a rare cause of peritonitis in children, and has previously been reported in four children. We report this condition in a 34-month-old toddler who presented with a two-week history of abdominal pain and four days of infraumbilical swelling and erythema. Abdominal ultrasonography (US) and computerized tomography (CT) scan with contrast were helpful in the preoperative evaluation, showing an inflammatory process involving the anterior abdominal wall. The child was treated with intravenous antibiotics, and the infected urachal cyst, other parts of the urachal remnant, and a small portion of the dome of the bladder were excised. The postoperative hospital course was uncomplicated. Because of its rarity and variable manifestations, prompt diagnosis depends on maintaining a high index of suspicion. This diagnosis should be entertained in children with peritonitis in association with umbilical and midline abdominal abnormalities.

Nitrous oxide (N2O) safely and rapidly alleviates the pain and distress of minor procedures in the emergency department (ED). We have found self-administration in children does not consistently achieve acceptable analgesia and sedation. The equipment generally available for ED use is designed for adults and delivers 50% N2O through a demand valve that requires an inspiratory effort of -3 to -5 cm of water to activate gas flow. This is difficult for young children who are crying, have more shallow respirations than adults, or cannot follow instructions. In collaboration with the Departments of Anesthesiology, Dentistry, and Respiratory Therapy, we constructed a continuous-flow system for delivering N2O and oxygen (O2). The following is a description of the components, assembly, and use of a continuous-flow machine that safely and inexpensively delivers N2O and O2 to children.

The objective of this study was to assess complications and risk factors among children undergoing conscious sedation (CS) with fentanyl (F) and midazolam (M) for reduction of fractures and dislocations. A 22-month retrospective review was made of an urban pediatric emergency department's records after implementing a CS protocol for the administration of F/M. Data collection was facilitated by standard CS forms, and data were analyzed using descriptive statistics, chi 2 analysis, Fisher's exact test, t test, odds ratio, and logistic regression. A total of 339 children (65% boys), mean age of 8.4 years, were enrolled in the study. The mean time to sedation was 11.3 +/- 6.2 minutes and to discharge was 92 +/- 36.3 minutes. The mean total doses of M and F were 0.17 +/- 0.08 mg/kg and 1.5 +/- 0.8 micrograms/kg, respectively. An alteration in respiratory status occurred in 37 (11.0%) patients: 28 (8.3%) had oxygen saturation < 90%; 16 (4.7%) received oxygen; 12 (3.6%) were given verbal breathing reminders, eight (2.4%) received airway positioning maneuvers, and 2 (0.6%) received naloxone. Four patients (1.2%) vomited. None required assisted ventilation, intubation, or admission resulting from complications of CS. Characteristics associated with the respiratory events included female sex (odds ratio = 2.2) and deep sedation (odds ratio = 2.7). We conclude that complications associated with F/M administered by protocol were few, minor, and easily managed. Patients who are female or who enter a state of deep sedation may be at modestly increased risk for alterations in respiratory status. Careful attention to monitoring vital functions on all patients is necessary to provide safe CS.

We undertook a prospective study of 377 children (two to 16 years old) presenting with abdominal pain to determine: 1) common discharge diagnoses; 2) what signs and symptoms are associated with appendicitis; and 3) follow-up of patients discharged from the emergency department (ED). Nine diagnoses accounted for 86% of all diagnoses made. The most common final diagnosis was "abdominal pain" (36%). The following findings were significantly associated with appendicitis: vomiting, right lower quadrant(RLQ) pain, tenderness, and guarding (all P less than 0.001). Ninety-seven percent (28/29) of patients with appendicitis had at least two of these four signs and symptoms, as did 28% (96/348) of patients without appendicitis. The sensitivity of the model is 0.96, and the specificity is 0.72 (positive predictive value = 0.24; negative predictive value = 0.99). Of the patients contacted within one week of the visit (237), 75% reported that the pain had resolved (mean contact time, 2.6 days). We conclude that 1) patients presenting to the ED with abdominal pain often leave with the diagnosis of abdominal pain; 2) of the patients contacted, the majority reported that their pain has resolved; and 3) a diagnosis of appendicitis should be considered in any patient with any two of the following signs or symptoms: vomiting, guarding, tenderness, or RLQ pain. Such patients should be evaluated and observed carefully for the possible diagnosis of appendicitis.

We reviewed the Tumor Registry for 1981 at the Children's Hospital of Philadelphia to identify all the children with newly diagnosed cancer who were seen initially in the emergency department (ED). Of the 220 new patients listed, 16 (7.3%) sought initial care in the ED (1 per 4,500 ED visits). Seven had leukemia, five had non-CNS solid tumors (2 lymphoreticular, 1 Wilms', 1 neuroblastoma, and 1 ovarian), and four had CNS tumors. Among the children with leukemia, pallor (6) and decreased activity (4) were the most common complaints. Duration of symptoms ranged from 4 days to 3 weeks. Physical examination showed pallor (5), splenomegaly (4), fever (3), hepatomegaly (3), lymphadenopathy (3), and ecchymoses or petechiae (2). The complete blood count and peripheral smears were all abnormal. The five patients with non-CNS solid tumors had symptoms related to the location of their neoplasms. The patients with Wilms' tumor, neuroblastoma, and ovarian dysgerminoma had abdominal masses; the patient with lymphoma had a large, painful inguinal node; and the patient with histiocytosis X had an infiltrative rash, gingivitis, and pneumonitis. Of the four children with CNS tumors, three had headache, and one had an incidentally detected scotoma following head trauma. All four eventually had abnormal neurologic exams and computer tomographic scans, but two were discharged initially with psychiatric diagnoses. We conclude that cancer, although rare in children, occurs with greater relative frequency in the referral hospital ED than that predicted by published cancer rates from the referring hospital's ED.(ABSTRACT TRUNCATED AT 250 WORDS)

Sharp object ingestions may require different management from other foreign body ingestions because of possible gastrointestinal tract perforation. Three cases of sharp object ingestion are presented to describe the possible outcomes. A review of the relevant literature follows.

A survey of 24 existing pediatric emergency medicine fellowship programs as of December 1987 was conducted in order to characterize the following attributes of training in pediatric emergency medicine: amount of clinical time, required and elective rotations, didactic and research experience, patient volume, and staffing. Time spent in the emergency department varies between three and 10 months annually, with a mean of 34.5 hours per week. Twenty-two (92%) of the programs have required rotations. All responding programs require research and some degree of didactic education. Patient volume varies between 20,000 and 70,000, with a median of 41,000. The data offered should act as a reference for the further development of new and existing programs.