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Background: Historically, the child care industry has been unprepared for emergencies. A previous study identified gaps in Michigan’s child care programs’ emergency plans. Study objectives were to reassess programs’ preparedness plans after introduction of state-mandated emergency plans and to examine the effect of the coronavirus disease 2019 (COVID-19) pandemic on programs’ operations. Methods: A 29-question survey was sent to ∼500 child care programs across Michigan in 2020 to assess emergency plans and response to COVID-19. Data were analyzed using descriptive statistics and qualitative methods. Results: A total of 346 programs (70%) responded. Most (92%) reported having a written plan, but one-third reported having no infectious outbreak plan pre-pandemic. One-third of programs lacked plans for special needs children (vs 40% in 2014); 62% lacked plans for child reunification (vs 60% in 2014); 46% reported staff received no preparedness training. COVID-19 impacted programs substantially: 59% closed, 20% decreased capacity, 27% changed disinfecting protocols. Several themes related to the pandemic’s effect on programs were identified: (1) changes in learning, (2) changes in socialization, (3) increased family burden, (4) financial challenges, (5) lack of guidance. Conclusions: Significant preparedness gaps remain among Michigan’s child care programs, suggesting the need for increased support and addition of emergency preparedness to programs’ quality ratings.

Background:Systematic monitoring of exanthema is largely absent from public health surveillance despite emerging diseases and threats of bioterrorism. Michigan Child Care Related Infections Surveillance Program (MCRISP) is the first online program in child care centers to report pediatric exanthema.Methods:MCRISP aggregated daily counts of children sick, absent, or reported ill by parents. We extracted all MCRISP exanthema cases from October 1, 2014 through June 30, 2019. Cases were assessed with descriptive statistics and counts were used to construct epidemic curves.Results:360 exanthema cases were reported from 12,233 illnesses over 4.5 seasons. Children ages 13-35 months had the highest rash occurrence (45%, n = 162), followed by 36-59 months (41.7%, n = 150), 0-12 months (12.5%, n = 45), and kindergarten (0.8%, n = 3). Centers reported rashes of hand-foot-mouth disease (50%, n = 180), nonspecific rash without fever (15.3%, n = 55), hives (8.1%, n = 29), fever with nonspecific rash (6.9%, n = 25), roseola (3.3%, n = 12), scabies (2.5%, n = 9), scarlet fever (2.5%, n = 9), impetigo (2.2%, n = 8), abscess (1.95, n = 7), viral exanthema without fever (1.7%, n = 6), varicella (1.7%, n = 6), pinworms (0.8%, n = 3), molluscum (0.6%, n = 2), cellulitis (0.6%, n = 2), ringworm (0.6%, n = 2), and shingles (0.2%, n = 1).Conclusion:Child care surveillance networks have the potential to act as sentinel public health tools for surveillance of pediatric exanthema outbreaks.

OBJECTIVES To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection. METHODS In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively. RESULTS Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4–24.5] 28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0–17). Infants with invasive HSV had a higher median score (6, interquartile range: 4–8) than those without invasive HSV (3, interquartile range: 1.5–4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80–0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43). CONCLUSIONS A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.

A growing number of adolescents are being diagnosed with acute myocarditis following mRNA COVID-19 vaccinations. This case describes an adolescent who presented to the emergency department with chest pain and tachycardia following the Pfizer-BioNTech COVID-19 vaccination. Point-of-care ultrasound was performed prior to the return of laboratory studies and revealed depressed left ventricular systolic function. Point-of-care ultrasound may be a tool used to rapidly diagnose or risk stratify patients with potential post-COVID-19 vaccine myocarditis.

Objective: To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting. Study design: We reviewed medical records of children 13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness. Results: A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children 26%. Conclusions: The HUS severity score was able to discriminate between high- and low-risk children

OBJECTIVE: This study aimed to assess if Michigan child care directors have created disaster management plans, and if local resources were used to develop and implement plans. METHODS: From December 2013 to March 2014, the Early Childhood Investment Corporation conducted a survey of licensed child care programs in Michigan. An online survey regarding disaster preparedness and training resources was distributed to the directors of a convenience sample of registered child care centers among the Early Childhood Investment Corporation's statewide network of 11 resource centers. RESULTS: A total of 210 child care programs responded. Most (91%) of respondents had a disaster plan, but 40% did not include accommodations for special needs children, 51% did not have a family/child identification or reunification plan, and 67% did not have car safety devices and a predetermined route for evacuation. Fewer than 9% made disaster plans available online. Few collaborated with local fire (22%), police (27%), or pediatric or emergency medicine organizations (11%). Online modules were the most desirable training format. CONCLUSIONS: In a state without mandated child care guidelines for disaster preparedness, a substantial proportion of child care programs were missing critical components of disaster planning. Future interventions must focus on increasing partnerships with local organizations and developing guidelines and training to include plans for special needs children, family/child identification and reunification, and evacuation/relocation. Language: en

Objective: Children in early learning settings are vulnerable to site-specific emergencies because of physical and developmental limitations. We examined parents’ knowledge of disaster plans in their child’s early learning settings. Methods: In May 2015, we conducted a nationally representative online household survey, including parents of children ages 0-5 years in child care settings. Parents were asked about their center’s disaster plans and key components: evacuation, special needs children, and disaster supplies. Bivariate analyses and logistic regression were conducted to identify factors associated with parental awareness of disaster plans. Results: Overall, 1,413 of 2,550 parents responded (rate = 55 percent). Sample included 1,119 parents of children 0-5 years old, with 24 percent (n = 264) requiring child care. Parents’ reported knowledge of five types of disaster plans: evacuation (66 percent), power outage (63 percent), severe weather (62 percent), lock-down (57 percent), and delayed parent pick-up (57 percent). Only 21 percent reported if plans included all four key components of evacuation (child identification, parent identification, rapid communication, and extra car seats). One-third (36 percent) reported plans accommodating special needs children. Parents’ knowledge of disaster supplies varied: generator (31 percent), radio (42 percent), water (57 percent), food (60 percent), and first aid (82 percent). Parents attending any disaster training events (34 percent) were more likely to be aware of all five types of disaster plans compared with parents who had not attended. Conclusions: Many parents were unaware of disaster plans at their children’s early learning settings. Although few parents attended training events, such participation was associated with higher levels of parental awareness .

Although disasters can affect anyone in a given community or region, those with access and functional needs have the highest rates of morbidity and mortality during an emergency or disaster. There are many unique and complex issues that should be considered when planning and caring for these individuals in a disaster situation. Who are these individuals, what specific issues should be addressed when considering these members of the population, and what recommendations can be made to address their unique needs? How can we include them as part of the all-hazard, comprehensive approach to disaster management? The first part of this three-part series identifies who is included in this population and what are the legal considerations that arise in caring for, not only this unique group but also all the members of the community in a disaster. The second part considers evacuation, sheltering, sheltering in place, communication, medical needs, independence, supervision, and transportation (CMIST) with a focus on mental health. The third part deals with the medical aspect of CMIST and with recommendations that may aid disaster responders and planners in caring for these high-risk individuals in a disaster.

Background: 14 million children attend summer camps yearly. While the American Academy of Pediatrics (AAP) recommends all campers and staff receive vaccinations, camp leaderships’ immunization practices and perspectives have not been well characterized. Our study objective was to assess the current state of summer camps’ immunization requirements, policies, and practices by surveying a national cohort of camp leadership. Methods: We partnered with CampDoc.com, an online camp electronic health record system and the Association of Camp Nursing to conduct a 20-question online survey of camp leadership regarding current immunization requirements, policies and …

Study objective We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures. Methods We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm3) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm3 for infants aged 28 days or younger and greater than or equal to 10 cells/mm3 for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis. Results Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days. Conclusion Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.

Background Shiga toxin–producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. Methods We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged Results Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69–.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42–4.54]), higher hematocrit (1.83 [1.21–2.77] per 5% increase) and serum creatinine (10.82 [1.49–78.69] per 1 mg/dL increase), platelet count Conclusions The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.

Although disasters can affect anyone in a given community or region, those with access and functional needs have the highest rates of morbidity and mortality during an emergency or disaster. There are many unique and complex issues that should be considered when dealing with these individuals in a disaster situation. Who are these individuals, what specific issues should be addressed when considering these members of the population, and what recommendations can be made in order to address their unique needs? How can we include them as part of the all-hazard, comprehensive approach to disaster management? The first part of this three-part series identifies who is included in this population and what are the legal considerations that arise in caring for not only this unique group but also all of the members of the community in a disaster. The second part considers evacuation, sheltering, sheltering in place, communication, medical needs, independence, supervision, and transportation (CMIST) with a focus on mental health. The third part deals with the medical aspect of CMIST and with recommendations that may aid disaster responders and planners in caring for these high-risk individuals in a disaster.

Although disasters can affect anyone in a given community or region, those with access and functional needs have the highest rates of morbidity and mortality during an emergency or disaster. There are many unique and complex issues that should be considered when dealing with these individuals in a disaster situation. Who are these individuals, what specific issues should be addressed, and what recommendations can be made in order to address their unique needs? How can we include them as part of the all-hazard, comprehensive approach to disaster management? The first part of this three-part series identifies who is included in this population and what are the legal considerations that arise in caring for not only this unique group but also all of the members of the community in a disaster. The second part considers evacuation, sheltering, sheltering in place, communication, medical needs, independence, supervision, and transportation (CMIST) with a focus on mental health. The third part deals with the medical aspect of CMIST and with recommendations that may aid disaster responders and planners in caring for these high-risk individuals in a disaster.

Children can be victims of mass casualty or illness, but their needs, with respect to their care and recovery are substantially different from adults. Emergency or urgent care physicians must be prepared to evaluate and manage child victims presenting to their facility in numbers or acuity that could significantly overwhelm normal operations. This article presents the general approach to pediatric disaster preparation in the United States, the expectations of emergency department providers, and different methods of disaster triage, and introduces the most likely types of mass illness (some of which are bioweapons or chemical agents) and their management.

BACKGROUND: Although neonatal herpes simplex virus (HSV) is a potentially devastating infection requiring prompt evaluation and treatment, large-scale assessments of the frequency in potentially infected infants have not been performed. METHODS: We performed a retrospective cross-sectional study of infants ≤60 days old who had cerebrospinal fluid culture testing performed in 1 of 23 participating North American emergency departments. HSV infection was defined by a positive HSV polymerase chain reaction or viral culture. The primary outcome was the proportion of encounters in which HSV infection was identified. Secondary outcomes included frequency of central nervous system (CNS) and disseminated HSV, and HSV testing and treatment patterns. RESULTS: Of 26 533 eligible encounters, 112 infants had HSV identified (0.42%, 95% confidence interval [CI]: 0.35%–0.51%). Of these, 90 (80.4%) occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7 to 9. The median age of HSV-infected infants was 14 days (interquartile range: 9–24 days). HSV infection was more common in 0 to 28-day-old infants compared with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4–6.2). Sixty-eight (0.26%, 95% CI: 0.21%–0.33%) had CNS or disseminated HSV. The proportion of infants tested for HSV (35%; range 14%–72%) and to whom acyclovir was administered (23%; range 4%–53%) varied widely across sites. CONCLUSIONS: An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.

Objective Children's summer camps are at risk for multiple pediatric casualties during a disaster. The degree to which summer camps have instituted disaster preparedness is unknown. We assessed disaster preparedness among selected camps nationally for a range of disasters. Methods We partnered with a national, web-based electronic health records system to send camp leadership of 315 camp organizations a 14-question online survey of disaster preparedness. One response from each camp was selected in the following order of importance: owner, director, physician, nurse, medical technician, office staff, and other. The results were analyzed using descriptive statistics. Results A total of 181 camps responses were received, 169 of which were complete. Camp types were overnight (60%), day (21%), special/medical needs (14%), and other (5%). Survey respondents were directors (52%), nurses (14%), office staff (10%), physicians (5%), owners (5%), emergency medical technicians (2%), and other (12%). Almost 18% of camps were located >20 mi from a major medical center, and 36% were >5 mi from police/fire departments. Many camps were missing emergency supplies: car/booster seats for evacuation (68%), shelter (35%), vehicles for evacuation (26%), quarantine isolation areas (21%), or emergency supplies of extra water (20%) or food (17%). Plans were unavailable for the following: power outages (23%); lockdowns (15%); illness outbreaks (15%); tornadoes (11%); evacuation for fire, flood, or chemical spill (9%); and other severe weather (8%). Many camps did not have online emergency plans (53%), plans for children with special/medical needs (38%), methods to rapidly communicate information to parents (25%), or methods to identify children for evacuation/reunification with parents (40%). Respondents reported that staff participation in disaster drills varied for weather (58%), evacuations (46%), and lockdowns (36%). The majority (75%) of respondents had not collaborated with medical organizations for planning. Conclusions A substantial proportion of camps were missing critical components of disaster planning. Future interventions must focus on developing summer camp-specific disaster plans, increasing partnerships, and reassessing national disaster plans to include summer camp settings.

Introduction:More than 14 million children in the United States attend summer camps yearly, including many special medical needs children. Summer camps are at risk for multiple pediatric casualties during a disaster. The American Camp Association, in the 2017 critical issues report, identified emergency preparedness as the top critical health and safety issue. Camps, compared to school-based settings, face unique challenges when planning for disasters, but research has been challenging because of the lack of access to camp leadership and data.Aim:Provide a targeted up-to-date synopsis on the current state of disaster preparedness and ongoing collaborative research and technology interventions for improving preparedness among summer camps.Methods:Researchers partnered with a national health records system (CampDoc.com) and American Academy of Pediatrics disaster experts to review results from a national camp survey. Main themes were identified to assess gaps and develop strategies for improving disaster preparedness.Results:169 camps responses were received from national camp leadership. A substantial proportion of camps were missing 4 critical areas of disaster planning: 1) Most lacked online emergency plans (53%), methods to communicate information to parents (25%), or strategies to identify children for evacuation/reunification (40%); 2) Disaster plans failed to account for special/medical needs children (38%); 3) Staff training rates were low for weather (58%), evacuation (46%), and lockdown (36%); 4) Most camps (75%) did not plan with disaster organizations.Discussion:Collaboration with industry and disaster experts will be key to address the gaps identified. Current research and interventions include the recent release of a communication alert tool allowing camps to send mass text emergency notifications. Additionally, a recent pilot to incorporate disaster plans into the electronic health records platform emphasizing communication, evacuation, and identification of local experts has begun. Efforts to develop a unified disaster tool kit for summer camps remains a challenge.

Background The lumbar puncture (LP) is a procedural competency deemed necessary by the Accreditation Council for Graduate Medical Education and the Emergency Medicine and Pediatric Residency Review Committees. The emergency department (ED) is a primary site for residents to be evaluated performing neonatal LPs. Current evaluation methods lack validity evidence as assessment tools. Objectives This was a pilot study to develop an objective structured assessment of technical skills for neonatal LP (OSATS-LP) and to document validity evidence for the instrument in regard to five sources of test validity: content, response process, relation to other variables, inter-rater reliability, and consequences of testing. Methods Pediatric residents were videotaped in the fall of 2011 for comparison of faculty evaluation of resident performance during a neonatal LP using a video-delayed format. Residents completed a demographic experience survey evaluating relations to other variables. Content and response process validity was obtained through expert panel meetings and resulted in the following seven domains of performance for the OSATS-LP: preparation, positioning, analgesia, needle insertion, cerebrospinal fluid (CSF) collection, management of laboratory studies, and sterility. t-tests assessed significance between level of training, previous intensive care unit experience, and residents' self-assessed confidence in comparison with their total performance score. The inter-rater agreement of the OSATS-LP was obtained using the Fleiss' kappa for each domain. Results Sixteen pediatric residents completed the simulation with six raters evaluating each resident (96 ratings). The domains of sterility and CSF collection had moderate statistical reliability (κ = 0.41 and 0.51, respectively). The domains of preparation, analgesia, and management of laboratories had substantial reliability (κ = 0.60, 0.62, and 0.62, respectively). The domains of positioning and needle insertion were less reliable (κ = 0.16 and 0.16, respectively). Individuals who had completed one or more rotations in the neonatal intensive care unit (NICU) had a higher total score (12.5 vs. 16.9; p

Purpose: The 2015 Save the Children report identified our state as one of several nationally not meeting minimum requirements for disaster preparedness in child care settings. Re-authorization of the Child Care and Development Block Grant Act requires states to establish disaster preparedness training for child care providers. Our state lacks available training. Our initiative partnered with Child Care Network (CCN) to pilot a new workshop at their annual conference. Our goal was to find deficits in provider’s current disaster plans and to teach basic principles of emergency preparedness during a …

We describe the occurrence of postdural puncture headache (PPDH) in an adolescent with idiopathic intracranial hypertension (IIH) and its successful management with an epidural blood patch. PPDH is a very rare occurrence in patients with intracranial hypertension and is described as a paradoxical situation in the literature. There are only two previous case reports (in adults) of the possible association. A 15-year-old obese patient with a diagnosis of IIH had an uneventful diagnostic spinal tap using a 22G Quincke needle in the pediatric emergency department but returned 24 h later with PPDH. After a failed trial of conservative management, she had an uneventful but curative epidural blood patch with 15 ml of autologous venous blood and was able to return to school the day after the blood patch. Follow-up review by her neuro-ophthalmologist shows resolution of her headaches, considerable improvement in her visual field defect and resolution of papilledema. This is the first report of PPDH and its successful management with an epidural blood patch in a pediatric patient with IIH.

Children with altered mental status who present to the emergency department have a broad differential diagnosis. We report a case of a 19-month-old girl who presented in coma and who was later found to have a fentanyl patch adhered to her back. She was found to have changes on brain magnetic resonance imaging consistent with a toxic spongiform leukoencephalopathy but had a good neurologic outcome. This case report illustrates the importance of a thorough physical examination in children in coma and a rarely reported magnetic resonance imaging finding that has been seen in opioid intoxication and is usually associated with severe morbidity and mortality.

Introduction Being procedurally competent to perform a lumbar puncture (LP) is an ACGME requirement for both emergency medicine and pediatric residents. There are few assessment tools with validity evidence for lumbar puncture. An objective structured assessment of technical skills for neonatal lumbar puncture (OSATS-LP) was developed and validity evidence was obtained in four of five areas of validity: content, response process, relation to other variables, and interrater reliability. Methods The development of this tool was part of a prospective study comparing pediatric resident performance of neonatal lumbar puncture with direct observation by faculty. T tests assessed significance between level of training, and previous ICU experience in comparison to their total performance score. The interrater agreement of the OSATS-LP was obtained using the Fleiss' Kappa for each domain. Results Sixteen pediatric residents completed the simulation with six raters evaluating each resident (96 ratings). The domains of sterility and cerebral spinal fluid collection had moderate statistical reliability (k = 0.41 and 0.51, respectively). The domains of preparation, analgesia, and management of labs had substantial reliability (k = 0.60, 0.62, and 0.62, respectively). The domains of positioning and needle insertion were less reliable (k = 0.16 and 0.16, respectively). Residents who had performed more LPs correlated with higher total score (Pearson's Correlation coefficient = 0.5, p < .05). Individuals who had completed one or more rotations in the neonatal intensive care unit had a higher total score (12.5 vs. 16.9; p < .01). The OSATS-LP has reasonable evidence in four of the five sources for test validity. Discussion This study serves as a launching point for using this tool in clinical environments such as the emergency department, and therefore, has the potential to provide real time formative and summative feedback to improve resident skills and ultimately lead to improvements in patient care. There are limited number of assessment tools for LP with validity evidence. This tool has demonstrated validity evidence in content, response process, and interrater reliability. This tool was successfully piloted in fifteen pediatric residents and showed increased competence in five of the seven domains with increasing PGY level.

Serious blunt scrotal trauma in the pediatric population is rare and can pose significant danger to the viability of the testes. The following case describes an adolescent boy who presented with a single testis in his scrotum after low-impact perineal trauma, consistent with testicular dislocation. The literature regarding scrotal trauma includes few cases of testicular dislocation from low-impact perineal trauma. Included is a brief review of the most recent data including epidemiology, differential diagnosis, acute management, and complications pertinent to the pediatric emergency clinician.

1. Marisa C. Louie, MD* 2. Stuart Bradin, DO* 1. *Pediatric Emergency Medicine Division, Department of Emergency Medicine, University of Michigan, Ann Arbor, Mich After completing this article, readers should be able to: 1. Recognize the presenting history, signs, and symptoms of patients who have swallowed or inhaled foreign bodies. 2. Discuss the long-term complications of gastrointestinal and airway foreign bodies. 3. Describe appropriate management strategies for patients who have common esophageal and gastric foreign bodies. 4. Identify the risks associated with ingestion of button batteries and recognize when emergent removal is necessary. 5. Maintain a high level of suspicion for aspirated foreign bodies, recognizing that delays in diagnosis can lead to increased complications. ### Case 1 A 3-year-old boy is brought to his pediatrician's office by his mother after an older sibling saw him swallow two small pieces from a magnetic building set. He is playful and smiling. There is no history of choking or distress. Radiography reveals two small rodlike objects in his stomach. ### Case 2 A 10-year-old girl who has developmental delay is brought to the emergency department after possibly swallowing a calculator battery 2 hours ago. She is asymptomatic. On the radiograph, a small round object is seen in the lower esophagus. ### Case 3 A 2-year-old boy is brought into an urgent care facility for new-onset wheezing. He has a low-grade fever and cough but no rhinorrhea. He has mild tachypnea with wheezing on the right side. Albuterol treatments and steroids are started. In spite of several treatments, he continues to wheeze. These three cases are examples of a common pediatric problem: foreign body ingestion and aspiration. Because toddlers explore the world with their mouths, tend to eat and run, and have a less developed chewing ability, they are the most common age group seen for foreign body complaints. Many studies report a slight male predominance. This review addresses foreign body ingestion and aspiration. ### Background Foreign body ingestion is a frequent reason for pediatric visits. Coins are common culprits, followed by small toys …

The ongoing spread of H5N1 avian influenza in Southeast Asia has raised concern about a worldwide influenza pandemic and has made clear the need to plan in advance for such an event. The federal government has stressed the importance of planning and, in particular, has asked hospitals and public health agencies to develop plans to care for patients outside of traditional healthcare settings. These alternative or acute care centers (ACCs) would be opened when hospitals, emergency departments (EDs), and clinics are overwhelmed by an influenza pandemic. The University of Michigan Hospital System (UMHS), a large tertiary care center in southeast Michigan, has been developing a model for offsite care of patients during an influenza pandemic. This article summarizes our planning efforts and the lessons learned from 2 functional exercises over the past 3 years.

Introduction Application of cricoid pressure (CP) is an important step during rapid sequence intubation. Previous surveys of anesthesia personnel showed a knowledge deficiency in the recommended level of cricoid force. There has been no previous attempt to assess the adequacy of knowledge of ED personnel in the application of CP. The objective of this study was to assess the theoretic knowledge of ED personnel about CP. Methods We carried out a convenience sample of all ED personnel present at the morbidity and mortality meeting of a major US teaching hospital. A questionnaire-based survey was distributed; respondents were unaware of the questions or the nature of the survey before participating. Results In total, 83 completed questionnaires were returned by 38 residents, 25 attending physicians, and 20 nurses. Many of the respondents knew the anatomic structure to which CP is applied. However, 24 respondents (14 nurses and 10 residents) thought that CP is applied to both the cricoid and thyroid cartilage. Interestingly, 70% of the nurses in this survey gave an incorrect response to the question on the anatomic localization of CP. Many of the participants in this survey either were unsure of the recommended amount of cricoid force in the asleep patient or quoted values that were too low. The majority of respondents rated their training in CP application as either poor or nonexistent. Most were able to name 2 contraindications to the application of CP. Discussion The theoretic knowledge about CP is poor in this survey from staff at a major US teaching hospital. Poor theoretic knowledge could lead to poor technique in the application of CP. More specific education and training are needed to improve the clinical use of CP and possibly increase patient safety.