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Children with sickle cell disease commonly experience vaso-occlusive pain episodes due to sickling of erythrocytes, which often requires care in the emergency department. Our objective was to assess the use and impact of intranasal fentanyl for the treatment of children with SCD-VOE on discharge from the emergency department in a multicenter study. We conducted a cross-sectional study at 20 academic pediatric emergency departments in the United States and Canada. We used logistic regression to test bivariable and multivariable associations between the outcome of discharge from the emergency department and candidate variables theoretically associated with discharge. There study included 400 patients; 215 (54%) were female. The median age was 14.6 (interquartile range 9.8, 17.6) years. Nineteen percent (n=75) received intranasal fentanyl in the emergency department. Children who received intranasal fentanyl had nearly nine-fold greater adjusted odds of discharge from the emergency department compared to those who did not (adjusted odds ratio 8.99, 95% CI 2.81-30.56, P0.001). The rapid onset of action and ease of delivery without IV access offered by intranasal fentanyl make it a feasible initial parenteral analgesic in the treatment of children with sickle cell disease presenting with vaso-occlusive pain episodes in the acute-care setting. Further study is needed to determine potential causality of the association between intranasal fentanyl and discharge from the emergency department observed in this multicenter study. This article is protected by copyright. All rights reserved.

It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis.To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results.Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results.Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count4 × 103 cells/mm3 and procalcitonin0.5 ng/mL.Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.

The objective of this study was to compare contamination rates in urine samples obtained by transurethral catheterization and clean-catch methods in preschool children aged 2 to 5 years.A retrospective, chart review was performed on patients evaluated in our emergency department over a 6-month period who had a urine culture obtained by either transurethral catheterization or clean-catch methods. The charts were reviewed for urine bacterial colony counts and divided into positive, negative, or contaminated cohorts. Demographic data were collected as well.Four hundred sixty patients met inclusion for this study. Of these patients, there were 120 samples collected by catheter (26.1%) and 340 samples collected by clean-catch method (73.9%).Female patients comprised 73% of the eligible samples (n = 336), and 27% were male (n = 124). Contamination rates significantly varied by collection method (P0.0001), with only 9 contaminated catheter samples (7.5%) and 125 contaminated clean-catch samples (36.76%). Contaminated samples were found in 122 of 336 female urine samples (36.3%), and 12 of 124 male urine samples (9.7%). There were no associations found between contamination rates and age within either sex.Our study demonstrated a higher urine culture contamination rate in preschool age children in the clean-catch method group compared with the transurethral catheterization group. This finding was particularly strong within the female subset, which could partially be accounted for by the small male sample size.

Vaso-occlusive pain events (VOE) are the leading cause of emergency department (ED) visits in sickle cell anemia (SCA). This study assessed the variability in use of intravenous fluids (IVFs), and the association of normal saline bolus (NSB), on pain and other clinical outcomes in children with SCA, presenting to pediatric emergency departments (PED) with VOE. Four-hundred charts of children age 3-21 years with SCA/VOE receiving parenteral opioids at 20 high-volume PEDs were evaluated in a retrospective study. Data on type and amount of IVFs used were collected. Patients were divided into two groups: those who received NSB and those who did not. The association of NSB use on change in pain scores and admission rates was evaluated. Among 400 children studied, 261 (65%) received a NSB. Mean age was 13.8 ± 4.9 years; 46% were male; 92% had hemoglobin-SS. The IVFs (bolus and/or maintenance) were used in 84% of patients. Eight different types of IVFs were utilized and IVF volume administered varied widely. Mean triage pain scores were similar between groups, but improvement in pain scores from presentation-to-ED-disposition was smaller in the NSB group (2.2 vs 3.0, P = .03), while admission rates were higher (71% vs 59%, P = .01). Use of NSB remained associated with poorer final pain scores and worse change in pain scores in our multivariable model. In conclusion, wide variations in practice utilizing IVFs are common. NSB is given to >50% of children with SCA/VOE, but is associated with poorer pain control; a controlled prospective trial is needed to determine causality.

Background: Urinary tract infections (UTIs) are the most common serious bacterial infection in young febrile infants, and the urinalysis (UA) is an accurate screening test for emergency department (ED) evaluation. Precise estimates of risk of concomitant bacteremia and/or bacterial meningitis (invasive bacterial infections; IBI) in febrile infants ≤ 60 days have been based on presence of UTIs rather than positive UAs, and lack large prospective study. Objective: We sought to determine the prevalence of IBIs in febrile infants 0-28 …

OBJECTIVES:To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).METHODS:We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.RESULTS:Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%–1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%–3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%–1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained.CONCLUSION:Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Each year, more than 30 million children visit U.S. emergency departments (EDs). Although the number of pediatric emergency medicine specialists continues to rise, the vast majority of children are cared for in general EDs outside of children's hospitals. The diverse workforce of care providers for children must possess the knowledge, experience, skills, and systemic support necessary to deliver excellent pediatric emergency care. There is a crucial need to understand the factors that drive the professional development and support systems of this diverse workforce. Through the iterative process culminating with the 2018 Academic Emergency Medicine consensus conference, we have identified five key research themes and prioritized a specific research agenda. These themes represent critical gaps in our understanding of the development and maintenance of the pediatric emergency care workforce and allow for a prioritization of future research efforts. Only by more fully understanding the gaps in workforce needs, and the necessary steps to address these gaps, can outcomes be optimized for children in need of emergency care.

Pediatric penile pain is an uncommon complaint and is associated with a wide differential diagnosis including infectious, inflammatory, traumatic, and idiopathic conditions. Penile fractures, anatomically known as rupture of the corpus cavernosum, are almost exclusively reported in sexually mature patients and usually involve forceful manipulation during sexual activity. Rupture of the corpus cavernosum is a true urologic emergency. Failure to recognize and treat rupture of the corpus cavernosum has been associated with residual penile angulation, persistent hematoma, abscess, erectile dysfunction, and fibrosis. We present the case of a previously healthy 7-year-old boy who presented to our emergency department with complaints of penile pain with movement after falling and colliding with staircase railing. Examination showed ecchymosis and swelling of the penile shaft; both testicles were palpable and nontender, with no perineal or scrotal bruising. Ultrasound noted discontinuity along the right corpus cavernosum consistent with a rupture of the right corpus cavernosum. Testicles were noted to be in the scrotum with normal Doppler flow. Flexible cystoscopy revealed an uninjured urethra and bladder. Our patient was urgently taken to the operating room for repair of his injury. Thanks to the timely surgical correction, there were no postsurgical complications, and he was discharged home on postoperative day 1. This case demonstrates that although most reports of corpus cavernosum injuries are associated with sexual intercourse, other modes are possible and should be considered for acute-onset penile pain in pediatric patients.

The primary objective of this study was to determine if children with abnormal body mass index (BMI) percentiles for age were admitted to the hospital from the emergency room at greater frequency than normal-weight children. This study also sought to evaluate what specific diagnoses both underweight and overweight children were being admitted with, and if a discrepancy exists.A prospective observational chart review was conducted of children evaluated in the emergency department of the Children's Hospital at the University of Oklahoma during the month of October 2011 (n = 1747). One thousand nine hundred thirteen patient charts were reviewed, but 166 were excluded because of inability to obtain a height or weight within a 3-month period of the child being seen in the emergency department.Thirty-five (24.5%) of underweight patients, 82 (14.6%) of overweight or obese, and 173 (16.6%) of the normal-weight patients were admitted to the hospital from the emergency department. The underweight patients were admitted more frequently than the normal-weight (P = 0.0206) and overweight or obese patients (P = 0.0046). In addition, underweight patients were admitted more frequently with respiratory infections than normal-weight (P = 0.0279) and overweight or obese (P = 0.0509) patients. In addition, underweight patients were admitted more than overweight or obese patients with fractures (P = 0.0278). There was no statistical difference between overweight or obese and normal-weight admissions within any of the diagnostic categories.Underweight children (BMI ≤5%) have an increased risk of hospitalization from the emergency department, even when adjusted for age and sex. In particular, hospitalization among underweight patients was increased for those patients with respiratory infections and fractures. No difference was seen between admission rates of overweight (BMI ≥85%) or obese (BMI ≥95%) patients from those of normal-weight patients. This warrants the need to counsel patients and their families on the dangers not only of obesity, but also of being underweight. Emphasis should be placed on healthy lifestyles that include well-balanced meals and exercise.

Although improvements in managing pediatric gastrointestinal diseases have occurred over time, the use of technical adjuncts to aid in management has greatly improved the survival and quality of life for these patients. This has increased the scope of presenting disorders, unique and challenging adverse effects, complications, and technical difficulties for which emergency care providers must be familiar. This article will include a review of gastrointestinal tubes and their complications and presurgical and postsurgical considerations for gastroschisis, omphalocele, and Hirschsprung disease. In addition, with increasing pediatric survival from organ transplantation, pretransplantation and posttransplantation issues will be discussed, specifically for liver and small bowel transplantation. Pediatric patients with short bowel syndrome are being encountered more frequently and use multiple high technical adjuncts to aid in their survival. These adjuncts, as well as a review of short bowel syndrome, will be discussed.

BACKGROUND: Blood cultures are often obtained in children hospitalized with skin and soft tissue infections (SSTIs). Because little evidence exists to validate this practice, we examined the yield of blood cultures in the evaluation of immunocompetent children with SSTIs. METHODS: Medical records were reviewed for all children admitted between January 1, 2007 and December 31, 2009 after emergency department evaluation and diagnosis of cellulitis or abscess. We compared patients with SSTIs (n = 482) with those with complicated SSTIs (cSSTIs; n = 98). A cSSTI was defined as surgical or traumatic wound infection, need for surgical intervention, or infected ulcers or burns. The SSTI group included patients without complicating factors. RESULTS: None of the patients in the SSTI group had a positive blood culture. In the cSSTI group, 12.5% of blood cultures were positive. The mean length of hospital stay (LOHS) of children with SSTIs was shorter than that of those with cSSTIs (P < .001). In the SSTI group, obtaining a blood culture was associated with a higher mean LOHS (P = .044). CONCLUSIONS: Blood cultures are not useful in evaluating immunocompetent children who are admitted to the hospital with uncomplicated SSTIs, and they are associated with a nearly 1-day increase in mean LOHS.

Background: Pain is the leading cause of hospitalization and pediatric emergency department (PED) visits for children with sickle cell disease (SCD). The National Heart, Lung and Blood Institute (NHLBI) recommends rapid evaluation and treatment of moderate-severe vaso-occlusive pain episodes (VOEs) in the acute care setting, with timely pain assessments and repeat analgesia delivery to control pain. Quality-of-care indicators for children with SCD include the receipt of parenteral analgesia within 30 minutes of triage or 60 minutes of registration, with frequent pain reassessments and re-dosing of opioids within 30 minutes. Objective: To assess adherence to the 2014 NHLBI guideline for VOE management with respect to time to 1st and 2ndparenteral opioid delivery and time to pain assessment and its reassessment frequency in PEDs across the United States and Canada. Methods: A retrospective chart review evaluated 20 consecutive charts per site from 20 high-volume PEDs (n=400 charts total) including 14 Pediatric Emergency Care Applied Research Network (PECARN) sites, assessing children age 3-21 years with SCD/VOE receiving parenteral opioids. Time from arrival and triage/room placement (whichever came first) to 1st and 2ndparenteral opioid administration, and time to pain assessment and reassessment were assessed. Adoption of bedside registration after triage/room placement at many sites decreased the relevance of a 60-minute window from registration; we therefore focused on triage time/room placement and arrival time to determine our quality outcome measures. Results: Annual SCD/VOE volume based on ICD-9 code discharge diagnosis for the 20 PED sites combined was 6082 visits, with an admission rate of 66%. Overall admission rate for the 400 patient chart review was 67%. Mean age of the chart review cohort was 14±5 years, 54% were female, and the majority (92%) had HbSS. Median (IQR) time from arrival to room placement was 4 (0, 10) minutes, while median time from triage/rooming to intravenous (IV) catheter placement was 46 (28, 76) minutes. Median time from triage/room placement to 1st parenteral opioid was 56 (32, 94) minutes; 24% within 30 min, 28% 31-60 min, and 48% >60 min. A total of 46% of patients received parenteral opioids within 60 minutes of ED arrival time. Analysis of children who received two or more opioid doses revealed that only 17% received a 2nd parenteral opioid dose within 30 minutes of their 1st dose. Only 17% of the cohort received both their 1st dose within 30 minutes of triage and 2nd parenteral opioid within 30 minutes of the first. Mean total number of parenteral opioid doses given while in the PED (min-max) was 2.4 (1-13), over a median (IQR) of 5 hours (4, 7) spent in the PED prior to disposition home or to the inpatient ward. Of admitted patients (n=268), 18% received only a single dose of parenteral opioids while in the PED, 30% received 2 doses and 52% received 3 or more doses. Pain assessment scores were documented in 99% of charts, within a median of 3 minutes (0, 12) of triage/rooming, and 89% had documentation of pain reassessment, occurring within a median of 27 minutes (10.0, 52.0) of 1stparenteral opioid delivery. The mean number of pain assessments documented during the PED stay was 5±2. Conclusions:Delays in pain management for children with SCD commonly occur across PEDs, despite NHLBI recommendations for rapid evaluation and treatment of VOEs in the acute care setting. Only a minority of children received rapid parenteral opioid administration defined by the 2014 NIH guidelines, although pain assessment is often performed immediately and with frequent reassessments. Although the majority of patients are rapidly triaged and placed in rooms, children commonly wait 45 minutes or longer for IV placement, which could contribute to delays in delivery of parenteral opioids. This data help identify areas for quality improvement that can be targeted to improve patient care in the future. Disclosures Morris: Nourish Life: Patents & Royalties: I am inventor of IP owned by UCSF Benioff Children's Hospital, Licenced to Nourish Life; Nestle: Honoraria; Calithera: Consultancy; Endeavor: Consultancy; Pfizer: Consultancy; MAST: Research Funding. Dampier:Eli Lilly and Company: Consultancy, Research Funding. Hsu:Pfizer: Consultancy, Research Funding; Hilton Publishing: Consultancy, Research Funding; EMMI Solutions: Consultancy; Purdue Pharma: Research Funding; Gerson Lehman Group: Consultancy; Mast Therapeutics: Research Funding; Centers for Medicare and Medicaid Innovation: Research Funding; Astra Zeneca: Consultancy, Research Funding; Sancilio: Research Funding; Eli Lilly: Research Funding.

Background: Pain is the leading cause of hospitalization and pediatric emergency department (ED) visits for children with sickle cell disease (SCD). The National Heart, Lung and Blood Institute (NHLBI) recommends an initial dose of parenteral opioids within 30 minutes (min) of triage for moderate-severe vaso-occlusive pain episodes (VOEs) in the acute care setting. Delays in pain management for children with SCD commonly occur across EDs despite these guidelines. Intranasal fentanyl (INF) provides rapid and powerful parenteral analgesia, with an onset of action of 5-10 min, and peak in 30 min. INF is a safe and effective method of pain management for children in the ED and other clinical settings. Objective:To assess the use and impact of INF and other common therapies for the treatment of children with SCD and VOE on discharge rates in EDs across the United States and Canada. Methods: A retrospective cohort study was performed evaluating practices in 20 consecutive charts per site from 20 high-volume EDs (n=400 charts total) including 14 Pediatric Emergency Care Applied Research Network (PECARN) sites, assessing children age 3-21 years with SCD/VOE requiring parenteral opioids. Variables evaluated for association with discharge included age, gender, triage level, time from triage/room placement (whichever came first) to 1st parenteral opioid use (intravenous (IV) or intranasal), INF use, dose of total parenteral opioid (TPO) equivalents (mg/kg/hr), ketorolac use, oral opioids, any use of IV fluids (bolus and/or maintenance), ED shift presentation (AM, PM or overnight) and site. Multiple logistic regression was performed using significant variables identified on univariate analysis. Regression analyses were restricted to the 15 sites that had INF available in their ED (n=294 subjects). Results: Mean age of the 400 children was 14±5 years; 54% were female; 92% had HbSS. Admission rate was 67%. All received parenteral opioids; 84% IV fluids, 66% ketorolac, and 26% oral opioids. INF was available at 15/20 sites and used at 10/20 sites; 19% (75/400) of all children received INF, 25% when restricted to the 15 sites with INF available. INF was used in 60% of patients receiving parenteral opioids within 30 min of triage/room placement at sites with INF available. Median time to 1st parenteral opioid in children receiving INF was 25 (26, 37) vs. 64 (38, 102) min (p Conclusions:It is notable that the odds of being discharged from the ED are nearly 3 times higher for patients who received INF compared to those who did not. Contrary to common belief, rapid delivery of first parenteral analgesia, a focus of the 2014 NHLBI guidelines for treatment of SCD/VOE, did not affect risk of admission in our cohort when controlling for other factors, although potential benefits related to pain relief and patient satisfaction were not evaluated. Variations in practice across the network and variables associated with ED discharge rate require further investigation. Causality of INF impact on discharge rates can't be shown without further study, however the rapid onset-of-action and ease of delivery without IV access offered by INF makes it an ideal initial parenteral analgesic in the treatment of children with SCD and pain in the acute care setting. Figure 1 Figure 1. Disclosures Morris: MAST: Research Funding; Pfizer: Consultancy; Calithera: Consultancy; Nourish Life: Patents & Royalties: I am the inventor of IP owned by UCSF-Benioff Children's Hospital that is licensed to NL; Endeavor: Consultancy; Nestle: Honoraria. Dampier:Eli Lilly and Company: Consultancy, Research Funding. Hsu:Gerson Lehman Group: Consultancy; Centers for Medicare and Medicaid Innovation: Research Funding; Astra Zeneca: Consultancy, Research Funding; Sancilio: Research Funding; Purdue Pharma: Research Funding; EMMI Solutions: Consultancy; Mast Therapeutics: Research Funding; Hilton Publishing: Consultancy, Research Funding; Eli Lilly: Research Funding; Pfizer: Consultancy, Research Funding.

Oculomotor nerve palsy is a rare finding in children and, when reported, is most frequently either congenital or acquired from postnatal trauma, infection, aneurysm, or migraine. Intracranial lipomas also represent an uncommon finding in children, and although their development is not completely understood, they are now thought to be congenital in nature. Here, we describe the case of a 23-month-old boy presenting to the emergency department with left-sided, complete, pupil-involving oculomotor nerve palsy. On magnetic resonance imaging, he was found to have an intracranial lipoma of the left interpeduncular fossa. The patient had gradual and spontaneous improvement of symptoms, with complete resolution reported at the 4-month follow-up visit. However, a second magnetic resonance image at 6 months revealed that the lipoma did not change in size. To our knowledge, intracranial lipomas have been previously reported as a possible cause of partial oculomotor nerve palsy in only one adult and have never been reported in a child. In addition, we did not find any reports of intracranial lipomas as a cause of complete, pupil-involving oculomotor palsy, although they are known to cause other cranial nerve pathology. We conclude that intracranial lipomas, although rare, should be considered in the differential diagnosis for oculomotor nerve palsy in children. Further investigation is needed to determine the true incidence of this association.

To determine if the addition of intravenous terbutaline provides any clinical benefit to children with acute severe asthma already on continuous high-dose nebulized albuterol.We conducted a prospective, randomized, double blind, placebo-controlled trial on pediatric patients with acute severe asthma presenting to a large inner city tertiary children's emergency department. Consecutive patients between 2 and 17 years of age who failed acute asthma management and needed intensive care unit admission underwent informed consent and were enrolled into the study. Patients not requiring intubation were randomized to receive either intravenous terbutaline or intravenous normal saline while on continuous high-dose nebulized albuterol, ipratropium bromide, and systemic corticosteroids. Outcome measures included a clinical asthma severity score, hours on continuous nebulized albuterol, and duration of stay in the pediatric intensive care unit. In addition, electrocardiograms, electrolytes, lactic acid, and troponin I levels were obtained at routine intervals during the first 24 hours after admission. Patients who significantly worsened while enrolled in the study received intravenous aminophylline according to protocol.Forty-nine patients were enrolled in the study. Patients on terbutaline had a mean improvement in the clinical asthma severity score over the first 24 hours of 6.5 points compared with 4.8 points in the placebo group (P = 0.073). Patients on terbutaline spent 38.19 hours on continuous nebulized albuterol compared with their placebo counterparts who spent 51.93 hours (P = 0.25). The length of stay in the PICU was on average 12.95 hours longer for those patients in the placebo group as compared with the terbutaline group (P = 0.345). One patient was removed from the study for a significant cardiac dysrhythmia. This patient was in the terbutaline group and recovered without complications. Troponin I values at 12 hours and 24 hours were elevated in 3 patients each, all within the terbutaline group.No outcome measures demonstrated statistical significance. Outcome measures revealed a trend toward improvement in the terbutaline group. Before recommending routine use of intravenous terbutaline for acute severe asthma, further study to determine safety and efficacy is necessary.