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Purpose This study was performed to identify risk factors associated with post-tonsillectomy hemorrhage (PTH)-related hospitalization in pediatric patients visiting an emergency department (ED). Methods We retrospectively reviewed the medical records of patients who underwent tonsillectomy at a single children’s hospital ED from January 2009 through December 2020. Data were collected on patient demographics, chief complaints, surgical methods, postoperative days, initial vital signs, and laboratory findings. The study population was divided into hospitalized and discharged groups. Results Among a total of 2,716 patients reviewed, 67 met the inclusion criteria. The hospitalized group showed a lower median systolic blood pressure (108.0 [interquartile range, 82.0-134.0] vs. 118.5 [89.8-147.2] mmHg; P = 0.021) and a faster median respiratory rate (23.0 [18.0-28.0] vs. 20.0 [17.0-23.0] breaths/minute; P = 0.019), compared with the discharged group. Multivariable logistic regression identified systolic blood pressure under 100 mmHg (odds ratio, 5.21; 95% confidence interval, 1.17-37.60) and respiratory rate over 24 breaths/minute (7.31; 1.07-145.79) as the factors associated with PTH-related hospitalization. Conclusion When pediatric patients visit EDs for PTH, close monitoring or hospitalization may be needed in those with low systolic blood pressure or rapid respiratory rate.

With the age of exposure to illegal substances decreasing and abuse of drugs such as methamphetamine increasing, substance abuse is no longer limited to adults. We report a Korean case of a 17-year-old girl with acute methamphetamine poisoning. The girl visited the emergency department for vomiting and loss of consciousness, with needle marks found on both arms. QT prolongation was confirmed on the initial electrocardiogram, so that we suspected drug addiction and proceeded with toxicologic tests. A lethal dose of methamphetamine was confirmed. We discontinued QT prolonging drugs, and closely monitored the girl in the pediatric emergency intensive care unit until the QT prolongation was resolved. This case highlights the recognition of pediatric methamphetamine poisoning in emergency departments.

Purpose Genital injury is a common pediatric injury. Given the lack of nationwide data, the authors aimed to show age group-related epidemiologic features of genital injury in Korea. Methods We reviewed the data from 2011-2016 Emergency Department-based Injury In-depth Surveillance registry, which involves 23 emergency departments in Korea. From the dataset, we included children (< 18 years) with the International Classification of Diseases, 10th Revision codes related to genital injury as the final diagnosis with excluding those with other codes or combined injuries. Age groups were defined as follows; infants (< 1 year), toddlers (1-3), preschoolers (4-6), schoolers (7-12), and adolescents (13-17). The clinical features and outcomes were analyzed. Results A total of 3,030 children were included with the median age of 6 years (interquartile range, 4-10) and the proportion of girls of 53.0%. Only 144 children (4.8%) were transported by the emergency medical service providers. The most common mechanism and place were blunt injury (1,826 [60.3%]) and home (1,535 [50.7%]), respectively. Of the codes, “Contusion of external genital organs (S30.2)” was most common (1,574 [51.9%]). As for outcomes, 2,770 children (91.4%) were discharged, 252 (8.3%) were hospitalized (intensive care units, 1 child [0.03%]), and 108 (3.6%) underwent surgery. Severe injury occurred in 111 children (3.7%) without a mortality. With increasing age in the age groups, non-accidental injury, school and sports-related injuries, hospitalization, and surgery (All Ps < 0.001). Conclusion Genital injury may occur at evening, in spring and summer, at home, and in the form of accidental or blunt injury. Most children are discharged. Contrary to these general features, older children tend to undergo more frequently non-accidental injury, school and sports-related injuries, hospitalization, and surgery. Thus, we need age-specific strategies for injury prevention.

Purpose In Korea, the Broselow tape (BT) is widely used to estimate weight in resuscitation. Validation of BT in Korean children is essential because the tool was developed based on children’s weight and height in the United States. The validation was previously performed in a small-scale dataset. The authors aimed to validate BT using the 2005 Korean nationwide anthropometric survey data. Methods From the population used for the survey, we sampled children aged 0-12 years. The weights estimated by BT were compared with measured weights of the children using Bland-Altman analysis with results recorded as percentage differences. We measured the accuracy of BT, defined as within a 10% error of the measured weight, and the concordance of the color-coded zones derived from the estimated and measured weights. The accuracy and concordance were further assessed according to the age groups and body mass index-for-age Z-score (< -2, underweight; > 2, overweight or obese). Results A total of 108,128 children were enrolled. The mean age was 55.2 ± 37.5 months. The bias was –5.4% (P < 0.001), and the limits of agreement were –28.3% and 17.6%, respectively. The accuracy and concordance of BT were 64.4% and 67.2%, respectively. Differences of no more than 1 color-coded zone between estimated and measured weights accounted for 89.8% and 84.1% of the under- and overweight (or obese) children, respectively. Conclusion BT accurately estimates weight in approximately two-thirds of Korean children. In addition, adjustment of 1 color-coded zone may be considered in children with extreme weight.

In pediatric patients, central venous catheterization (CVC) is necessary for administration of fluids, drugs, high concentration electrolytes, vasopressors or inotropic drugs, transfusion, intravenous nutrition, and dialysis. Using an anatomical landmark for the CVC insertion may have a low success rate in children due to the positional variation between the deep vein and the landmarks, the small size of body and blood vessels, low insertion frequency, and operator skill. In order to improve the success rate, ultrasound guided CVC insertion is recommended in critically ill children. It is also expected to reduce mechanical complications, which are more common with subclavian CVC insertion. However, the association between the insertion site and the infection or thrombosis is unclear. Since thrombosis is relatively common, further studies are needed on the association between the incidence rate and insertion sites.

Purpose To develop a clinical scoring system for children with presumed appendicitis who visit the emergency department. Methods A registry based-retrospective study was conducted in the pediatric emergency department between September 2015 and December 2016. Patients aged 4 to 17 years who had a > 1 of 5 Likert scale for possibility of appendicitis were included. Multiple logistic regressions based on Akaike information criterion were performed using variables regarding clinical features and inflammatory markers to develop the clinical scoring system. Results A total of 233 patients were included, and 93 (39.9%) had the final diagnosis of appendicitis. The final model with the lowest Akaike information criterion (171.7) consisted of 5 variables, including vomiting (1 point), absence of watery diarrhea (1 point), duration of symptoms ≤ 3 days (1 point), rebound tenderness (1 point), and white blood cell count > 10.0 × 109/L (2 points). If the clinical score was ≥ 4 of 6 points, the area under the receiver operating characteristic curve was 0.78 (95% confidence interval, 0.71-0.86) with a 78.9% sensitivity, 66.7% specificity, positive and negative predictive values of 70.0% and 76.2%, respectively, and positive and negative likelihood ratios of 2.4 and 0.3, respectively. Conclusion The 5-item clinical scoring system shows a fair performance for prediction of pediatric appendicitis. This simple tool could be applied to predict the pediatric appendicitis, and to avoid the use of potentially unnecessary computed tomography.

Interfacility transport of critically ill children (transport) is a challenging component of pediatric critical care. The risk associated with the transport may be reduced by a specialized pediatric transport team, a screening tool for critically ill children, and a standardized handover between referring and referred physicians. Further research is necessary in Korea regarding the above measures for the safe and effective transport.

Knowing a pediatric patient's weight is crucial in resuscitation since the decision on the dose of resuscitation drug and the size of the instrument is made mostly based on a patient's weight. However, using a scale may not always be practical in resuscitation. Therefore, it is important to know the methods of weight estimation in resuscitation. The weight estimation can be performed based on various factors: visual assessment, age, height, and body habitus. One of the most common problems of these methods is that the weight tends to be underestimated as a patient's age increases. This is due to an inappropriate reflection of body habitus. Further research is needed to overcome this problem.

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare, congenital genitourinary anomaly involving the Müllerian and Wolffian structures, and is characterized by the triad of uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis. It usually presents in adolescent girls in whom hematometrocolpos produces a pronounced mass effect and pain on the side of the obstructed hemivagina. Accurate diagnosis and surgical treatment can be delayed for several months or even years. Here, we report a case of a 12-year-old girl who presented to the emergency department with lower abdominal pain and mass that had lasted for 2 weeks. After the confirmation of HWW syndrome with magnetic resonance imaging, hysteroscopic septostomy was carried out as a definitive treatment. When we evaluate adolescent girls with lower abdominal pain and mass, we should consider the possibility of HWW syndrome.

Purpose The purpose of this study is to investigate the effect of oral ondansetron on the incidence of vomiting in children who receive intramuscular (IM) ketamine for procedural sedation and analgesia in the emergency department (ED). Methods In this double-blind, randomized, placebo-controlled trial in a children's hospital ED, patients receiving IM ketamine (5 mg/kg) for ED procedures were randomized to receive either oral ondansetron (2 mg or 4 mg) or placebo 15 minutes before the ketamine injection. We recorded whether vomiting occurred in the ED postsedation or up to 12 hours after discharge with telephone follow-up and compared ED length of stay and parental satisfaction. Results Thirty two children were randomized to placebo and 31 to ondansetron. The groups were similar in age, sex, and fasting duration. ED vomiting was no significant difference with ondansetron: 7 of 31 (22.6%) versus 6 of 32 (18.8%), P=0.707, difference -3.8 (95% confidence interval -23.8% to 16.2%). Follow-up completed in 82.5%. The vomiting in the ED or after discharge in two groups, there was no significant difference: 7 of 27 (25.9%) versus 12 of 25 (48.0%), P=0.165, difference 22.1% (95% confidence interval -3.5% to 47.7%). ED length of stay and parental satisfaction were similar between groups. Conclusion There is no significant reduction of the incidence of vomiting in oral ondansetron group with IM ketamine procedural sedation in children.

Purpose The purpose of this paper is to assess the experience and satisfaction of the trainees participating in the Emergency Pediatric Ultrasound Training Course, which has been developed from a close cooperation between the Korean Society of Pediatric Emergency Medicine and Society of Emergency and Critical Care Imaging. Methods A task-force team was formed consisting of 8 members, collectively from both Korean Society of Pediatric Emergency Medicine and Society of Emergency and Critical Care Imaging. Over 9 separate discussion sessions, the team reviewed related articles to reach a consensus on an educational framework, a curriculum for the training course, and teaching methods to adapt to the conditions of Pediatric Emergency Medicine in South Korea. Results After running the course twice with a developed curriculum, the trainees were polled for their training experiences. A total of 36 trainees completed the course. The response rates were 81.3% and 40% in the first and second course, respectively. On average, the ratings by participants in the survey were above a 4 for all questions, which are significantly high scores. Over sixty percent of participants rated 4 or above in the Likert scale for all of the questions. Conclusion Korean Society of Pediatric Emergency Medicine and Emergency Imaging Study Group (now renamed to Society of Emergency & Critical Care Imaging) successfully developed the Emergency Pediatric Ultrasound Course, which was rated significantly favorably by the trainees.

Intussusception is the most common cause of gastrointestinal obstruction in children, which occurs most commonly in children aged between 3 and 12 months. Small bowel intussusception is uncommon in children compared to adults, and is not reduced by air reduction, unlike illeocecal intussusception. During the post-enema reduction period, patients could experience a delayed complication of hypovolemic shock. We report a case of small bowel intussusception that required explorative laparotomy due to hypovolemic shock. The patient was a 5 month-old female infant, who was diagnosed with small bowel intussusception and small bowel obstruction by sonography after a second air enema reduction. While observing her symptom, the patient's vital sign was becoming increasingly unstable. The patient received a large amount of fluid and inotropics. After a diagnostic computed tomography (CT) scan, the patient underwent explorative laparotomy to rule out bowel ischemia or necrosis. However, the patient's bowel was clear without minimal laceration on the surface of the bowel. After the operation, the patient recovered spontaneously. We suspect the patient's symptom and sign were caused by hypovolemia due to prolonged bowel ischemia and obstruction. Furthermore, resolving hypovolemic shock was caused by small bowel intussusception self-reduction. When pediatric physician is faced with small bowel intussusception in pediatric patients, they should provide adequate fluid supply and management along patient's state.

Significant pancreatic injuries can occur with minor handlebar trauma. Timely diagnosis of pancreatic injuries is critically important, since delayed diagnosis is the greatest determinant of morbidity. Children presenting to the emergency department after bicycle accidents should be treated with a high concern of suspicion regarding combined intra-abdominal trauma. The standard clinical approach of repeated regular physical examination and the use of abdomen CT examination should be followed. We report a case of pancreatic injury after blunt trauma by a bicycle handlebar. This 7-year-old boy experienced spleen preserving distal pancreatectomy with cholecystectomy. The initial symptom and signs were vague or uncertain. However, he revisited the emergency department with aggravated abdominal pain and vomiting. In conclusion, handlebar injuries must be considered potentially serious, no matter how trivial the accident may appear.

Anaphylaxis is a severe systemic allergic reaction, which progresses rapidly and may cause death. However, the diagnosis of anaphylaxis is difficult because initial symptoms and signs of anaphylaxis have various patterns. We reported a case of anaphylaxis with unusual clinical presentation that made diagnosis difficult. A 14-year-old male presented emergency department with dizziness and temporary hypotonia. While observing his symptom, the patient’ s blood pressure decreased rapidly. After thorough history taking, we found out that he had been suffered from pruritus and nausea for two days. The patient received a large volume of crystalloid and intramuscular epinephrine. And the blood pressure recovered soon. When physicians evaluate patients with respiratory or circulatory compromise, we should consider the possibility of anaphylaxis through careful history taking and administer epinephrine immediately if necessary.