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A cross-sectional, retrospective review of consecutive patients who presented to 1 of 2 pediatric emergency departments with post-tonsillectomy hemorrhage was undertaken. The study population included children who had secondary hemorrhage (bleeding at greater than 24 hours after tonsillectomy). Over a period of 2 years, 90 children received emergency care for secondary post-tonsillectomy hemorrhage. The average age was 8.5 years and there were 40 (44%) males. The average time from tonsillectomy to emergency department (ED) presentation was 7.3 days. One patient was hypotensive, and 7 had hemoglobins <10 mg/dL. Signs of bleeding on examination of the tonsillar fossa were active (4), oozing (18), clots (48), and none (14). Of the 70 children with signs of bleeding, 63 (90%) were treated surgically and 7 (10%) were observed. Four (6%) of the 63 children who had signs of bleeding and were managed surgically and 3 (43%) of the 7 children who had signs of bleeding and were managed by observation had repeat episodes of bleeding. Of the 14 patients with no signs of bleeding, all were observed and none had repeat episodes of bleeding. Signs of bleeding were not documented in 6 patients. Active hemorrhage and cardiovascular compromise were uncommon in this study population. Surgical management is recommended for children who have signs of bleeding, while observation appears to be appropriate for children who have no signs of bleeding. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine variables predictive of abnormal comprehensive metabolic panel (CMP) results in pediatric emergency department (PED) patients and the potential cost savings of a basic metabolic panel (BMP) versus a CMP., Methods: This is a retrospective cross-sectional descriptive study of children (<18 y) at an urban academic PED (annual census, 22,000). Clinical data included 12 clinical variables: right upper quadrant pain, overdose, emesis, liver disorder, malignancy, heart disease, bleeding disorder, jaundice, right upper quadrant tenderness, hepatomegaly, ascites/peripheral edema and shock, and the liver function test (LFT) results not in a BMP (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, total protein, and albumin)., Results: There were 207 children in the study population. The mean age was 8 years. There were 106 boys (51%).Variables significantly associated with abnormal LFT result were history of liver disease (P = 0.007), history of heart disease (P = 0.040), jaundice (P = 0.045), and hepatomegaly (P = 0.048). The false-negative rate was 16%. However, of the 10 patients for whom this false-negative rate remained true, the LFT values were marginally abnormal, and performance of further investigation of these results was minimal to none. There were 66 patients with no clinical variables and normal CMP results. With a cost difference of $21 between BMP and CMP, this gives a potential savings of $7125 if extrapolated for 1 year in our PED., Conclusions: Limiting testing to a BMP for patients with none of the 12 clinical variables has the potential annual cost savings of $7125.

Background: Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes., Objectives: We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets., Methods: We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates., Results: There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates., Conclusions: An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Greater attention to and management of anxiety and pain in pediatric patients signifies a healthy evolution in the care of children in emergency departments (EDs). Interventions to address such distress may involve unanticipated adverse effects. Midazolam, a benzodiazepine commonly administered to children for anxiolysis, may precipitate paradoxical agitation and delirium, a rare but alarming effect that warrants prompt identification and treatment., Case Report: The case presented is that of a 4-year-old girl who received oral midazolam and developed a paradoxical reaction, which was reversed successfully with flumazenil. This is the first such case report in an ED involving a child. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must stay abreast of the adverse and unintended effects of the treatments provided. The literature on benzodiazepine-induced paradoxical reactions is reviewed, and flumazenil as well as other treatment options and anxiolytic alternatives are presented., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Skin and soft-tissue infections (SSTIs) are common disease presentations to the emergency department (ED), with the majority of the infections attributed to community-acquired methicillin-resistant Staphylococcus aureus. Rapid and accurate identification of potentially serious SSTIs is critical. Clinician-performed ultrasonography (CPUS) is increasingly common in the ED, and assists in rapid and accurate identification of a variety of disease processes., Case Report: A 21-year-old female presented to the ED with chin swelling and "boils." Although her visual examination was benign, CPUS of her facial swelling quickly established a more concerning disease process, which was eventually confirmed by aspiration and bone biopsy to be mandibular osteomyelitis. The causative organism, Serratia odorifera, is rarely associated with infections, and we are aware of no previously reported cases of osteomyelitis due to this species. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case of mandibular osteomyelitis, CPUS rapidly and accurately identified abnormal bony cortex of the mandible and an associated fluid collection. CPUS of an otherwise benign presentation of a facial infection led to a maxillofacial computed tomography scan, aspiration and biopsy, and then elective debridement of the bone infection. Emergency physicians should be aware of the utility of CPUS and the need to carefully investigate SSTIs presenting to the ED., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To describe a tertiary care pediatric emergency department (PED) experience with bougienage for esophageal coins., Methods: This was a large retrospective case series of children with esophageal coins presenting to a tertiary PED from January 2004 to October 2012. Bougienage eligibility criteria were medically stable, no prior gastro-esophageal surgery or disease, single coin, and witnessed ingestion within 24 hours. Abstracted data were age, signs and symptoms, coin type, management, efficacy, complications, returns, length of stay (LOS), and hospital charges. Main outcomes included procedural success and complications. Secondary outcomes included LOS and hospital charges., Results: There were 245 patients with esophageal coins with 136/145 (94%) successful bougienage procedures and 109/109 (100%) successful surgical retrievals. There were 18 minor complications and 5 return visits for patients with bougienage. There were 10 minor and 2 major complications with surgical retrieval. Patients undergoing bougienage were 4 years (SD 2) vs 3 years (SD 3) for surgical retrieval (P < 0.001). Mean LOS for successful bougienage was 137 minutes (SD 54) vs 769 (SD 535) for surgical retrieval. The difference in the means was 632, 95% CI for the difference in means of -723 to -541 (P < .001). Mean charges for successful bougienage were $984 (SD $576) vs. $7022 (SD $3132) for surgical retrieval. The difference in means was $6038, 95% CI -$6,580 to -$5,496 (P < .001)., Conclusions: Esophageal bougienage is safe and highly effective. It is also more time and cost efficient than other treatment options., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To determine the effectiveness of a medicolegal lecture on risk-reduction documentation by residents in a pediatric emergency department., Design/methods: Pediatric residents at an academic children's hospital were offered a 1-hour lecture on reducing medicolegal risks. Residents in attendance made up the intervention group (IG) and nonattendants were the control group (CG). The primary outcome was risk-reduction documentation (RRD) using patients with chief complaints of abdominal pain, extremity fractures, and lacerations with potential foreign body., Results: For abdominal pain patients, RRD by IG improved 6.1% compared with 15.1% for the CG. For fracture patients, RRD by IG improved 20% compared with 26.5% decrease by CG. For laceration patients, RRD by IG decreased 20.8% compared with 30.6% decrease by CG. Although none reached statistical significance, the postintervention IG rates were greater., Conclusions: We showed a trend toward improvement in the rate of risk-reduction medical record documentation.

Objective: The objectives of this study were to highlight the intimate role that cognitive biases play in clinical decision making in the pediatric emergency department and to recommend strategies to limit their negative impact on patient care outcomes., Methods: This was a descriptive study of 3 cases of presumed asthma exacerbation evolving into alternate diagnoses., Results: The role cognitive biases played in either delay to diagnosis or missed diagnosis contributing to patient morbidity are illustrated in each case., Conclusions: Common cognitive biases play a role in the unique milieu of the pediatric emergency department. A case series of presumed patients with asthma illustrates how mental shortcuts (heuristics) taken in times of high decision density and uncertainty may lead to diagnostic errors and patient harm. Suggestions to address and prevent cognitive biases are presented.

Cerebral sinovenous thrombosis (CSVT) is a pediatric stroke syndrome that occurs uncommonly in association with a number of common pediatric problems, most notably dehydration and infection-otitis media in older children, in particular. Cerebral sinovenous thrombosis involves considerable risk of morbidity and mortality. In the pediatric population, neonates are most commonly affected, but no age group is spared. The clinical manifestations of CSVT vary across age groups and include headache, nausea/vomiting, diplopia, seizures, altered mental status, cranial nerve palsies, and papilledema. Neuroimaging is critical to establishing the diagnosis, and although a variety of modalities are available, the diagnosis is most convincingly made via magnetic resonance imaging with venographic sequencing. Management of CSVT combines medical and surgical approaches and should occur in a multidisciplinary pediatric hospital setting. Anticoagulation is a controversial but generally recommended element of CSVT treatment. Prognosis is related to the extent of vessel and brain parenchymal involvement as well to timeliness of diagnosis and institution of therapy. Long-term follow-up should involve pediatric neurology and ophthalmology and, whenever indicated, rehabilitational therapy as well.

Study Objective: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events., Methods: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events., Results: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route., Conclusion: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Study Objective: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies., Methods: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events., Results: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation., Conclusion: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Objective: To determine the effectiveness of temporal artery thermometry (TAT) as an alternative for temperature assessment of children 1 to 4 years of age in the pediatric emergency department., Methods: Prospective cross-sectional study conducted at an urban children's hospital emergency department. TAT and rectal temperatures are compared in a convenience sample of children 1 to 4 years of age. Comparison of the temperatures is performed using Pearson correlation coefficient and regression analysis., Results: TAT and rectal temperatures are measured in 42 children 1 to 4 years of age. TAT predicts 83% of rectal temperatures. A receiver operating characteristic curve analysis shows that a cutoff of 37.7 degrees C or greater for fever in TAT is equivalent to rectal temperature greater than or equal to 38.3 degrees C with 100% sensitivity and 93.5% specificity., Conclusion: TAT is an effective screening tool in identifying fever in children 1 to 4 years of age.

Aspirated or swallowed coins are a common phenomenon resulting in a pediatric patient presenting to the Emergency Department. The location of the coin (trachea vs. esophagus) is commonly determined by the alignment of the coin on radiographic studies. We present a child who had an esophageal coin but radiographic findings that supported a coin located in the trachea. Our case illustrates the importance of performing radiographic studies that include both anteroposterior and lateral neck/chest views in patients who aspirate or swallow coins.

Childhood obesity has become a pandemic health care problem. A complication of childhood obesity is type 2 diabetes mellitus which has increased 10-fold in the past 20 years. A serious complication of type 2 diabetes mellitus is hyperglycemic hyperosmolar syndrome (HHS). The following case is an obese adolescent boy with a newly diagnosed HHS. The demographic and clinical characteristics of our case and those of 17 other cases from recently published small case series are presented. Of the 18 cases, there were 13 deaths (72%). The purpose of this report and literature review is to emphasize the importance of early diagnoses and treatment of pediatric HHS.

A study was done to estimate the prevalence of hypoglycemia among children with dehydration due to acute gastroenteritis, and to identify clinical variables associated with hypoglycemia in these children. A retrospective case series of children older than 1 month of age and younger than 5 years of age who presented to an urban children's hospital Emergency Department with acute gastroenteritis and dehydration was performed. Medical records were reviewed; demographic and clinical data, including pretreatment serum glucose concentrations, were recorded. There were 196 children comprising the study population. Eighteen children (9.2%) were hypoglycemic. The duration of vomiting was longer for the children with hypoglycemia (2.6 days, SD +/- 1.5) than for those without hypoglycemia (1.6, SD +/- 1.8), 95% CI 0.13 to 1.88. Hypoglycemia may complicate dehydration due to acute gastroenteritis in young children. Clinicians should examine the serum glucose concentration in these children.

The purpose of this case report is to illustrate the diagnostic difficulties of pericardial tamponade and to suggest that focused cardiac ultrasound be included in the resuscitative care of pediatric shock. Three cases of cardiac tamponade are presented. Each patient had a syncopal episode and presented with altered mental status and hypotension. Muffled heart tones, distended neck veins, and electrocardiogram and chest radiograph abnormalities were not present. Hypotension was not responsive to intravenous volume expansion treatment. Diagnostic delays would have been prevented if focused cardiac ultrasound had been included in the resuscitative care of shock.

Study Objective: The purpose of this study was to determine the prevalence of hypoglycemia and describe the clinical variables associated with hypoglycemia in children receiving resuscitation care., Methods: A cross-sectional study of consecutive children receiving resuscitation care in an emergency department was performed. Rapid glucose testing was prospectively established as one of the initial resuscitation steps, and clinical variables were obtained from a retrospective chart review. The setting was an urban children's hospital ED (Level II trauma center) with a census of 31, 000 per year and a 10% admission rate. The patient population consisted of children (birth to 20 years of age) receiving resuscitation care for altered consciousness, status epilepticus, respiratory failure, cardiac failure, and cardiopulmonary arrest., Results: Over a 1-year period, 49 nontrauma-related children received resuscitation care. Nine (18%; 95% confidence interval 8.7 to 32.2) were hypoglycemic (glucose level

Study Objective: To assess the implementation of published injury prevention strategies in injured youth ice hockey players, to examine factors contributing to current youth ice hockey injuries, and to assess attitudes of participants toward injury-risk activities., Methods: Case series describing a convenience sample of 103 children presenting to a children's hospital emergency department with an injury sustained playing youth ice hockey. Using a questionnaire, patients self-reported their compliance with protective equipment guidelines, the circumstances of injury, and their attitudes toward risk-taking in youth ice hockey., Results: A total of 103 patients suffered 113 injuries. For each piece of required equipment, compliance approached 100%. Penalties were assigned on 4% of plays causing injury. An additional 36% of patients injured during game play felt that a penalty should have been assigned. Fifty-seven percent of injuries were caused by checking. Fifty-eight percent of injuries caused by checking met our criteria for significant injury. Significant injury was more likely when initiating or receiving a check perceived to be legal than when receiving a check perceived as illegal (P = 0.032). Twenty-four percent of patients stated spinal cord injury and 45% stated brain injury was not possible given their usual protective equipment. To win, 32% of patients stated that they would check illegally, and 6% stated that they would purposely injure., Conclusion: While compliance with protective equipment requirements was good, rule enforcement was perceived to be inadequate. Elimination of checking would potentially reduce the number of significant injuries more than would the enforcement of existing rules. Injured youth hockey players are underinformed about the hazards of their sport and are too willing to engage in potentially injurious activities.