Epidemiologic features of pediatric genital injury in emergency departments in Korea

Purpose@#Genital injury is a common pediatric injury. Given the lack of nationwide data, the authors aimed to show age group-related epidemiologic features of genital injury in Korea. @*Methods@#We reviewed the data from 2011-2016 Emergency Department-based Injury In-depth Surveillance registry, which involves 23 emergency departments in Korea. From the dataset, we included children (< 18 years) with the International Classification of Diseases, 10th Revision codes related to genital injury as the final diagnosis with excluding those with other codes or combined injuries. Age groups were defined as follows; infants (< 1 year), toddlers (1-3), preschoolers (4-6), schoolers (7-12), and adolescents (13-17). The clinical features and outcomes were analyzed. @*Results@#A total of 3,030 children were included with the median age of 6 years (interquartile range, 4-10) and the proportion of girls of 53.0%. Only 144 children (4.8%) were transported by the emergency medical service providers. The most common mechanism and place were blunt injury (1,826 [60.3%]) and home (1,535 [50.7%]), respectively. Of the codes, “Contusion of external genital organs (S30.2)” was most common (1,574 [51.9%]). As for outcomes, 2,770 children (91.4%) were discharged, 252 (8.3%) were hospitalized (intensive care units, 1 child [0.03%]), and 108 (3.6%) underwent surgery. Severe injury occurred in 111 children (3.7%) without a mortality. With increasing age in the age groups, non-accidental injury, school and sports-related injuries, hospitalization, and surgery (All Ps < 0.001). @*Conclusion@#Genital injury may occur at evening, in spring and summer, at home, and in the form of accidental or blunt injury. Most children are discharged. Contrary to these general features, older children tend to undergo more frequently non-accidental injury, school and sports-related injuries, hospitalization, and surgery. Thus, we need age-specific strategies for injury prevention.

A clinical prediction tool to predict urinary tract infection in pediatric febrile patients younger than 2 years old: a retrospective analysis of a fever registry

Objective@#Urinary tract infection (UTI) is a significant issue in young febrile patients due to potential long-term complications. Early detection of UTI is crucial in pediatric emergency departments (PEDs). We developed a tool to predict UTIs in children. @*Methods@#Clinical data of patients <24 months of age with a fever and UTI or viral infection were extracted from the fever registry collected in two PEDs. Stepwise multivariate logistic regression was performed to establish predictors of identified eligible clinical variables for the derivation of the prediction model. @*Results@#A total of 1,351 patients were included in the analysis, 643 patients from A hospital (derivation set) and 708 patients from B hospital (validation set). In the derivation set, there were more girls and a lower incidence of a past history of UTI, older age, less fever without source, and more family members with upper respiratory symptoms in the viral infection group. The stepwise regression analysis identified sex (uncircumcised male), age (≤12 months), a past history of UTI, and family members with upper respiratory symptoms as significant variables. @*Conclusion@#Young febrile patients in the PED were more likely to have UTIs if they were uncircumcised boys, were younger than 12 months of age, had a past history of UTIs, or did not have families with respiratory infections. This clinical prediction model may help determine whether to perform urinalysis in the PED.

Pain Passport as a tool to improve analgesic use in children with suspected fractures in emergency departments

Background@#In the emergency department (ED), adequate pain control is essential for managing patients; however, children with pain are known to receive less analgesia than adults with pain. We introduce the Pain Passport to improve pain management in paediatric patients with suspected fractures in the ED. @*Methods@#This was a before-and-after study. We reviewed the medical records of paediatric patients who were primarily diagnosed with fractures from May to August 2015. After the introduction of the Pain Passport, eligible children were enrolled from May to August 2016. Demographics, analgesic administration rates, time intervals between ED arrival and analgesic administration, and satisfaction scores were obtained. We compared the analgesic prescription rate between the two periods using multiple logistic regression. @*Results@#A total of 58 patients were analysed. The baseline characteristics of subjects during the two periods were not significantly different. Before the introduction of the Pain Passport, 9 children (31.0%) were given analgesics, while after the introduction of the Pain Passport, a significantly higher percentage of patients (24/29, 82.8%) were treated with analgesics (P < 0.001). The median administration times were 112 (interquartile range [IQR], 64-150) minutes in the pre-intervention period and 24 (IQR, 20-74) minutes in the post-intervention period. The median satisfaction score for the post-intervention period was 4 (IQR, 3-5). The adjusted odds ratio for providing analgesics in the post-intervention period was 25.91 (95% confidence interval, 4.36-154.02). @*Conclusions@#Patient-centred pain scoring with the Pain Passport improved pain management in patients with suspected fractures in the paediatric ED.

Underuse of Epinephrine for Pediatric Anaphylaxis Victims in the Emergency Department: A Population-based Study

PURPOSE: Epinephrine is a key drug for treating anaphylaxis; however, its underuse is still a significant issue worldwide. The objective of this study was to compare epinephrine use between pediatric and adult patients who were treated with anaphylaxis in the emergency department (ED). METHODS: The data were retrieved from the National Sample Cohort of South Korea, which contains claim data from the National Health Insurance Service. We included patients who visited the ED with a discharge code of anaphylaxis between 2004 and 2013. We assessed prescription information of epinephrine, antihistamine and systemic steroid, previous medical history and discharge disposition from the ED. The study population was categorized based on age at the visit. RESULTS: A total of 175 pediatric and 1,605 adult patients with anaphylaxis were identified. Only 42 (24%) of the pediatric patients were treated with epinephrine, while 592 (36.9%) of the adult patients were treated with epinephrine (P = 0.001). Furthermore, the pediatric patients were less likely to be treated with systemic steroid than the adult patients (6.9% vs. 12.3%, P = 0.047). The odds ratios for the administration of epinephrine relative to the baseline in the 19-65 age group were 0.34 (95% confidence interval [CI], 0.15–0.67), 0.56 (95% CI, 0.28–1.03) and 0.79 (95% CI, 0.45–1.33) in the < 7, 7–12 and 13–18 age groups, respectively. CONCLUSIONS: The pediatric patients with anaphylaxis experienced a lower rate of epinephrine injection use than the adult patients and the injection use decreased as age decreased.

The difference of Use of CT in the general versus pediatric emergency departments for adolescent patients in the same tertiary hospital

OBJECTIVE: The use of computed tomography (CT) in pediatric patients has decreased since the association between radiation and cancer risk has been reported. However, in adolescent patients being treated as adult patients, there has been a high incidence of CT use in emergency departments (EDs). Thus, this study aimed to evaluate the CT use in adolescent patients with complaints of headache or abdominal pain in the general and pediatric EDs of the same hospital.METHODS: A retrospective chart review of patients aged 15 to 18 years, who presented with headache or abdominal pain at the general and pediatric EDs of Seoul National University Hospital from January 2010 to December 2014, was conducted.RESULTS: A total of 407 adolescent patients with complaints of headache and 980 with abdominal pain were included in this study. The adolescent patients in the general ED were more likely to undergo CT scans than those in the pediatric ED, with both patients having headache (42.4% vs. 20.5%, respectively, P<0.001) and abdominal pain (29.0% vs. 18.4%, respectively, P<0.001). There was no statistical difference in the rates of positive CT findings between the general and pediatric EDs. The frequency of visits to the general ED was associated with high rates of CT use in adolescent patients with complaints of headache (odds ratio, 3.95; 95% confidence interval, 2.01 to 7.77) and those with abdominal pain (odds ratio, 1.76; 95% confidence interval, 1.18 to 2.64).CONCLUSION: The ED setting influences the use of CT on adolescent patients, and a child-friendly environment could reduce the radiation risks.

Long-term changes in computed tomography and ultrasound utilization in a pediatric emergency department

OBJECTIVE: Many studies have proposed reducing unnecessary use of computed tomography (CT), and ongoing studies in pediatric populations are aiming to decrease radiation dosages whenever possible. We aimed to evaluate the long-term changes in the utilization patterns of CT and ultrasound (US) in pediatric emergency departments (PEDs). METHODS: This retrospective study reviewed the electronic medical data of patients who underwent CT and/or US in the PED of a tertiary referral hospital from 2000 to 2014. We compared the changes in utilization patterns of brain and abdominal CT scans in pediatric patients and analyzed changes in abdominal US utilization in the PED. RESULTS: During the study period, 196,371 patients visited the PED. A total of 12,996 brain and abdominal CT scans and 12,424 abdominal US were performed in the PED. Comparison of CT use in pediatric patients before and after 2007 showed statistically decreasing trends after 2007, expressed as the coefficient values of the differences in groups. The numbers of brain and abdominal CT scans showed a significant decreasing trend in children, except for abdominal CT in adolescents. The abdominal US/CT ratio in the PED showed a statistically significant increase (2.68; 95% confidence interval, 1.87 to 3.49) except for the adolescent group (5.82; 95% confidence interval, -2.06 to 13.69). CONCLUSION: Overall, CT use in pediatric patients has decreased since 2007. Pediatric US use has also shown a decreasing trend; however, the abdominal US/CT ratio in pediatric patients showed an increasing trend, except for adolescents.

Quality improvement activity for improving pain management in acute extremity injuries in the emergency department

OBJECTIVE: The aim of this study was to investigate the effectiveness of a quality improvement activity for pain management in patients with extremity injury in the emergency department (ED). METHODS: This was a retrospective interventional study. The patient group consisted of those at least 19 years of age who visited the ED and were diagnosed with International Classification of Diseases codes S40–S99 (extremity injuries). The quality improvement activity consisted of three measures: a survey regarding activities, education, and the triage nurse’s pain assessment, including change of pain documentation on electronic medical records. The intervention was conducted from January to April in 2014 and outcome was compared between May and August in 2013 and 2014. The primary outcome was the rate of analgesic prescription, and the secondary outcome was the time to analgesic prescription. RESULTS: A total of 1,739 patients were included, and 20.3% of 867 patients in the pre-intervention period, and 28.8% of 872 patients in the post-intervention period received analgesics (P < 0.001). The prescription rate of analgesics for moderate-to-severe injuries was 36.4% in 2013 and 44.5% in 2014 (P=0.026). The time to analgesics prescription was 116.6 minutes (standard deviation 225.6) in 2013 and 64 minutes (standard deviation 75.5) in 2014 for all extremity injuries. The pain scoring increased from 1.4% to 51.6%. CONCLUSION: ED-based quality improvement activities including education and change of pain score documentation can improve the rate of analgesic prescription and time to prescription for patients with extremity injury in the ED.

Relationship between the time to positivity of blood culture and mortality according to the site of infection in sepsis

OBJECTIVE: The time to positivity (TTP) of blood culture reflects bacterial load and has been reported to be associated with outcome in bloodstream infections. This study was performed to evaluate the relationship between the TTP of blood culture and the mortality rates associated with sepsis and septic shock according to the site of infection. METHODS: We performed a retrospective cohort study on patients with sepsis and septic shock. The rates of blood culture positivity and mortality as well as the relationship between the TTP and 28-day mortality rate were compared among patients with different sites of infection, such as the lungs, abdomen, urogenital tract, and other sites. RESULTS: A total of 2,668 patients were included, and the overall mortality rate was 21.6%. The rates of blood culture positivity and mortality were different among the different infection sites. There was no relationship between the TTP and mortality rates of total, lung, and urogenital infections. Patients with abdominal infections showed a negative correlation between the TTP and 28-day mortality rate. In patients with abdominal infections, a TTP < 20 hours was independently associated with 28-day mortality compared with patients with negative blood culture (hazard ratio, 1.73; 95% confidence interval, 1.16–2.58). However, there was no difference in mortality rates of patients with a TTP≥20 hours and a negative blood culture. CONCLUSION: The shorter TTP in patients with abdominal infections in sepsis and septic shock was associated with a higher 28-day mortality rate.

Development of a clinical scoring system for appendicitis in children with presumed appendicitis

PURPOSE: To develop a clinical scoring system for children with presumed appendicitis who visit the emergency department. METHODS: A registry based-retrospective study was conducted in the pediatric emergency department between September 2015 and December 2016. Patients aged 4 to 17 years who had a > 1 of 5 Likert scale for possibility of appendicitis were included. Multiple logistic regressions based on Akaike information criterion were performed using variables regarding clinical features and inflammatory markers to develop the clinical scoring system. RESULTS: A total of 233 patients were included, and 93 (39.9%) had the final diagnosis of appendicitis. The final model with the lowest Akaike information criterion (171.7) consisted of 5 variables, including vomiting (1 point), absence of watery diarrhea (1 point), duration of symptoms ≤ 3 days (1 point), rebound tenderness (1 point), and white blood cell count > 10.0 × 109/L (2 points). If the clinical score was ≥ 4 of 6 points, the area under the receiver operating characteristic curve was 0.78 (95% confidence interval, 0.71-0.86) with a 78.9% sensitivity, 66.7% specificity, positive and negative predictive values of 70.0% and 76.2%, respectively, and positive and negative likelihood ratios of 2.4 and 0.3, respectively. CONCLUSION: The 5-item clinical scoring system shows a fair performance for prediction of pediatric appendicitis. This simple tool could be applied to predict the pediatric appendicitis, and to avoid the use of potentially unnecessary computed tomography.

Change in Guardians' Favor in Computed Tomography after Explained by Emergency Physicians in Pediatric Head Injury

PURPOSE: Head injury in children is a common problem presenting to emergency departments, and cranial computed tomography scan is the diagnostic standard for these patients. Several decision rules are used to determine whether computed tomography scans should be used; however, the use of computed tomography scans is often influenced by guardian favor toward the scans. The objective of this study was to identify changes in guardian favor for explanation of minor head injuries based on the institutional clinical practice guidelines. METHODS: A survey was conducted between July 2010 and June 2012. Patients younger than 16 years with a Glasgow Coma Scale score of 15 after a head injury and guardians of these patients were included. Pre- and post-explanation questionnaires were administered to guardians to evaluate their favor for computed tomography scans and factors related to the degree of favor. Treating physicians explained the risks and benefits of cranial computed tomography scans using the institutional clinical practice guidelines. Guardian favor for a computed tomography (CT) scan was examined using a 100-mm visual analog scale. RESULTS: A total of 208 patients and their guardians were included in this survey. Guardian favor for computed tomography scans was significantly reduced after explanation (46.7 vs. 17.4, p<0.01). Pre-explanation favor and the degree of physician recommending computed tomography were the most important factors affecting pre- and postexplanation changes in favor. CONCLUSION: Explanation of the risks and benefits of cranial computed tomography scans using the institutional clinical practice guidelines may significantly reduce guardian favor for computed tomography scans.

Methods of weight estimation in pediatric resuscitation

Knowing a pediatric patient's weight is crucial in resuscitation since the decision on the dose of resuscitation drug and the size of the instrument is made mostly based on a patient's weight. However, using a scale may not always be practical in resuscitation. Therefore, it is important to know the methods of weight estimation in resuscitation. The weight estimation can be performed based on various factors: visual assessment, age, height, and body habitus. One of the most common problems of these methods is that the weight tends to be underestimated as a patient's age increases. This is due to an inappropriate reflection of body habitus. Further research is needed to overcome this problem.