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This chapter of the What Do I Do Now series on Pediatric Radiology discusses the indicated approach to imaging when evaluating an infant when there is a suspicion for physical abuse. The chapter addresses when clinicians should be concerned for abusive injuries, regardless of the provided history. The chapter reviews and discusses the mechanism of the most commonly seen inflicted injuries, including classic metaphyseal lesions (CML), rib fractures, and subdural hematomas (SDH). It also reviews the most commonly conducted imaging studies to identify inflicted injuries, including head computed tomography (CT) scans and skeletal surveys as recommended by the American College of Radiology and the American Academy of Pediatrics.

Supracondylar fractures are one of the most common pediatric fractures. They occur in children between the ages of 5 and 7 years after a fall on an outstretched hand with the elbow in extension (FOOSH). However, a small percentage occur from landing directly onto a flexed elbow. The hallmark feature is elbow pain and refusal to move the elbow. Proper and thorough physical exam is needed to evaluate for neurovascular injury. Ultimately, the diagnosis is made by an adequately obtained anteroposterior (AP) and lateral radiograph of the elbow. Management varies depending on the degree of displacement (Gartland classification).

The altered activity of drug metabolism enzymes (DMEs) is a hallmark of chemotherapy resistance. Cytochrome P450s (CYPs), mainly CYP3A4, and several oxidoreductases are responsible for Phase I metabolism of doxorubicin (DOX), an anthracycline widely used in breast cancer (BC) treatment. This study aimed to investigate the role of Phase I DMEs involved in the first stages of acquisition of DOX-resistance in BC cells. For this purpose, the expression of 92 DME genes and specific CYP-complex enzymes activities were assessed in either sensitive (MCF-7 parental cells; MCF-7/DOXS) or DOX-resistant (MCF-7/DOXR) cells. The DMEs genes detected to be significantly differentially expressed in MCF-7/DOXR cells (12 CYPs and eight oxidoreductases) were indicated previously to be involved in tumor progression and/or chemotherapy response. The analysis of CYP-mediated activities suggests a putative enhanced CYP3A4-dependent metabolism in MCF-7/DOXR cells. A discrepancy was observed between CYP-enzyme activities and their corresponding levels of mRNA transcripts. This is indicative that the phenotype of DMEs is not linearly correlated with transcription induction responses, confirming the multifactorial complexity of this mechanism. Our results pinpoint the potential role of specific CYPs and oxidoreductases involved in the metabolism of drugs, retinoic and arachidonic acids, in the mechanisms of chemo-resistance to DOX and carcinogenesis of BC.

Every year, millions of pediatric patients seek emergency care. Significant barriers limit access to optimal emergency services for large numbers of children. The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have a strong commitment to identifying these barriers, working to overcome them, and encouraging, through education and system changes, improved access to emergency care for all children.

When confronted with a case of an infant with a bruise, it is cardinal to remember “if the infant is not cruising, they should not be bruising.” In patients who are nonmobile, a bruise could be a sign of child maltreatment, in particular physical abuse. In these cases, it is imperative that the history take into account the age and developmental stage of the patient. Complete exposure of the patient and a thorough physical exam is critical to identify any other injuries. Patterned bruising may resemble the object that struck the child or what the child was struck with. Laboratory evaluation and imaging are dependent on the age. Consideration of a medical explanation such as a bleeding disorder should also be excluded.

Fractures are common accidental and nonaccidental injuries. It is the job of the physician to be able to gather the necessary historical information, place the injury in developmental context, and identify and recognize abusive injury patterns. It is important to consider the age and development of the child paired with the history, location, type, and mechanism of the injury. Further workup may be needed in cases of suspected child maltreatment with physical abuse to look within and beyond the skeletal system for additional injuries such as neurologic and gastroenterological in nature. It is imperative to consider insufficient nutrition and genetic causes as differential diagnoses for fractures.

Chronic pain is defined as pain that is either persistent (ongoing) or recurrent (episodic) and is thought to be multifactorial, involving biological, psychological, and sociocultural factors. Generally, pain is considered chronic when the pain itself or recurrent episodes of pain persist greater than 3 to 6 months. Assessing children’s pain can be challenging, and validated tools should be used such as the Wong-Baker FACES Pain Rating Scale or the OUCHER Pain Scale (younger children) and verbal numerical scales (older children). Following assessment, treatment can be initiated based on the severity, nature, and presumed etiology of the pain. Management of acute or chronic pain episodes should follow evidence-based recommendations, which include both pharmacological and nonpharmacological principle. A stepwise escalation in pain medication may be required to adequately control the patient’s pain.

This is a revision of the previous joint Policy Statement titled “Guidelines for Care of Children in the Emergency Department.” Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report “The Future of Emergency Care in the US Health System.” Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration-Pediatric Emergency Medicine in Non-Children's Hospital"). This subcommittee consisting of emergency medicine, pediatric emergency medicine, and quality improvement (QI) experts, as well as a patient advocate, identified main outcome gaps in the care of children in the emergency departments (EDs) in the following areas: variations in pediatric care and outcomes, pediatric readiness, and gaps in knowledge translation. The goal for this session was to create a research agenda that facilitates collaboration and partnering of diverse stakeholders to develop a system of care across all ED settings with the aim of improving quality and increasing safe medical care for children. The following recommended research strategies emerged: explore the use of technology as well as collaborative networks for education, research, and advocacy to develop and implement patient care guidelines, pediatric knowledge generation and dissemination, and pediatric QI and prepare all EDs to care for the acutely ill and injured pediatric patients. In conclusion, collaboration between general EDs and academic pediatric centers on research, dissemination, and implementation of evidence into clinical practice is a solution to improving the quality of pediatric care across the continuum.

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

Background Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. Methods Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. Results Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. Conclusions Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.

Emergency care providers share a compelling interest in developing an effective patient-centered, outcomes-based research agenda that can decrease variability in pediatric outcomes. The 2018 Academic Emergency Medicine Consensus Conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps (AEMCC)" aimed to fulfill this role. This conference convened major thought leaders and stakeholders to introduce a research, scholarship, and innovation agenda for pediatric emergency care specifically to reduce health outcome gaps. Planning committee and conference participants included emergency physicians, pediatric emergency physicians, pediatricians, and researchers with expertise in research dissemination and translation, as well as comparative effectiveness, in collaboration with patients, patient and family advocates from national advocacy organizations, and trainees. Topics that were explored and deliberated through subcommittee breakout sessions led by content experts included 1) pediatric emergency medical services research, 2) pediatric emergency medicine (PEM) research network collaboration, 3) PEM education for emergency medicine providers, 4) workforce development for PEM, and 5) enhancing collaboration across emergency departments (PEM practice in non-children's hospitals). The work product of this conference is a research agenda that aims to identify areas of future research, innovation, and scholarship in PEM.

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

The diagnosis and management of pediatric cardiac emergencies can be challenging and complicated. Early presentations are usually the result of ductal-dependent lesions and appear with cyanosis and shock. Later presentations are the result of volume overload or pump failure and present with signs of congestive heart failure. Acquired diseases also present as congestive heart failure or arrhythmias.

Copyright © 2016 by the American Academy of Pediatrics. Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient's care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

Dissertação de mestrado, Biologia Marinha, Faculdade de Ciências e Tecnologia, Univerdade do Algarve, 2015 Understand how the distribution of deep-sea species is shaped by environment is a challenge for ecologists, given the difficulty of sampling at these locations. Paramuricea clavata is a long-lived species that inhabits the Mediterranean coralligenous assemblages. Its known distribution was so far described as being restricted to Mediterranean Sea, however, new populations were found in the neighboring Atlantic Ocean, suggesting a wider distribution. BRT is a modeling technique that uses algorithms to describe the relation between environmental and presence data, in order to assess species distribution. This method has been applied to ecological studies, showing good accuracy in predicting suitable habitats, since it copes well with the major problems associated with niche modeling. We use BRT to describe the suitable habitat of Paramuricea clavata by determining the variables that limit its distribution, and the species’ tolerance range for these variables. Our results accurately revealed that the suitable habitat is mainly characterized by complex bottom topography (represented by slope) and temperature, presenting a wide range for the first variable (> 0.3⁰) and a well-defined range for the second (12.3 to 26.5⁰C). In addition to the previous known distribution, new potential sites of occurrence were revealed in the Mediterranean Sea, along the coast of Morocco, Algeria, Tunisia and Strait of Sicily, and on the Atlantic coasts between Morocco and southwest Iberia. With this study we were able to describe, for the first time, the ecological niche and potential global distribution of this important structuring species. Moreover, our results contribute to the achievement of future studies of monitoring and conservation of benthic communities in poorly-sampled areas. With the predicted climate change for Mediterranean, the occurrence of mortality events in benthic communities will continue, especially to those found in shallower areas, putting P. clavata at risk. O clima tem um papel fundamental na forma como molda a distribuição global dos organismos, sendo por isso importante conhecer e compreender os limites de tolerância dos mesmos a variações ambientais. Devido à dificuldade de amostragem em ecossistemas profundos, existe ainda uma grande lacuna no que diz respeito aos factores que controlam a distribuição das espécies que neles habitam, nomeadamente as comunidades bentónicas. O Mediterrâneo é um ecossistema que apresenta características muito particulares, abrigando uma vasta diversidade de organismos essencialmente associados às comunidades coralígenas. A Paramuricea clavata é uma das espécies estruturantes mais importantes destas comunidades, tendo um papel muito importante no funcionamento e manutenção do ecossistema. Nos últimos anos, o aumento da temperatura observado no Mediterrâneo tem provocado eventos de mortalidade massiva junto das comunidades bentónicas, levando à perda de populações desta gorgónia. A distribuição conhecida desta espécie era até hoje restrita ao Mediterrâneo, principalmente na zona Norte. Contudo, novas populações foram encontradas no Atlântico adjacente, junto a costa sul e oeste de Portugal e no mar Alboran, indicando uma distribuição mais ampla. Boosted Regression Tress (BRT) é um método de modelação recentemente aplicada na área da ecologia, que permite relacionar dados ambientais com dados de presença, possibilitando a descrição de padrões de distribuição para as espécies. Este método usa algoritmos que aprendem a relação existente entre os dados tipos de dados, permitindo a descrição do seu padrão. BRT resulta da junção de dois algoritmos, árvores de regressão e agregação, o que permite que o modelo final seja construído tendo em conta as interações existentes entre os dados. A flexibilidade do BRT permite contornar os principais problemas associados à modelação de dados ecológicos tais como: 1) capacidade de lidar com diferentes tipos de dados; 2) minimização da perda de função que ocorre devido à tendência de amostragem (sampling bias), existência de locais na área de estudo com maior numero de amostras que outros; 3) é dos métodos menos afetados pela resolução dos dados; e 4) reduz o sobre-ajuste do modelo aos dados da amostra (overfitting), por considerar todas as possíveis combinações destes. Por ser uma técnica que tem revelado boa capacidade de previsão da distribuição, nós utilizamos o BRT para descrever o habitat adequado para a P. clavata. Deste modo, determinámos quais as variáveis mais relevantes para descrição da distribuição desta espécie e quais os seus limites de tolerância. O método mostrou-se eficaz, apresentado um excelente poder preditivo (AUC: 0.98; TSS: 0.96; sensibilidade: 0.98, especificidade: 0.98). O habitat adequado para esta gorgónia é caracterizado por uma topografia de fundo complexa, elevada produtividade e hidrodinamismo de moderado a forte. Os nossos resultados revelaram a topografia do fundo, representada pelo declive, como sendo a variável mais importante para a caracterização do habitat desta espécie, apresentando uma contribuição de 21.5% e um intervalo de tolerância sem limite máximo, > 0.3⁰. Esta variável é um bom indicador da dinâmica que ocorre no fundo, sendo que elevações topográficas estão normalmente associadas a alterações no padrão das correntes, e a zonas de maior produtividade. A Temperatura tem também um papel muito importante (contribuição de 19%), contudo, o intervalo de tolerância é bastante restrito (12.3 a 26.5⁰C), limitando assim a sua área de distribuição. Através deste modelo, verificámos também que, apesar dos nossos dados de presença ocorrerem entre os 15 e 100 m de profundidade, esta consegue atingir os 200 m. Este facto é interessante, visto que a partir de uma determinada profundidade as perturbações ocorridas à superfície não se fazem sentir com tanta intensidade. Neste sentido, a existência de populações profundas pode ser um indicador de zonas de refúgio. A distribuição da espécie ocorre numa estreita linha da costa, ao longo do Mediterrâneo e Atlântico adjacente, e também em ilhas e outras em elevações topográfica do fundo, como montes e bancos submarinos. Para além dos novos locais de presença ocorridos no Atlântico e mar Alboran, o nosso modelo prevê uma boa probabilidade de ocorrência para a região sul do Mediterrâneo, nomeadamente ao longo da costa de Marrocos, Argélia e costa noroeste da Tunísia. Para o Atlântico, a área entre Agadir, Marrocos, e a costa sudoeste da Península Ibérica revela também a possibilidade de ocorrência desta gorgónia. Tendo em conta que se tratam de regiões pouco estudadas, os nossos dados sugerem estas áreas como potenciais alvos para estudos futuros de monitorização e conservação destes habitats. Com as alterações climáticas previstas para o Mediterrâneo, há uma forte possibilidade de ocorrer perda de grande parte das populações da espécie, especialmente das que habitam zonas menos profundas.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

Freestanding urgent care centers are in- creasing as a source of after-hours pediatric care. These facilities may be used as an alternative to hospital emer- gency departments for the care and stabilization of seri- ous and critically ill and injured children. The purpose of this policy statement is to provide recommendations for assuring appropriate stabilization in pediatric emergency situations and timely transfer to a hospital for definitive care when necessary. F reestanding urgent care facilities remain a fix- ture in provision of health services in a man- aged care environment. Although the Academy does not approve of the routine use of urgent care facilities because it detracts from the medical home concept, 1,2 the use of these facilities as part of urgent and emergent care systems is increasing in the man- aged care environment. The term urgent care may imply to the public that a facility is capable of man- aging critical or life-threatening emergencies. There- fore, these facilities must have the capability to iden- tify patients with emergency conditions, stabilize them, and provide timely access to definitive care should critically ill or injured children need care. Urgent care facilities must have appropriate pediat- ric equipment and staff trained and experienced to provide critical support for ill and injured children until transferred for definitive care. It is necessary for urgent care facilities to have prearranged access to comprehensive emergency services through transfer and transport agreements to which both facilities adhere. Available and appropriate modes of trans- port should be identified in advance. When after-hours urgent care clinics are used as a resource for pediatric urgent care, they should solicit help from the pediatric professional community, and pediatricians should be accessible who are prepared to assist in the stabilization and management of crit- ically ill and injured children. Pediatricians respon- sible for managing the health care of children may occasionally need to use the resources of urgent care facilities after hours. When such clinics are recom- mended to patients, pediatricians should be certain that the urgent care center is prepared to stabilize and manage critically ill and injured children. RECOMMENDATIONS

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

Este caso de estudo tem como objetivo demonstrar a utilidade da utilização de imagens de satélite de alta resolução para a produção de cartografia temática em áreas urbanas, bem como, experimentar a extracção de elementos de uma imagem de alta resolução a partir de protocolos de segmentação, aplicando uma abordagem orientada por regiões, e recorrendo a dados de uma cena do satélite WorldView2 com as suas novas 4 bandas adicionais. Definiu-se uma nomenclatura de ocupação de solo com base na fotointerpretação da imagem, criou-se uma legenda hierarquizada por 3 níveis de desagregação. No primeiro nível incluiu-se sete classes, no segundo nível as classes foram classificadas pelo nome dos objetos identificados na fotointerpretação, e o terceiro nível foram classificados pelas características dos objetos definidos no nível anterior. Foram criados segmentos de treino através do algoritmo da segmentação, que tem como função criar segmentos vetoriais com base na similaridade espectral e no valor espectral dos conjuntos dos pixéis vizinhos, testou-se varios parâmetros de segmentação de modo a obter o nível de segmentação que visivelmente na imagem se aproximasse mais aos objetos reconhecidos, para assim se gerar as assinaturas espectrais dos objetos representados pela segmentação, procedendo-se à classificação de ocupação de solo baseada nos segmentos.

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.

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.

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.

The unique characteristics of the pediatric population expose them to errors in the emergency department (ED) with few standard practices for the safety of care. Young children and high-acuity patients are at increased risk of adverse events both in the prehospital and ED settings. We provide an overview of the problems and possible solutions to the threats to pediatric patient safety in the ED. Endorsing a culture of safety and training to work in a team are discussed. Medication errors can be reduced by using organizational systems, and manufacturing and regulatory systems, by educating health care providers, and by providing caregivers tools to monitor prescribing. The consensus is that a safe environment with a high quality of care will reduce morbidity and mortality in ED pediatric patients.

Emergency departments are vital in the management of pediatric patients with mental health emergencies. Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. Emergency departments must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses, including those with mental retardation, autistic spectrum disorders, and attention-deficit/hyperactivity disorder and those experiencing a behavioral crisis. Emergency departments also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, posttraumatic stress disorder, and maltreatment and those exposed to violence and unexpected deaths. Emergency departments must address not only the physical but also the mental health needs of patients during and after mass-casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support advocacy for increased mental health resources, including improved pediatric mental health tools for the emergency department, increased mental health insurance coverage, and adequate reimbursement at all levels; acknowledgment of the importance of the child’s medical home; and promotion of education and research for mental health emergencies.

Note: Please be advised that the American Academy of Pediatrics and the American College of Emergency Physicians are in the process of independently developing technical reports on this issue that will provide more in-depth educational and clinical information for their respective members on the death of a child in the emergency department. When completed, these reports will be published separately by each organization to supplement this joint policy statement.