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Importance Although most massive transfusion protocols incorporate cryoprecipitate in the treatment of hemorrhaging injured patients, minimal data exist on its use in children, and whether its addition improves their survival is unclear. Objective To determine whether cryoprecipitate use for injured children who receive massive transfusion is associated with lower mortality. Design, Setting, and Participants This retrospective cohort study included injured patients examined between January 1, 2014, and December 31, 2017, at one of multiple centers across the US and Canada participating in the Pediatric Trauma Quality Improvement Program. Patients were aged 18 years or younger and had received massive transfusion, which was defined as at least 40 mL/kg of total blood products in the first 4 hours after emergency department arrival. Exclusion criteria included hospital transfer, arrival without signs of life, time of death or hospital discharge not recorded, and isolated head injuries. To adjust for potential confounding, a propensity score for treatment was created and inverse probability weighting was applied. The propensity score accounted for age, sex, race/ethnicity, injury type, payment type, Glasgow Coma Scale score, hypoxia, hypotension, assisted respirations, chest tube status, Injury Severity Score, total volume of blood products received, hemorrhage control procedure, hospital size, academic status, and trauma center designation. Data were analyzed from December 11, 2019, to August 31, 2020. Exposures Cryoprecipitate use within the first 4 hours of emergency department arrival. Main Outcomes and Measures In-hospital 24-hour and 7-day mortality. Results Of the 2387 injured patients who received massive transfusion, 1948 patients were eligible for analysis. The median age was 16 years (interquartile range, 9-17 years), 1382 patients (70.9%) were male, and 807 (41.4%) were White. A total of 541 patients (27.8%) received cryoprecipitate. After propensity score weighting, patients who received cryoprecipitate had a significantly lower 24-hour mortality when compared with those who did not (adjusted difference, −6.9%; 95% CI, −10.6% to −3.2%). Moreover, cryoprecipitate use was associated with a significantly lower 7-day mortality but only in children with penetrating trauma (adjusted difference, −9.2%; 95% CI, −15.4% to −3.0%) and those transfused at least 100 mL/kg of total blood products (adjusted difference, −7.7%; 95% CI, −15.0% to −0.5%). Conclusions and Relevance In this cohort study, early use of cryoprecipitate was associated with lower 24-hour mortality among injured children who required massive transfusion. The benefit of cryoprecipitate appeared to persist for 7 days only in those with penetrating trauma and in those who received extremely large-volume transfusion.

Importance In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. Objective To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Design, Setting, and Participants Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. Exposures Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Results We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Conclusions and Relevance We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

OBJECTIVES: To assess the performance of the Yale Observation Scale (YOS) score and unstructured clinician suspicion to identify febrile infants ≤60 days of age with and without serious bacterial infections (SBIs). METHODS: We performed a planned secondary analysis of a prospective cohort of non–critically ill, febrile, full-term infants ≤60 days of age presenting to 1 of 26 participating emergency departments in the Pediatric Emergency Care Applied Research Network. We defined SBIs as urinary tract infections, bacteremia, or bacterial meningitis, with the latter 2 considered invasive bacterial infections. Emergency department clinicians applied the YOS (range: 6–30; normal score: ≤10) and estimated the risk of SBI using unstructured clinician suspicion (50%). RESULTS: Of the 4591 eligible infants, 444 (9.7%) had SBIs and 97 (2.1%) had invasive bacterial infections. Of the 4058 infants with YOS scores of ≤10, 388 (9.6%) had SBIs (sensitivity: 51/439 [11.6%]; 95% confidence interval [CI]: 8.8%–15.0%; negative predictive value: 3670/4058 [90.4%]; 95% CI: 89.5%–91.3%) and 72 (1.8%) had invasive bacterial infections (sensitivity 23/95 [24.2%], 95% CI: 16.0%–34.1%; negative predictive value: 3983/4055 [98.2%], 95% CI: 97.8%–98.6%). Of the infants with clinician suspicion of CONCLUSIONS: In this large prospective cohort of febrile infants ≤60 days of age, neither the YOS score nor unstructured clinician suspicion reliably identified those with invasive bacterial infections. More accurate clinical and laboratory predictors are needed to risk stratify febrile infants.

The aim of this study was to evaluate the variability of clinician-performed Focused Assessment with Sonography for Trauma (FAST) examinations and its impact on abdominal computed tomography (AbCT) use in hemodynamically stable children with blunt torso trauma (BTT). The FAST is used with variable frequency in children with BTT.We performed a planned secondary analysis of children (18 years) with BTT. Patients with a Glasgow Coma Scale (GCS) score of less than 9, those with hypotension, and those taken directly to the operating suite were excluded. Clinicians documented their suspicion for intra-abdominal injury (IAI) as very low, less than 1%; low, 1% to 5%; moderate, 6% to 10%; high, 11% to 50%; or very high, greater than 50%. We determined the relative risk (RR) for AbCT use based on undergoing a FAST examination in each of these clinical suspicion strata.Of 6,468 (median age, 11.8 years; interquartile range, 6.3-15.5 years) children who met eligibility, 887 (13.7%) underwent FAST examination before CT scan. A total of 3,015 (46.6%) underwent AbCT scanning, and 373 (5.8%) were diagnosed with IAI. Use of the FAST increased as clinician suspicion for IAI increased, 11.0% with less than 1% suspicion for IAI, 13.5% with 1% to 5% suspicion, 20.5% with 6% to 10% suspicion, 23.2% with 11% to 50% suspicion, and 30.7% with greater than 50% suspicion. The patients in whom the clinicians had a suspicion of IAI of 1% to 5% or 6% to 10% were significantly less likely to undergo a CT scan if a FAST examination was performed: RR, 0.83 (0.67-1.03); RR, 0.81 (0.72-0.91); RR, 0.85 (0.78-0.94); RR, 0.99 (0.94-1.05); and RR, 0.97 (0.91-1.05) for patients with clinician suspicion of IAI of less than 1%, 1% to 5%, 6% to 10%, 11% to 50%, and greater than 50%, respectively.The FAST examination is used in a relatively small percentage of children with BTT. Use increases as clinician suspicion for IAI increases. Patients with a low or moderate clinician suspicion of IAI are less likely to undergo AbCT if they receive a FAST examination. A randomized controlled trial is required to more precisely determine the benefits and drawbacks of the FAST examination in the evaluation of children with BTT.Prognostic and epidemiologic study, II.

Background Despite being an effective analgesic for children with fractures, some clinicians may avoid prescribing ibuprofen due to its potentially harmful effect on bone healing. Objective To determine if exposure to ibuprofen is associated with an increased risk of bone healing complications in children with fractures. Methods We performed a retrospective study of children aged 6 months to 17 years who presented to the pediatric emergency department (PED) with a fracture of the tibia, femur, humerus, scaphoid, or fifth metatarsus and who followed up with the orthopedic service. We chose these fractures due to their higher risk for complications. We classified patients as exposed if they received ibuprofen in the PED or during hospitalization or were prescribed ibuprofen at discharge. The main outcome was a bone healing complication as evidenced by nonunion, delayed union, or re-displacement on follow-up radiographs. Results Of the 808 patients included in the final analysis, 338 (42%) were exposed to ibuprofen. Overall, 27 (3%) patients had a bone healing complication; 8 (1%) developed nonunion, 3 (0.4%) developed delayed union, and 16 (2%) developed re-displacement. Ten (3%) patients who were exposed to ibuprofen, and 17 (4%) who were not, developed a bone healing complication (odds ratio 0.8, 95% confidence interval 0.4–1.8; p = 0.61). There was no significant association between ibuprofen exposure and the development of a bone healing complication despite adjustment for potential confounders. Conclusion Children with extremity fractures who are exposed to ibuprofen do not seem to be at increased risk for clinically important bone healing complications.

OBJECTIVE To determine whether emergency departments (EDs) at pediatric emergency medicine (PEM) fellowship training institutions have a departmental policy regarding the evaluation and management of febrile infants and if reported policies are based on published guidelines (PGs). METHODS A 32-item telephone survey was administered to PEM fellowship directors (FDs). Departmental demographics and criteria used to evaluate febrile infants were collected. Scenarios were presented regarding the evaluation and management of low-risk febrile infants. Reported consistency among ED attending physicians at the same institution was also assessed. RESULTS The response rate was 83% (53 of 64). Fifty-one percent (26 of 53) of FDs reported the existence of a departmental policy regarding the evaluation of febrile infants. Of those who have a departmental policy, 19% (5 of 26) stated that it was one of the PGs. The FDs who reported the existence of a departmental policy were significantly more likely to report consistent management by all ED attending physicians in their department compared with those without a departmental policy (81% vs 19%, P < 0.05). The most frequent age and temperature cutoff for a mandatory sepsis evaluation were 28 days (45%, 28 of 53) and 100.4°F (66%, 35 of 53). The FDs reported a lack of consistency among ED attending physicians at the same institution regarding age and temperature (66% and 17% of the time, respectively). Eighty-five percent (45 of 53) of FDs reported that a new guideline is needed. CONCLUSIONS Nearly one half of EDs at PEM fellowship training institutions are reported not to have a departmental policy regarding the management of febrile infants, and departmental policies rarely conform to any of the PGs. There is substantial interdepartmental and intradepartmental practice variability regarding the management of febrile infants and a strong consensus regarding the need for a new guideline.

The purposes of this study were to describe the characteristics of a normal anterior fat pad (AFP) and to determine the association between a normal AFP and the absence of fracture.A prospective cohort of children aged 1 to 18 years with elbow trauma underwent radiographic examination. All patients received standard orthopedic management and follow-up 7 to 14 days after injury. A pediatric radiologist evaluated all radiographs for the presence or absence of fracture and documented whether the AFP was normal or abnormal on the lateral view. The radiologist also recorded specific measurements of the AFP including the apical angle, which is formed by the intersection of the humerus and the superior aspect of the AFP. The interpretation of the AFP on the initial lateral radiograph was compared with the final patient outcome (fracture/no fracture).Two hundred thirty-one patients had elbow radiographs; 34 patients (15%) were lost to follow-up. A total of 56 fractures were identified: 49 (87%) on the initial radiograph and an additional 7 (13%) on follow-up radiographs. This latter group was defined as occult fractures. Among the 197 patients available for analysis, 113 (57%) had a normal AFP on the initial radiograph. Of these, 2 children had a final diagnosis of fracture. The sensitivity of a normal AFP was 96.4% (95% confidence interval, 86.6%-99.4%), and the negative predictive value was 98.2% (95% confidence interval, 93.1%-99.7%). There was a significant difference in mean AFP angle when the AFP was read as normal (14.7 [SD, 3.3] degrees) compared with when it was read as abnormal (27.0 [SD, 6.8] degrees) (P0.01).Our data suggest that a normal AFP is highly associated with absence of elbow fracture and that the determination of a normal AFP can be aided by measuring the apical angle of the AFP.

Objective To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections. Study design Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants. Results Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis. Conclusions Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.

Objective Patient safety may be enhanced by using reports from front-line staff of near misses and unsafe conditions to identify latent safety events. We describe paediatric emergency department (ED) near-miss events and unsafe conditions from hospital reporting systems in a 1-year observational study from hospitals participating in the Pediatric Emergency Care Applied Research Network (PECARN). Design This is a secondary analysis of 1 year of incident reports (IRs) from 18 EDs in 2007–2008. Using a prior taxonomy and established method, this analysis is of all reports classified as near-miss (events not reaching the patient) or unsafe condition. Classification included type, severity, contributing factors and personnel involved. In-depth review of 20% of IRs was performed. Results 487 reports (16.8% of eligible IRs) are included. Most common were medication-related, followed by laboratory-related, radiology-related and process-related IRs. Human factors issues were related to 87% and equipment issues to 11%. Human factor issues related to non-compliance with procedures accounted for 66.4%, including 5.95% with no or incorrect ID. Handoff issues were important in 11.5%. Conclusions Medication and process-related issues are important causes of near miss and unsafe conditions in the network. Human factors issues were highly reported and non-compliance with established procedures was very common, and calculation issues, communications (ie, handoffs) and clinical judgment were also important. This work should enable us to help improve systems within the environment of the ED to enhance patient safety in the future.

Objectives Plain chest x-ray (CXR) is often the initial screening test to identify pneumothoraces in trauma patients. Computed tomography (CT) scans can identify pneumothoraces not seen on CXR (“occult pneumothoraces”), but the clinical importance of these radiographically occult pneumothoraces in children is not well understood. The objectives of this study were to determine the proportion of occult pneumothoraces in injured children and the rate of treatment with tube thoracostomy among these children. Methods This was a planned substudy from a large prospective multicenter observational cohort study of children younger than 18 years old evaluated in emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network (PECARN) for blunt torso trauma from May 2007 to January 2010. Children with CXRs as part of their trauma evaluations were included for analysis. The faculty radiologist interpretations of the CXRs and any subsequent imaging studies, including CT scans, were reviewed for the absence or presence of pneumothoraces. An “occult pneumothorax” was defined as a pneumothorax that was not identified on CXR, but was subsequently demonstrated on cervical, chest, or abdominal CT scan. Rates of pneumothoraces and placement of tube thoracostomies and rate differences with 95% confidence intervals (CIs) were calculated. Results Of 12,044 enrolled in the parent study, 8,020 (67%) children (median age = 11.3 years, interquartile range [IQR] = 5.3 to 15.2 years) underwent CXRs in the ED, and these children make up the study population. Among these children, 4,276 had abdominal CT scans performed within 24 hours. A total of 372 of 8,020 children (4.6%; 95% CI = 4.2% to 5.1%) had pneumothoraces identified by CXR and/or CT. The CXRs visualized pneumothoraces in 148 patients (1.8%; 95% CI = 1.6% to 2.2%), including one false-positive pneumothorax, which was identified on CXR, but was not demonstrated on CT. Occult pneumothoraces were present in 224 of 372 (60.2%; 95% CI = 55.0% to 65.2%) children with pneumothoraces. Tube thoracostomies were performed in 85 of 148 (57.4%; 95% CI = 49.0% to 65.5%) children with pneumothoraces on CXR and in 35 of 224 (15.6%; 95% CI = 11.1% to 21.1%) children with occult pneumothoraces (rate difference = –41.8%; 95% CI = –50.8 to –32.3%). Conclusions In pediatric patients with blunt torso trauma, pneumothoraces are uncommon, and most are not identified on the ED CXR. Nearly half of pneumothoraces, and most occult pneumothoraces, are managed without tube thoracostomy. Observation, including in children requiring endotracheal intubation, should be strongly considered during the initial management of children with occult pneumothoraces. Resumen Objetivos La radiografia de torax simple (RXT) es a menudo la prueba de despistaje inicial para identificar los neumotorax en los pacientes con traumatismo. La tomografia computarizada (TC) puede identificar neumotorax no vistos en la RXT (“neumotorax ocultos”), aunque la importancia clinica de estos neumotorax radiograficamente ocultos en los ninos no esta muy estudiada. Los objetivos de este estudio fueron determinar la proporcion de neumotorax ocultos en los ninos accidentados y el porcentaje de tratamiento con tubo de toracostomia en estos ninos. Metodologia Subestudio disenado a partir de un gran estudio observacional de cohorte prospectivo multicentrico de ninos menores de 18 anos atendidos en los servicios de urgencias (SU) de la Pediatric Emergency Care Applied Research Network (PECARN) que habian sido evaluados por traumatismo toracico cerrado de mayo de 2007 a enero de 2010. Se incluyeron en el analisis los ninos en los que la RXT fue parte de la evaluacion inicial del traumatismo. Las interpretaciones del radiologo de las RXT y de cualquier estudio de imagen posterior, incluyendo a TC, se revisaron para la ausencia o presencia de neumotorax. Se definio “neumotorax oculto” como un neumotorax que no fue identificado en la RXT pero que fue posteriormente visualizado en la TC abdominal, torocica o cervical. Se calcularon los porcentajes de neumotorax e insercion de tubo de toracostomia y las diferencias de sus porcentajes con los intervalos de confianza (IC) al 95%. Resultados De los 12.044 incluidos en el estudio principal, se llevo a cabo una RXT en el SU en 8.020 (67%) ninos (mediana de edad 11,3 anos, rango intercuartilico 5,3 a 15,2), que constituyeron la poblacion de estudio. De estos ninos, 4.276 tuvieron una TC realizada en las primeras 24 horas. En 372 de los 8.020 ninos (4,6%; IC 95% = 4,2% a 5,1%) se identifico un neumotorax en la RXT y/o la TC. La RXT mostro neumotorax en 148 pacientes (1,8%; IC 95% = 1,6% a 2,2%), incluyendo un falso positivo de neumotorax, que fue identificado en la RXT pero que no fue demostrado en la TC. Los neumotorax ocultos estuvieron presentes en 224 de los 372 ninos con neumotorax (60,2%; IC 95% = 55,0% a 65,2%). Se insertaron tubos de toracostomia en 85 de los 148 ninos con neumotorax en la RXT (57,4%; IC 95% = 49,0% a 65,5%), y en 35 de los 224 ninos con neumotorax oculto (15,6%; IC 95% = 11,1% a 21,1%; diferencia de porcentajes -41,8%; IC 95% = -50,8 a -32,3%). Conclusiones En los pacientes pediatricos con traumatismo toracico cerrado, los neumotorax son poco frecuentes, y la mayoria no son identificados en la RXT en el SU. Casi la mitad de los neumotorax, y la mayoria de los neumotorax ocultos son manejados sin tubo de toracostomia. La observacion, incluyendo en los ninos que requieren intubacion endotraqueal, deberia ser especialmente considerada durante el manejo inicial de los ninos con neumotorax ocultos.

Purpose To review the epidemiology and management of facial fractures in a pediatric population. Materials and Methods This study was a retrospective review of patients younger than 18 years who presented to a pediatric emergency department during a 5-year period in an urban, academic, level 1 designated trauma center. Results Of the 156 patients identified, most were boys (87%) and the mean age was 13.5 years (standard deviation, 4.9 yr; interquartile range, 12 to 17 yr). The most common mechanism of injury was assault (48.1%). Mandibular fractures (40.7%) were most common. Multiple fractures occurred in 26.9% of patients. Concomitant injuries occurred in 73.7% of patients, most commonly concussions (39.1%). Intracranial hemorrhages were associated with panfacial ( P = .005), frontal ( P = .001), and orbital ( P = .04) fractures. Most patients (91.7%) were admitted, and nonoperative repair was undertaken in 57.1%. There was an independent association of surgical intervention with age older than 14 years and with mandibular fractures ( P Conclusions Assault was the most common mechanism of injury and mandibular fracture was the most commonly encountered. Concomitant nonfacial injuries occurred in most patients. Patients sustaining panfacial, frontal, and orbital fractures should provoke an evaluation for other intracranial injuries. Children older than 14 years and those with mandibular fractures should prompt mobilization of resources for operative repair.

Atrial fibrillation occurs commonly after coronary artery bypass surgery. However, despite numerous attempts at prediction, no accurate and generally accepted method exists to predict its occurrence. P-wave-triggered P-wave signal averaging was performed on 54 patients before coronary artery bypass surgery to evaluate the utility of this method to predict atrial fibrillation after coronary artery bypass surgery. After excluding six patients with unevaluable P-wave signal averages and three patients with postoperative arrhythmias other than atrial fibrillation, the P-wave signal averages of 45 patients were analyzed. Sixteen patients had postoperative atrial fibrillation and 29 did not. The mean P-wave duration of the filtered, signal-averaged P wave was 163 +/- 19 msec in the 16 patients with atrial fibrillation and 144 +/- 16 msec in the 29 patients without (p < 0.005). Left atrial enlargement on the surface electrocardiogram (ECG) was the only other statistically significant variable that correlated weakly with the onset of postoperative atrial fibrillation (p = 0.04). Other clinical variables such as P-wave duration in ECG lead II, left ventricular hypertrophy on ECG, age, sex, hypertension, and left ventricular ejection fraction were not significantly different between the two groups. With a cut point of 155 msec, chi-squared analysis revealed a p value of < 0.005, yielding a sensitivity of 69%, a specificity of 79%, a positive predictive value of 65%, and a negative predictive value of 82%. Signal-averaging of the P wave in patients before coronary artery bypass surgery provides a good predictor of postoperative atrial fibrillation.

Study objective We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. Methods We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. Results We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). Conclusion A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

UNLABELLED Responses to orthostasis may be altered in states associated with autonomic dysfunction. Computerized impedance cardiography, a noninvasive method for continuous assessment of stroke volume and mean blood pressure, was utilized to study the postural hemodynamic changes in eight normal and 27 patients with DDD pacemakers. Twenty patients with complete heart block (five with heart failure) were studied in the VDD mode and seven patients with sick sinus syndrome were assessed in DVI (four) or VDD (three). The results with pacemaker patients are significantly different from those observed in normal. Pacemaker patient responses to standing included: (1) a reduction in systolic, diastolic, and mean blood pressure; (2) an increase in heart rate in patients with intact sinus node function and no change in patients with sick sinus syndrome; and (3) stroke volume was unchanged in patients with sick sinus syndrome or heart failure and only modest reduction occurred in the remaining patients. CONCLUSIONS (1) No reduction in stroke volume during upright posture occurs in DDD patients with sick sinus syndrome and this appears to be a compensatory reaction to an inadequate heart rate response to standing; (2) The hemodynamic response of DDD patients to the assumption of an upright posture is consistent with autonomic dysfunction; and (3) The primary cause for autonomic dysfunction in DDD patients may be the asynchronous ventricular depolarization caused by right ventricular pacing.

Objective: To compare bedside ultrasonography (BUS) to radiography for identifying long bone fractures, the need for reduction, and the adequacy of reduction. Methods: Children aged 2 to 17 years presenting to a pediatric emergency department with long bone injuries were prospectively enrolled. Bedside ultrasonography was performed before ordering initial radiographs. If a fracture was identified, measurements of angulation and displacement were made based on BUS images. Radiographs were used to guide management. Patients who had a fracture identified on radiograph underwent standard care. Later, agreement between BUS and radiography for fracture identification, the need for reduction, and the adequacy of reduction were determined. Results: Thirty-three patients were enrolled, the mean age was 9.1 years (±3.1 years). Sixty six bones were studied; 56 (84.8%) involved the upper extremity. Fractures were identified in 59.1% of all bones; 13 (33.3%) required reduction. Results: The agreement between BUS and radiography for fracture identification was 95.5%, for the need for reduction 92.3%, and for the adequacy of reduction 92.3%. The sensitivity and specificity of BUS for fracture identification, need for reduction and reduction adequacy was 0.97 (95% confidence interval [CI], 0.85-1.00), 0.93 (95% CI, 0.74-0.99), and 1.00 (95% CI 0.79-1.00), and 0.85 (95% CI, 0.61-0.96), 1.00 (95% CI, 0.59-1.00) and 0.80 (95% CI, 0.30-0.99), respectively. Conclusions: These data suggest that BUS evaluation of upper extremity injuries not involving joints maybe comparable to radiography for identifying fractures, the need for reduction, and the adequacy of reduction in children. If further investigations which include a larger number of lower extremity, growth plate, and joint injuries support our findings, BUS may gain a more prominent role in managing children with all long bone injuries.

This is a review article of intraosseous infusion methods and devices.

We compare test characteristics of abdominal computed tomography (CT) with and without oral contrast for identifying intra-abdominal injuries.This was a planned subanalysis of a prospective, multicenter study of children (18 years) with blunt torso trauma. Children imaged in the emergency department with abdominal CT using intravenous contrast were eligible. Oral contrast use was based on the participating centers' guidelines and discretions. Clinical courses were followed to identify patients with intra-abdominal injuries. Abdominal CTs were considered positive for intra-abdominal injury if a specific intra-abdominal injury was identified and considered abnormal if any findings suggestive of intra-abdominal injury were identified on the CT.A total of 12,044 patients were enrolled, with 5,276 undergoing abdominal CT with intravenous contrast. Of the 4,987 CTs (95%) with documented use or nonuse of oral contrast, 1,010 (20%) were with and 3,977 (80%) were without oral contrast; 686 patients (14%) had intra-abdominal injuries, including 127 CTs (19%) with and 559 (81%) without oral contrast. The sensitivity in the detection of any intra-abdominal injury in the oral contrast versus no oral contrast groups was sensitivitycontrast 99.2% (95% confidence interval [CI] 95.7% to 100.0%) versus sensitivityno contrast 97.7% (95% CI 96.1% to 98.8%), difference 1.5% (95% CI -0.4% to 3.5%). The specificity of the oral contrast versus no oral contrast groups was specificitycontrast 84.7% (95% CI 82.2% to 87.0%) versus specificityno contrast 80.8% (95% CI 79.4% to 82.1%), difference 4.0% (95% CI 1.3% to 6.7%).Oral contrast is still used in a substantial portion of children undergoing abdominal CT after blunt torso trauma. With the exception of a slightly better specificity, test characteristics for detecting intra-abdominal injury were similar between CT with and without oral contrast.

This report presents selected prevalence estimates for children ages 4-17 years with difficulties in emotions, concentration, behavior, or being able to get along with others using data from the 2001, 2002, and 2003 National Health Interview Surveys (NHIS).Data for the U.S. civilian noninstitutionalized population were collected using computer-assisted personal interviews (CAPI). In 2001, a total of 10,367 interviews were completed about sample children ages 4-17 years by the member of the household most knowledgeable about the child's health. The number of completed interviews about sample children ages 4-17 years was 9,512 in 2002 and 9,399 in 2003. Questions on children's emotional and behavioral difficulties from the Strengths and Difficulties Questionnaire (SDQ) were first asked in the NHIS in 2001. SUDAAN software was used to tabulate statistics shown in this report.In 2001, 2002, and 2003, approximately 5% of U.S. children ages 4-17 years had emotional or behavioral difficulties, and for approximately 80% of these children, there was an impact on their functioning. Children with difficulties in emotions, concentration, behavior, or being able to get along with others varied by sex, age, race, family structure, poverty status, and health insurance status. About 50% of these children were upset or distressed by their emotional or behavioral difficulties, and about 80% had difficulties that impacted their family life, friendships, learning, or leisure activities.

Hemodynamic assessment of pacemaker patients is necessary for gauging responses to changes in programming or other conditions affecting circulation. Impedance cardiography permits noninvasive determinations of cardiac output at short intervals but data regarding variability of this method in patients with pacemakers is unavailable. Thirty-eight patients with pacemakers (24 with DDD and 14 with WI devices) and 6 normal subjects were studied. Each patient was studied in the supine position and repeated impedance measurements were obtained. Fourteen patients were studied during sinus rhythm, 24 were studied during DDD pacing, and 32 patients were studied during WI pacing. Variability was assessed by methods that analyzed both serial measurements and variability between 2 consecutive and nonconsecutive measurements. The mean indexes and coefficients of variation of 2 and serial measurements in sinus rhythm and DDD were 4%; in WI it was 6%. The precision of impedance cardiography in all pacing modes, as demonstrated by analysis of variability, indicates that detected changes of stroke volume and cardiac output >7% on serial (2 and more) measurements, performed by the same operator and during the same session, represent true hemodynamic alterations with 95% confidence. The precision of impedance cardiography demonstrated may be comparable or superior to other frequently used techniques, and the data obtained are valuable both investigationally and clinically.

Objective hemodynamic assessment of pacemaker patients is necessary for gauging responses to changes in programming or other conditions that affect the circulation. Impedance cardiogrphy permits noninvasive, repetitive determinations of cardiac output at short intervals, but data regarding variability of this method in patients with pacemakers is unavailable. Thirty-eight patients with implanted pacemakers (24 DDD, 14 VVI) and six normal subjects were studied, A computerized impedance cardiograph was used to calculate cardiac output from the product of the first derivative of the thoracic impedance signal (dZ/dt), the ventricular ejection time, and heart rate. Each patient was studied while supine after a period of at least 15 minutes of rest and repeated impedance measurements (about ten) were performed. Fourteen patients were studied in sinus rhythm, 24 were studied during DDD pacing, and 32 patients were studied during VVI pacing. Cardiac and stroke indices were calculated 706 times on the basis of 11,296 accepted beats. Variability was assessed by methods that analyzed serial measurements and variability between two consecutive and nonconsecutive measurements. The mean indices and coefficients of variation of two measurements and of serial measurements in sinus rhythm and during DDD pacing were 4%; in VVI it was 6%. The precision of impedance Cardiography in all pacing modes, as demonstrated by analysis of variability, indicates that detected changes of stroke volume and cardiac output > 7% on serial (two and more) measurements, performed by the same operator and during the same session, represent true hemodynamic alterations with 95% confidence. Conclusions are that the precision of impedance Cardiography may be comparable or superior to other commonly used techniques and that the data obtained by this technique is valuable investigationally and clinically.