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Point-of-care ultrasound (POCUS) has been described as a useful tool for identification of coronavirus disease 2019 (COVID-19) in adults and children. Although several case reports describe POCUS findings in children with COVID-19, to our knowledge, there have been no published multicenter case series describing the large heterogeneity in lung POCUS findings in pediatric COVID-19. This series includes 7 symptomatic patients with COVID-19 who had a lung POCUS performed at 6 institutions by pediatric emergency attendings and fellows. The findings were variable, ranging from no findings to the appearance of B-lines, pleural abnormalities, consolidations, and a pleural effusion. Further studies are needed to improve our understanding, characterization, and prognostic correlation of POCUS findings in this novel disease in children.

Asthma guidelines recommend assessment of asthma control and treatment with an ICS when appropriate. Children seen for asthma in the ED often have poorly controlled asthma. Validated questionnaires are rarely used in the ED and ICS are prescribed at less than 5% of ED asthma encounters, leaving many children at risk for continued poor outcomes.To determine if use of a validated asthma questionnaire can increase the proportion of children who receive an ICS prescription during an ED asthma visit.We administered a validated asthma questionnaire (Pediatric Asthma Control and Communication Instrument-ED version [PACCI-ED]) to parents of children 2 - 17 years old presenting for asthma care at a large, urban, academic pediatric ED. Based on national asthma guidelines, the PACCI-ED results were used to determine ICS dose recommendations. ED physicians reviewed the PACCI-ED results and ICS dose recommendations and chose whether to prescribe an ICS upon discharge. ICS prescribing rates during the intervention period were assessed via medical record review and compared to historical controls. We also surveyed parents to examine the association of sociodemographic factors with receipt of an ICS prescription, and surveyed physicians regarding their prescribing decisions.Thirteen physicians and seventy-nine children participated. Historically, the ICS prescribing rate for asthma exacerbations discharged from the ED was 13%. The intervention increased ICS prescribing to 56% (A validated asthma questionnaire increased ICS prescribing for children presenting for to the ED for asthma care. Additional strategies are needed to promote prescribing in this setting and ensure that all eligible children receive guideline-based asthma care.

1. Kathryn H. Pade, MD* 2. Marie R. Waterhouse, MD† 1. *Department of Emergency Medicine, Rady Children’s Hospital, San Diego, CA 2. †Department of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA A 2-year-old girl with no significant medical history presents to the pediatric emergency department (ED) with a 1-month history of decreased frequency of bowel movements and hard stools. She had intermittent abdominal pain during this time as well. She was brought to her pediatrician as well as multiple EDs, where radiographs were obtained and showed “constipation,” according to her parents. Her parents had been consistently giving the patient a bowel regimen, but she continued to get worse. In the past week she had intermittent nausea and nonbloody, nonbilious vomiting. She also complained of 1 day of dysuria and decreased urine output. In the ED her vital signs are as follows: temperature, 99.3°F (37.4°C); heart rate, 130 beats/min; respiratory rate, 26 breaths/min; blood pressure, 114/79 mm Hg; and oxygen saturation, 98% on room air. She is tired appearing, with dry mucous membranes. Her abdomen is soft, mildly tender with palpation in the suprapubic region, nondistended, and without palpable masses or hepatosplenomegaly. Rectal examination reveals normal tone and no stool present in the rectal vault. Urine dipstick analysis is significant for specific gravity greater than 1.030, ketone levels greater than 160 mg/dL, and trace leukocyte esterase. Initial screening laboratory tests include a complete blood cell count, basic metabolic panel, and lactate dehydrogenase and uric acid levels, the results of which are all normal. Abdominal and pelvic ultrasonography shows a heterogeneous oblong mass in the expected right ovary location (Fig 1), with slight color Doppler flow (Fig 2). The left ovary is visualized with normal Doppler flow. Abdominal/pelvic computed tomography shows an oblong soft tissue mass posterior to the uterus measuring 4.2×3.4×2.2 cm …

National asthma guidelines recommend use of an asthma action plan (AAP) as part of chronic asthma care. Unfortunately, AAPs have not been tailored for use in acute care settings, where many patients at risk for poor chronic asthma care are seen, including those who are non-English-speaking or have low literacy levels. We previously developed a picture-based medication plan (PBMP), a unique type of AAP for use in an ambulatory setting and designed to increase patient use and understanding. However, little is known about how parents seeking emergency department (ED) asthma care would perceive the PBMP.To assess parental attitudes toward an asthma PBMP in the largest pediatric ED in Los Angeles County.We surveyed a consecutive sample of English- or Spanish-speaking parents of children 2-17 years seeking ED asthma care. Parents used a 5-point Likert scale for various statements regarding their perceptions of the PBMP. Responses were analyzed by sociodemographics, asthma control, and health literacy using Chi-squared and90 parents provided feedback on the PBMP. The majority of parents endorsed the PBMP. Endorsement was 20%-30% higher among Spanish-speaking parents and those who did not complete high-school compared to English-speaking parents and parents with a high school education or higher (Spanish-speaking parents and parents with less than a high-school education overwhelmingly endorsed the PBMP. It may be useful to consider incorporating the PBMP as part of patient-centered chronic asthma care strategies for populations seen in ED settings.

1. Courtney Brennan, MD* 2. Kathryn Pade, MD† 1. *Department of Emergency Medicine and Transport, Children’s Hospital Los Angeles, Los Angeles, CA 2. †Department of Emergency Medicine, Rady Children’s Hospital, San Diego, CA A 12-month-old previously healthy girl presents to the emergency department for 3 months of progressive abdominal distention. They note that her abdomen has seemed very firm in the past month and it seems to be causing her discomfort. Parents report that she has continued to breastfeed for 10 to 15 minutes at a time but will often fall asleep during feedings, and she has been refusing to eat solid foods in the past month. They deny any dysphagia. She has maintained her normal urine output, and they deny any vomiting or changes in her stooling. She had been meeting developmental milestones appropriately, but she has seemed more tired in the past 2 to 3 months and no longer wants to crawl or sit unassisted. Her verbal and fine motor skills have continued to progress. They deny any known changes to her growth parameters. She had an upper respiratory tract infection approximately 2 weeks earlier. Review of systems is otherwise negative. Physical examination reveals an alert, smiling, and interactive infant. Vital signs are significant for tachypnea (respiratory rate of 48 breaths/min) and initial hypertension (blood pressure of 110/98 mm Hg), but a normal temperature of 99.9°F (37.7°C), heart rate of 122 beats/min, and oxygen saturation of 97%. Her weight is at the 71st percentile for age. Her lungs are clear to auscultation, and her heart rate is regular …

BACKGROUND Pediatric limp is a common presenting complaint to emergency departments. Despite this, diagnosis can be difficult in young patients with no history of trauma. Ultrasound can be used to identify a hip effusion, which may be the etiology of limp in pediatric patients. Brief educational training sessions have successfully been used to introduce novice ultrasound users to point-of-care (POC) ultrasound; however, the education of POC hip ultrasound is underexplored, and the efficacy of educational training sessions in this domain remains unknown. OBJECTIVE To evaluate the feasibility and efficacy of using a brief educational training session to teach novice ultrasound users to identify hip anatomy and effusions. METHODS Medical and physician assistant students were enrolled during an ultrasound education conference. A pretest evaluated prior knowledge, experience, and confidence level regarding POC hip ultrasound. Students attended a brief didactic session and then completed an objective structured assessment of technical skill as well as a posttest. RESULTS Twenty-eight students naive to hip ultrasound participated in this study. Levels of training included medical and physician assistant students. Mean test scores increased from the pretest (4.8 of 9, SD = 1.6) to the posttest (7.9 of 9, SD = 0.72) (P < 0.001). Average objective structured assessment of technical skill was 4.6 of 5 (SD, 0.75; 95% confidence interval, 4.3-4.9). After the sessions, confidence levels in identifying landmarks, joint space, and a joint effusion significantly increased (P < 0.001). CONCLUSIONS Pediatric hip ultrasound knowledge, performance, skills, and confidence improved as demonstrated by novice ultrasound users after a brief educational training session. Our study shows that a brief, targeted educational intervention was a feasible and effective method of introducing pediatric POC hip ultrasound to novices.

Objective: To learn factors associated with desire for asthma specialist care among parents of children seeking emergency department (ED) care for asthma, and if referral was indicated base...

Undiagnosed asthma in children presenting to the emergency department (ED) for respiratory illnesses might be associated with subsequent asthma morbidity and repeat ED visits.To examine the prevalence of undiagnosed asthma among children presenting for ED care, and explore associations with sociodemographic and clinical characteristics.We surveyed parents of children ages 2-17 years seeking ED care for respiratory symptoms (including asthma) regarding sociodemographic characteristics, asthma symptoms, prior asthma care and morbidity, and prior asthma diagnosis. Undiagnosed asthma was defined as a positive screening for asthma and no prior diagnosis. We compared sociodemographic and clinical factors of those with diagnosed versus undiagnosed asthma using chi-square, t-tests and multivariable logistic regression model.Of 362 children, 36% had undiagnosed asthma. Undiagnosed children were younger, had younger parents, and had parents less likely to speak English versus diagnosed children (allChildren presenting to the ED with undiagnosed asthma commonly experience significant prior asthma morbidity. Strategies to improve asthma diagnosis and messaging to their parents may reduce future morbidity.

Study objective: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. Methods: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. Results: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI −0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). Conclusion: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

BACKGROUND: Transesophageal echocardiography (TEE) is used in the emergency department to guide resuscitation during cardiac arrest. Insertion of a TEE transducer requires manual skill and experience, yet in some residency programs cardiac arrest is uncommon, so some physicians may lack the means to acquire the manual skills to perform TEE in clinical practice. For other infrequently performed procedural skills, simulation models are used. However, there is currently no model that adequately simulates TEE transducer insertion. The aim of this study is to evaluate the feasibility and efficacy of using a cadaveric model to teach TEE transducer placement among novice users. METHODS: A convenience sample of emergency medicine residents was enrolled during a procedure education session using cadavers as tissue models. A pre-session assessment was used to determine prior knowledge and confidence regarding TEE manipulation. Participants subsequently attended a didactic and hands-on education session on TEE placement. All participants practised placing the TEE transducer until they were able to pass a standardized assessment of technical skill (SATS). After the educational session, participants completed a post-session assessment. RESULTS: Twenty-five residents participated in the training session. Mean assessment of knowledge improved from 6.2/10 to 8.7/10 (95% confidence interval [CI] of knowledge difference 1.6–3.2, P

Background: Asthma guidelines recommend specialist care for patients experiencing poor asthma outcomes during emergency department (ED) visits. The prevalence and predictors of asthma specialist ca...

Objectives Pediatric emergency departments (PED) are overcrowded and at times inefficient with malaligned resources, especially regarding the use of intravenous (IV) catheters which are placed frequently, yet may be underused. This study seeks to determine which pediatric patients are more likely to need IV access in a PED. Methods This retrospective study examined patients 3 days to 21 years seen in a tertiary PED from January 1, 2013, to February 28, 2013, who were triaged using the Emergency Severity Index, levels 1 to 3. Extracted data included age, chief complaints, chronic medical conditions, final diagnoses, evidence of venipuncture, and IV placement and usage. Patients were excluded if they entered the PED with an IV or central venous catheter, were older than 21 years, or had charts with missing data. Results Four thousand three hundred twenty-two patients were initially evaluated, and 122 patients were excluded. Mean age of the patients was 6.2 years (SD = 5.65), most common triage was level 3 (urgent), and the majority of patients (n = 2898, 69.0%) did not have a chronic medical condition. Five hundred forty-five (13%) had IVs placed, and of those, 152 (27.9%) had IVs placed and not used. Patients triaged as critical or emergent, patients older than 10 years, and those with a gastrointestinal chief complaint and chronic medical conditions involving hematology, oncology/immunology, or endocrinology were most likely to have an IV placed and used. Conclusions Patients with higher acuities, specified systemic complaints, certain chronic medical conditions, and patients older than 10 years are more likely to need an IV.

A previously healthy 5-year-old boy presented to the emergency department with a history of tactile fevers, cough, congestion, decreased appetite, and abdominal pain. He had diffuse abdominal pain on examination and pain with ambulation. Emergency point-of-care ultrasound was used to diagnose appendicitis with an appendicolith. The diagnosis was confirmed by a radiology-performed ultrasound, and he was taken to the operating room for an appendectomy.

Study Design Computed tomographic (CT) study of thoracic spine pedicles. Objective To analyze the usefulness of the superior articular process (SAP) as an external landmark for determining the transverse plane angulation of thoracic pedicles. Summary of Background Data The use of thoracic pedicle screws has become commonplace. Although most authors report them to be safe, their use poses a risk to neurovascular structures. Previous studies have provided useful information regarding thoracic pedicle anatomy, but this information is difficult to apply intra-operatively. To avoid neurovascular injury, it is important to determine the correct transverse plane angulation of screw insertion. Methods Two separate investigators reviewed thoracic spine CT scans of 53 patients, 26 years of age or younger. Measurements were taken of the angular relationship of the pedicle and the SAP of T4–T11. A 90° angle was subtended from a line parallel to the SAP with a starting point at the midpoint of the lateral half of the SAP. Measurements were then adjusted laterally for medial breeches and medially for lateral breeches, to align the trajectory down the middle of the pedicle. The degree of correction was recorded. Each investigator made 3 sets of measurements. We calculated kappa values to assess intra-observer/interobserver agreement. Results Of the 4,008 measurements, 95.2% were contained within bone, leaving 4.8% pedicle violations. The average correction made for medial and lateral breeches was 6.3% and 6.7%, respectively. The first rater had 92.6% agreement, and an intra-observer kappa value of 0.57. The second rater had a 95.3% agreement and an intra-observer kappa value of 0.40. Conclusions The results support the hypothesis that the SAP can be a useful external landmark for determining the transverse plane angulation of thoracic pedicle screw insertion.