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An increasing incidence of newborn emergency department visits in the United States has been documented; this may be due to a higher number of home births and hospital policies directing earlier discharge of newborns from nurseries. Although many of these visits are for benign conditions, it is imperative that the emergency physician know how to manage a critically ill neonate (a newborn in the first 28 days of life). The mnemonic, THE MISFITS, provides a method for remembering many of the serious conditions that present acutely in the neonatal period: trauma (accidental trauma and child abuse), heart disease (structural and nonstructural) and hypovolemia, endocrinopathies, metabolic abnormalities (electrolyte imbalances), inborn errors of metabolism, sepsis, formula mishaps (under- or overdilution), intestinal catastrophes (e.g., necrotizing enterocolitis and midgut volvulus), toxic exposures, and seizures. This chapter provides the essential clinical information for several of these conditions.

The question of how to engender patient trust in a pandemic is not easy to answer, and yet it is a critical question that requires a convincing response. On March 14, 2020, the surgeon general of the United States called for a stop to elective procedures. Ultimately, that led us at Scripps Health to close some clinics to protect personal protective equipment supplies and then furlough staff because of the decrease in patient visits. It soon became evident, however, that patients needed our care more than ever, and we had to pivot to provide the services they needed-but in a very different way. Our team rose to the challenge and quickly redesigned the entire organizational approach to accelerate telehealth services for the convenience of our patients. In the process, we also targeted a patient outreach program to our high-risk patients, which turned out to be an important aspect of our COVID-19 patient care initiative.

Emergency Department (ED) overcrowding and ensuing concern about patients who leave without treatment have become a mounting national concern. In addition, the Centers for Medicaid and Medicare Services released regulatory standards for EDs requiring reporting of time from initial triage to decision to admit, as well as actual time of admission.To implement an improved ED patient flow process.We performed a comparative, pre- and post-intervention ED redesign study evaluating three primary end points between two similar, seasonal time periods.Despite an 11% increase in daily patient volume in 2010, analysis of time to provider pre-ED redesign and post-ED redesign implementation revealed a mean of 126.7 min in 2009 (SD 37.03) vs. a mean of 26.3 min in 2010 (SD 1.17). The p-value was significant at0.001. Overall ED average length of stay (ALOS) in 2009 was 5.5 h (SD 0.68) and 3.6 h (SD 1.16) in 2010, reflecting a mean reduction in ALOS of 1.9 h. The p-value was significant at0.01. The proportion of patients who left without treatment (LWOT) also decreased. The proportion of LWOTs during the 2009 study period was 8.7% (95% confidence interval [CI] 6.14-11.26%), compared to 0.2% (95% CI 0.14-0.36%; p0.005) in the 2010 study period. Although the overall ED-visit Press Ganey patient-satisfaction scores improved during the 2010 study period, the results were not statistically significant (p0.1).Our study demonstrated that a tailored ED redesign process can dramatically decrease the time to provider, ALOS, and LWOT rates.

Although children and infants are likely to be victims in a disaster and are more vulnerable in a disaster than adults, disaster planning and management has often overlooked the specific needs of pediatric patients. We discuss key components of disaster planning and management for pediatric patients including emergency medical services, hospital/facility issues, evacuation centers, family separation/reunification, children with special healthcare needs, mental health issues, and overcrowding/ surge capacity. Specific policy recommendations and an appendix with detailed practical information and algorithms are included.The first part of this three part series on pediatric issues in disaster management addresses the emergency medical system from the field to the hospital and surge capacity including the impact of crowding. The second part addresses the appropriate set up and functioning of evacuation centers and family separation and reunification.The third part deals with special patient populations: the special healthcare needs patient and mental health issues.

Infectious disease outbreaks, epidemics, and subsequent pandemics are not typical disasters in the sense that they often lack clearly delineated phases. As in any event that is biological in nature, its onset may be gradual with signs and symptoms that are so subtle that they go unrecognized, thus missing opportunities to invoke an early response and implement containment strategies. An infectious disease outbreak—whether caused by a novel virus, a particularly virulent influenza strain, or newly emerging or resistant bacteria with the capability of human-to-human transmission—can quickly degrade a community’s healthcare infrastructure in advance of coordinated mitigation, preparation, and response activities. The Transitional Medical Model (TMM) was developed to aid communities with these crucial phases of disaster response as well as to assist with the initial steps within the recovery phase. The TMM is a methodology that provides a crosswalk between the routine operations and activities of a community’s public health infrastructure with action steps associated with the mitigation, preparedness, response, and recovery phases of an infectious disease outbreak.

Although children and infants are likely to be victims in a disaster and are more vulnerable in a disaster than adults, disaster planning and management has often overlooked the specific needs of pediatric patients. We discuss key components of disaster planning and management for pediatric patients including emergency medical services, hospital/facility issues, evacuation centers, family separation/reunification, children with special healthcare needs, mental health issues, and overcrowding/surge capacity. Specific policy recommendations and an appendix with detailed practical information and algorithms are included. The first part of this three part series on pediatric issues in disaster management addresses the emergency medical system from the field to the hospital and surge capacity including the impact of crowding. The second part addresses the appropriate set up and functioning of evacuation centers and family separation and reunification. The third part deals with special patient populations: the special healthcare needs patient and mental health issues.

Objectives To evaluate the time of onset and recovery from and the efficacy and safety of intravenous ketamine-propofol sedation for reduction of forearm fractures in the pediatric emergency department setting. Study design Prospective, observational pilot study. Methods Children presenting to an urban pediatric emergency department requiring sedation for closed reduction of forearm fractures received ketamine 0.5 mg/kg and propofol 1 mg/kg. We measured time intervals from drug administration to reduction, recovery, and attainment of discharge criteria, and obtained ratings of depth of sedation, pain, and ease of reduction. A follow-up survey elicited patient recall, parental satisfaction, and delayed complications. Complications were recorded during the procedure and by chart review. Results Reduction was successful in 19 of 20 patients with one requiring open reduction. Median time intervals measured from initiation of ketamine injection were 5 minutes to reduction completion, 10 minutes to first purposeful response, and 38 minutes to suitability for discharge. Three patients recalled reduction or casting, but in no case was reduction reported to be the most painful aspect of visit. Emergency physicians and orthopedic residents rated sedation and ease of reduction favorably. Complications included mild hypoxia, vomiting, and transient ataxia. No apnea, hemodynamic compromise, dysphoria, or injection pain occurred. Conclusions In this pilot study, the combination of ketamine and propofol provided effective sedation with rapid recovery and no clinically significant complications for children requiring closed reduction of forearm fractures.

In 2005, the American Heart Association updated the guidelines for newborn and pediatric resuscitation. These changes are now being taught in the current Basic Life Support and Pediatric Advanced Life Support classes. This article reviews the pertinent new changes in caring for the critically ill child.

Apparent life-threatening events are an ongoing diagnostic dilemma for clinicians. Since most apparent life-threatening event episodes occur in infants under 6 months of age, they can generate considerable anxiety in parents and providers. This review will discuss issues to consider in the evaluation of infants after an apparent life-threatening event. To ensure proper management, a systematic approach should be taken to attempt to determine the cause of the event.More recent literature suggests that infants with apparent life-threatening events frequently present without signs or symptoms of illness. Obtaining a careful history and physical examination is essential in determining the cause of the event. In this article, we will review the most current literature and discuss the American Academy of Pediatrics new recommendations on sudden infant death syndrome prevention.After a careful review of the literature, prone sleeping is one of the biggest risk factors for sudden infant death syndrome. The association between apparent life-threatening events and sudden infant death syndrome remains to be explored further, but current evidence suggests minimal risk after an apparent life-threatening event episode. This article will help clinicians prepare for this difficult challenge by providing up-to-date information and identifying problems to be addressed in future research.

Emergency department (ED) discharge is safe when croup-related stridor has resolved after corticosteroids and a single dose of racemic epinephrine (RE). Little evidence supports the traditional practice of hospital admission after ≥ 2 doses of RE.Our aim was to describe the frequency and timing of clinically important inpatient interventions after ≥ 2 ED RE doses.We identified patients hospitalized for croup after ED treatment with corticosteroids and ≥2 doses of RE. We compared asymptomatic (admitted solely on the number of RE doses) and symptomatic (admitted due to disease severity) groups with regard to inpatient RE administration, supplemental oxygen, helium-oxygen mixture (heliox) therapy, intubation, or transfer to a higher level of care, time to hospital discharge, and revisit and readmission rates within 48 h of discharge.Of 200 subjects admitted after ≥ 2 ED RE doses, 72 (36%) received clinically important inpatient interventions: RE (n = 68 [34%]), heliox (n = 9 [5%]), and supplemental oxygen (n = 4 [2%]). Of patients who received inpatient RE, 53% received only 1 dose. No patients underwent intubation or transfer to higher level of care. The 112 asymptomatic patients had fewer interventions (14% vs. 63%; p0.001) and shorter hospital durations (14.5 vs. 22 h; p0.001). Only 14% of the asymptomatic group received RE, with 75% receiving a single dose. There were no differences in revisit and readmission rates.Inpatient interventions after ≥ 2 ED doses of RE for croup were infrequent, most commonly RE administration. Most patients asymptomatic upon admission require 0-1 inpatient RE doses and may be candidates for outpatient management.

Seizures are the most common pediatric neurologic disorder. Four to ten percent of children suffer at least one seizure in the first 16 years of life. The incidence is highest in children less than 3 years of age, with a decreasing frequency in older children. Epidemiologic studies reveal that approximately 150,000 children will sustain a first-time unprovoked seizure each year, and of those, 30,000 will develop epilepsy. This article describes the types, diagnoses, and management and disposition of this pediatric neurologic disorder.

The evaluation and appropriate management of the critically ill neonate requires knowledge of the physiologic changes and life-threatening pathologies that may present during this time period. A broad systematic approach to evaluating the neonate is necessary to provide a comprehensive yet specific differential diagnosis for a presenting complaint or symptom. Efficient recognition and prompt management of illness in the neonatal period may be life saving. Recently, it has become more important for the emergency department physician to be familiar with the neonate because of early discharge policies. This review provides a systematic approach to the recognition, emergency stabilization, and management of the more common newborn emergencies.

Arrhythmias in children are less common than in adults but are increasing because of successful repair of congenital heart diseases. Supraventricular tachycardia is the most common symptomatic pediatric tachyarrhythmia. Atrial flutter and atrial fibrillation in children are attributed largely to structural heart disease. Bradycardia is defined as a heart rate less than the lower limit of normal for a child's age, and the most common cause is sinus bradycardia. Despite the infrequent occurrence of arrhythmias, it is crucial to expeditiously identify and treat certain rhythm abnormalities because they can lead to further decompensation.

Abdominal pain and gastrointestinal symptoms such as vomiting or diarrhea are common chief complaints in young children who present in emergency departments. It is the emergency physician's role to differentiate between a self-limited process such as viral gastroenteritis or constipation and more life-threatening surgical emergencies. Considering the difficulties inherent in the pediatric examination, it is not surprising that appendicitis, intussusception, and malrotation with volvulus continue to be among the most elusive diagnoses. This article reviews both the self-limited and more life-threatening gastrointestinal conditions that may present in the emergency department.

The care of children is an integral aspect of emergency medicine. This article reviews the many important contributions that emergency physicians have made in advancing the acute care of children.

Coins are the most commonly encountered foreign body ingestions presenting to the emergency department (ED). The purpose of our study was to retrospectively evaluate a new institutional protocol implemented in 1998, in which healthy patients with acute (less than 24 h) coin ingestions located below the thoracic inlet, were observed at home with next-day follow-up. If repeat radiographs revealed a persistent esophageal foreign body, then the coin was removed.The charts of all patients who presented to the ED with a complaint of esophageal foreign body were reviewed from 1 January 1998 until 31 December 2001. Patients were excluded if they had non-acute ingestions, known esophageal pathology, severe symptoms such as stridor or inability to tolerate oral fluids, or incomplete records.Of 31 patients with esophageal coin ingestions, 16 had coins above the thoracic inlet. Three of these patients were asymptomatic and all experienced spontaneous coin passage into the stomach within 2 h of ED presentation while awaiting coin removal. There were eight eligible patients with coins located below the thoracic inlet. Three of five patients with mid-esophageal coins experienced spontaneous coin passage while the remaining two required coin removal on next-day follow-up for persistent esophageal coins. Three of three patients with distal-esophageal coin ingestions experienced spontaneous coin passage. There were no complications in any of the patients who underwent delayed coin removal either due to the procedure itself or to a delay in therapy.Patients with acute esophageal coin ingestions may experience spontaneous coin passage and therefore, patients with coins located below the thoracic inlet with minor symptoms may be candidates for next-day follow-up. If repeat radiographs reveal a persistent esophageal coin, then the coin should be immediately removed. Furthermore, asymptomatic patients with coins above the thoracic inlet should undergo repeat radiographs in 2-5 h, as spontaneous coin passage may occur. Our protocol may also be more convenient and cost-effective as patients can be observed at home.

Surgical emergencies can be missed easily in children, who are not always able to volunteer relevant information. Awareness of the entities discussed in this review might help the EP uncover subtle clues to early diagnoses that might not be initially apparent. Ill-appearing children who have abdominal pain and vomiting should be considered to have ischemic or necrotic bowel until proven otherwise. Possible diagnoses include volvulus, intussusception, and necrotizing enterocolitis. Bilious vomiting, especially in a young infant, should be considered to be an indication of a high bowel obstruction such as midgut volvulus, which warrants immediate surgical consultation. Significant rectal bleeding with abdominal pain can result from intussusception, volvulus, or an inflamed Meckel's diverticulum. Rectal bleeding with unstable vital signs can result from an upper GI bleed (eg, peptic ulcer disease). Painless rectal bleeding can result from a Meckel's diverticulum, polyps, arteriovenous malformation, or a tumor. Examination of the genitalia is imperative, especially in boys, to exclude the possibility of an incarcerated hernia or testicular torsion.

Fever is a common pediatric complaint in the Emergency Department. Emergency Physicians often must be conservative in their management of febrile children, as patient follow-up is not always available. A unified approach for the management of febrile infants will be discussed in this article.

Study objectives: We confirm the ability of the self-inflating bulb to indicate endotracheal tube position in children and determine which method of bulb compression is more accurate. Methods: This single-blind, prospective, single cohort, repeated measures comparison of the on-deflate and the off-deflate methods of bulb compression was conducted in the operating room of a children's hospital. Seventy-five patients weighing more than 20 kg were enrolled. All patients had an endotracheal tube placed in both the trachea and the esophagus, 5 mL/kg of air was insufflated into the stomach, and 4 measurements were obtained on each patient. The bulb was either applied to the endotracheal tube and then compressed (on-deflate method), or compressed before its attachment to the endotracheal tube (off-deflate method). The order in which the methods were utilized was determined by a computer-generated permuted block randomization scheme. The blinded assessor told the anesthesiologist when to start and stop the clock after each intervention. Five seconds was used as the cut-off time for which the clock was stopped. If the bulb reexpanded within 5 seconds, then the tube was considered to be in the trachea; if it did not reexpand, then this was considered to be an esophageal intubation. Results: The mean patient age was 11 years. The on-deflate method had a sensitivity of 99% and a specificity of 92% for detecting tracheal intubations. The off-deflate method had a sensitivity of 99% and a specificity of 100% (95% confidence interval [CI] for the difference between methods: sensitivity −6 to 6, specificity −14 to 0.4). The inaccuracy rate for the off-deflate method was 1%, whereas the inaccuracy rate for the on-deflate method was 5% (Δ4; 95% CI 0.2 to 9). Conclusion: The self-inflating bulb is a reliable method of detecting endotracheal tube position in children. Furthermore, the off-deflate method may be more reliable and accurate than the on-deflate method when used in children weighing more than 20 kg. [ Ann Emerg Med. 2003;41:623-629.]

Prolonged QT syndrome may be either congenital, as in Jervell and Lange-Nielsen or Romano-Ward syndromes, or acquired in nature. Affected children are at risk for syncope, seizures, dysrhythmias and sudden death. Physicians should consider long QT syndrome (LQTS) in all patients who present with syncope. A thorough personal and family history should be documented, with particular attention to prior syncopal episodes, congenital deafness, and unexplained sudden death. Syncope that is either recurrent or induced by exercise or stress is concerning and also should be noted. An electrocardiogram with manual calculation of the QT interval should be performed on all patients with a suggestive history. Furthermore, the diagnosis of LQTS warrants evaluation of all other family members. With recognition and appropriate treatment of affected patients, the potentially fatal consequences of LQTS may be prevented.

OBJECTIVES This article aimed to study the impact of a rapid medical assessment (RMA) program on patient flow and left without being seen (LWBS) rates in a pediatric emergency department (ED). RMA is designed to evaluate and discharge uncomplicated patients quickly or initiate diagnostic workup and treatment before the patient is placed in an ED bed. METHODS Rapid medical assessment was initiated January 1, 2008 with an assigned midlevel provider. We compared 6 months of data from January 1 to June 30, 2007 (pre-RMA), to January 1 to June 30, 2008 (post-RMA). Data studied were obtained from a tracking system and include the time to provider, ED length of stay, and the LWBS rate. t Test was used to compare results, and χ test was used to compare LWBS rates. RESULTS During the study period, there were 28,360 patients seen in 2007 and 32,053 in 2008. Time to provider mean time was 80 minutes (median = 57) in 2007 and 53 minutes (median = 39) in 2008, with a difference of 27 minutes (95% confidence interval, 25-28 minutes). Mean length of stay in 2007 was 239 minutes (median = 220) compared to 181 minutes (median = 162) in 2008, with a difference of 58 minutes (95% confidence interval, 56-60 minutes). The LWBS rate decreased from 9% in 2007 to 3% in 2008 (χ P < 0.01). CONCLUSIONS Rapid medical assessment is an effective way to improve patient flow and reduce the LWBS rate. A decrease in the LWBS rate allows the ED to provide health care to these potentially high-risk patients.

Visits to the emergency department (ED) by neonates and their parents can cause anxiety for parents and the ED staff. Many of the presenting complaints are unique to the neonatal population, and an understanding of both common problems and true medical emergencies is paramount. This article discusses the complaints the EDs have seen more frequently as a result of earlier newborn discharges from hospitals.

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.

Introduction: The objectives of this study were to (a) evaluate the emergency department management of pediatric patients with bleeding disorders, specifically regarding time intervals from triage to administration of replacement therapy, and (b) to review resultant patient outcomes. Methods: A retrospective review was performed of charts from June 1996 to June 1998 for all patients with known bleeding disorders whose course was followed by the hematology clinic. Records were reviewed for all emergency department visits that required replacement therapy. Time intervals from triage to initiation of therapy were evaluated. Results: Eleven of 24 patients required administration of factor or desmopressin acetate. The mean time from triage to therapy administration was 103 minutes (range, 7 to 175 minutes; SD ± 38). The mean time from triage to placement in a room was 34.3 minutes (SD ± 32.6). The mean time to order replacement therapy was 26.7 minutes (SD ± 27.4). The mean time from physician evaluation to administration of replacement therapy was 34.2 minutes (SD ± 15.9). These intervals were believed to be suboptimal, and a new nursing driven protocol was established to expedite patient care. Discussion: Simple delays in time to replacement therapy may result in increased patient morbidity. We present an easy-to-follow algorithm that can be implemented to expedite the care of pediatric patients with a known bleeding disorder. J Pediatr Health Care. (2001). 15, 10-13.

Children represent our greatest and most vital resource. As such, the need for quality emergency care is an ever-expanding aspect of medicine. Over the last 20 years, significant advances and improvements have occurred in the delivery of emergency care to children, including emergency medicine residency training in pediatric emergencies, pediatric trauma care, pain management for children, pediatric drug dosages, pediatric equipment/supplies in emergency departments and on ambulances, and a national poison control system [1]. Even with these great strides, the practice of pediatric emergency medicine continues to evolve. This issue of Pediatric Clinics of North America is the second of two issues this year dedicated to state-of-the-art information regarding the emergency care of children. Current areas of interest, clinical practice, and controversy are addressed. Exposures to drugs and toxins in the pediatric age group constitute most calls to United States regional poison centers. Several common drugs and toxins can result in potentially deadly ingestions with one or two doses in children. This edition of the Clinics discusses several of these deadly ingestions. Procedural sedation and analgesia is a safe, effective, and humane method of managing the pain and anxiety of a child who presents with a painful condition or situation that requires a painful intervention. This issue also discusses an approach to pediatric sedation and analgesia. Fever remains one of the most common chief complaints of children who seek medical attention, and it resulted in more than 5 million

With the passage of the Affordable Care Act, increased emphasis has been placed on optimizing quality and reducing expenditures. The use of an emergency department case manager (EDCM) is reemerging as an important initiative in the quest to provide high-quality care and decrease unnecessary hospital admissions. A pilot study of the use of EDCMs was conducted in one of the authors' EDs during a 6-month trial period. By using evidence-based criteria, the EDCM helped in real time to verify admission criteria, assisted with inpatient versus outpatient designation, found community alternatives to hospital admission, and initiated discharge planning for patients who required admission and were at high risk for readmission. EDCMs also worked with pharmacists to assist with medication management for patients who required assistance with obtaining prescriptions. Because of the pilot study's success, the authors' health care system will be implementing EDCMs throughout the organization.

Introduction: This study aims to characterize the population of patients presenting to a pediatric emergency department (ED) for a first complex febrile seizure, and subsequently assess the rate of acute bacterial meningitis (ABM) occurrence in this population. Furthermore, this study seeks to identify whether a specific subset of patients may be atlesser risk for ABM or other serious neurological disease. Methods: This retrospective cohort study reviewed the charts of patients between the ages of 6 months to 5 years of age admitted to an ED between 2005 and 2010 for a first complex febrile seizure (CFS). The health information department generated a patient list based onadmission and discharge diagnoses, which was screened for patient eligibility. Exclusion criteria included history of a complex febrile seizure, history of an afebrile seizure, trauma, or severe underlying neurological disorder. Data extracted included age, gender, relevant medical history, descriptions of seizure, treatment received, and follow-up data. Patientspresenting with two short febrile seizures within 24 hours were then analyzed separately to assess health outcomes in this population. Results: There were 193 patients were eligible. Lumbar puncture was performed on 136 subjects; it was significantly more likely to be performed on patients that presented with seizure focality, status epilepticus, or a need for intubation. Fourteen patients were found tohave pleocytosis following white blood cell (WBC) count correction, and 1 was diagnosed with ABM (0.5% [95% confidence interval: 0.0–1.5, n = 193]). Forty-three patients had 2 brief febrile seizures within 24 hours. Of the 43, 17 received lumbar puncture while in the ED. None of these patients were found to have ABM or other serious neurological disease. Conclusion: ABM is rare in patients presenting with a first complex febrile seizure. Patients presenting only with 2 short febrile seizures within 24 hours may be less likely to have ABM, and may not require lumbar puncture without other clinical symptoms of neurological disease. [West J Emerg Med. 2013;14(3):206–211.]

Pseudotumor cerebri is a difficult diagnosis to establish. Neurologic symptoms may be lacking, and the patient most often reports headache and vomiting, two rather nonspecific symptoms. A high index of suspicion must be maintained to detect this disorder. We present the case of an adolescent boy whose chief complaint was persistent headache and vomiting. His final diagnosis was pseudotumor cerebri and hypercalcemia resulting from vitamin A toxicity. [Sharieff GQ, Hanten K: Pseudotumor cerebri and hypercalcemia resulting from vitamin A toxicity. Ann Emerg Med April 1996;27:518-521.]

Objectives: 1) To assess performance and comfort level with cardiopulmonary resuscitation (CPR), foreign body removal (FBR), and seizure management in foster parents of medically fragile children; 2) To determine if the parents' performance and comfort levels increase with an individual teaching session with a medical professional to review CPR and FBR. Methods: In this single cohort pilot study, 18 foster parents of medically fragile children were asked to rate their comfort level with pediatric CPR and FBR on a 5-point scale (1 = very uncomfortable, 5 = very comfortable). They then underwent five mock code scenarios and were evaluated using a 5-point scale (1 = poor performance, 5 = outstanding performance). A 6-month follow-up evaluation using similar scenarios was conducted. Results: At visit 1, the percentage of parents demonstrating adequate performance of CPR, FBR, and seizure management was: I) CPR: infant (78%); child (78%); 2) Foreign body removal: age 1 year (65%); 3) Seizures (94%). At visit 2, performance improved in all areas, especially FBR, where the percentage of parents demonstrating adequate performance increased to 71% for children 1 year. As measured by the 5-point scales, CPR and FBR performance and parent comfort level with CPR improved significantly (Wilcoxon signed-ranks test, P < 0.004), but parent comfort level with FBR did not (P = 0.12). Conclusions: Based on this pilot study, foster parents of medically fragile children benefit from an individual teaching session by a medical professional. CPR instruction for this group of foster parents should include adequate review and assessment of foreign body removal procedures.

Most well-appearing children who have had an afebrile seizure can be managed as outpatients with instructions for an outpatient electroencephalogram and primary care physician follow-up. Laboratory studies are needed only in children younger than 6 months, in patients with prolonged seizures or altered level of consciousness, or in those with history of a metabolic disorder or dehydration. Emergent neuroimaging is not recommended in children with a first unprovoked afebrile seizure, although studies should be considered in children with a predisposing condition or focal seizures if younger than 3 years.

Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicine's report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems' administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Children's National Medical Center, Family Voices, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.

Objective: To determine the accuracy of portable bedside fluoroscopy in documenting postreduction fracture alignment in the pediatric emergency department (ED). Design/Setting: Prospective trial in an urban pediatric ED. Participants: Convenience sample of 80 pediatric patients requiring ED reduction of isolated long bone fractures. Methods: Patients who underwent closed fracture reduction using portable fluoroscopic guidance (FluoroScan) in the ED were enrolled in the study. Postreduction images were obtained using both bedside fluoroscopy and conventional radiographs. A pediatric orthopedic subspecialist, blinded to clinical outcome, reviewed the fluoroscopic and radiographic images for adequacy of alignment and rated the utility of conventional radiography for fracture management. Results: The patients were 2.5 to 16 years of age (mean 8.3). Distal radial and radioulnar fractures comprised 96% (76/80) of cases. Sixty-three percent of the fractures were displaced, and the mean angulation of the primary fracture site was 24°. Fluoroscopy was found to be 100% sensitive (75/75 cases) and 100% specific (5/5 cases) in predicting postreduction fracture position when compared to conventional radiographs. Intrarater observer agreement on the necessity of conventional postreduction radiographs was 0.92 (95% CI 0.82-1.00) using the kappa coefficient. In no case did postreduction radiographs alter acute fracture management. Conclusions: Bedside fluoroscopy with printed fluoroscopic images are highly reliable in evaluating fracture reduction and can replace conventional radiography in documenting adequate distal forearm fracture reduction when there is no intraarticular involvement.

Background: Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain. Objective: To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis. Discussion: The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported. Conclusions: In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.

Pediatric respiratory infections are a common presenting complaint to the emergency department. This article discusses the presentation and management of infectious conditions, including bacterial tracheitis, bronchiolitis, croup, epiglottitis, pertussis, pneumonia, and retropharyngeal abscess.

Interpretation of pediatric electrocardiograms (ECGs) can be challenging for the Emergency Physician. Part of this difficulty arises from the fact that the normal ECG findings, including rate, rhythm, axis, intervals and morphology, change from the neonatal period through infancy, childhood, and adolescence. These changes occur as a result of the maturation of the myocardium and cardiovascular system with age. Along with these changes, up to 20% of pediatric ECGs obtained in the acute setting may have clinically significant abnormal findings. This article will discuss the approach to the interpretation of ECGs in children, the age-related findings and alterations on the normal pediatric ECG, and those ECG abnormalities associated with pediatric cardiac diseases, including the variety of congenital heart diseases seen in children.