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Constipation is a very common emergency room complaint and is often multifactorial. Clinicians should have a high index of suspicion for Hirschsprung’s disease in infants who fail to pass meconium within the first 24 hours after delivery or who have a history of infrequent explosive bowel movements and poor weight gain. Examination can reveal abdominal distention, tight anal sphincter, and empty rectum with expulsion of gas and stool (positive “squirt sign”). Abdominal radiographs and contrast enemas can help to diagnose a distal obstruction or transition zone but may also be normal. Rectal biopsy is the gold standard for diagnosis. It is important to be mindful of complications of Hirschsprung’s disease, such as colonic perforation and enterocolitis, as these can occur years after surgical repair and have high rates of mortality.

Bloody stools in a neonate can be from a variety of etiologies such as benign anal fissures or milk protein allergy, or from more life-threatening etiologies such as volvulus, infectious colitis, or necrotizing enterocolitis (NEC). Older children may have bloody stools associated with intussusception, usually diagnosed with ultrasound, and treated with contrast enema or Meckel’s diverticulum diagnosed with a technetium scintigraphy. NEC is most commonly seen in premature infants but must be excluded in infants presenting to the Emergency Department with bloody stools. An abdominal radiograph is the initial imaging modality of choice for the diagnosis of NEC. Pathognomonic features of NEC seen on x-ray include pneumatosis intestinalis (air within the bowel wall), portal vein air, or pneumoperitoneum from intestinal perforation. NEC should be managed with IV fluids, bowel rest with gastric decompression, IV antibiotics, and surgical consultation.

Introduction Infants aged 0 days to 28 days are at high risk for serious bacterial infection and require an extensive evaluation, including blood, urine, and cerebrospinal fluid cultures, and admission for empiric antibiotics. Although there are no guidelines that recommend a specific time to antibiotics for these infants, quicker administration is presumed to improve care and outcomes. At baseline, 19% of these infants in our emergency department received antibiotics within 120 minutes of arrival, with an average time to antibiotics of 192 minutes. A quality improvement team convened to increase our percentage of infants who receive antibiotics within 120 minutes of arrival. Methods The team evaluated all infants aged 0 days to 28 days who received a diagnostic evaluation for a serious bacterial infection and empiric antibiotics in our emergency department. A nurse-driven team implemented multiple Plan-Do-Study-Act cycles to improve use of triage standing orders and improve time to antibiotics. Data were analyzed using statistical process control charts. Results Through use of triage standing orders and multiple educational interventions, the team surpassed initial goals, and 84% of the infants undergoing a serious bacterial infection evaluation received antibiotics within 120 minutes of ED arrival. The average time to antibiotics improved to 74 minutes. Discussion The use of triage standing orders improves time to antibiotics for infants undergoing a serious bacterial infection evaluation. Increased use, associated with nurse empowerment to drive the flow of these patients, leads to a joint-responsibility model within the emergency department. The cultural shift to allow nurse-initiated work-ups leads to sustained improvement in time to antibiotics.

ObjectiveTo determine rates of skeletal survey completion and injury identification as a function of age among children who underwent subspecialty evaluation for concerns of physical abuse.Study designThis was a retrospective secondary analysis of an observational study of 2609 children 50% of subjects, but rates decreased to less than 35% for subjects >36 months. New fracture identification rates for skeletal survey were similar between children 24-36 months of age (10.3%, 95% CI 7.2-14.2) and children 12-24 months of age (12.0%, 95% CI 9.2-15.3) CONCLUSIONS: Skeletal surveys identify new fractures in an important fraction of children referred for subspecialty consultation with concerns of physical abuse. These data support guidelines that consider skeletal survey mandatory for all such children