Children With Elbow Injuries and Sonographic Elevated Posterior Fat Pad but No Identifiable Posterior Fat Pad on Lateral Radiographs: A Case Series.

Point of Care Ultrasound (POCUS) is used to evaluate the injured pediatric elbow. Standard of care, however, remains radiography. POCUS performed in the setting of normal radiographs have been obtained may demonstrate radiologic occult lipohemarthrosis indicative of occult fracture. We reviewed our pediatric emergency department (PED) POCUS archive for lipohemarthrosis, and then isolated those cases with normal elbow radiography. Radiography was deemed to be normal per the interpretation of the treating PED physician, and was reviewed for this series by an experienced ABR board certified pediatric radiologist. Fracture on POCUS was defined as fracture line or lipohemarthrosis in a posterior sagittal or transverse view of the distal humerus. Fracture was confirmed by signs of cortical healing on follow-up radiography, or clinical course consistent with fracture as documented by an orthopedist. We identified four children with elbow fractures who had no fracture line or elevated posterior fat pad on radiography but demonstrated lipohemarthrosis on POCUS. POCUS may elicit evidence of fracture even after normal radiography, and POCUS findings suggesting occult fracture may allow for more effective guidance on discharge.

The Medical Somatic Dissociation Questionnaire Assessment For Childhood Sexual Abuse: A Brief Report.

Child sexual abuse is a prevalent phenomenon worldwide. However, a gap exists between its incidence and its disclosure rate. Furthermore, assessment tools and techniques capable to identify the source of symptoms are lacking. This study investigates the extent to which the validated Medical Somatic Dissociation Questionnaire (MSDQ) can differentiate between sexually and non-sexually abused children. A total of 794 children and youth between the ages of 8 and 18 (mean age: 12.2 (SD = 2.3); 42% female, 58% male) were recruited from the general population; other participants were residents of boarding schools and children who were referred to medical treatment. The anonymous online questionnaire included queries about demographics, a condensed version of the Traumatic Life Events Questionnaire, and the MSDQ. Findings indicate strong internal consistency, reliability, incremental validity, and predictive validity of the instrument, indicating the superiority of the MSDQ's ability to predict sexual abuse compared to physical abuse or the loss of a family member. It is concluded that the MSDQ can be integrated into the evaluation process performed by healthcare professionals in the diagnosis of minors with unexplained symptomatology.

Persistent post-concussive syndrome in children after mild traumatic brain injury is prevalent and vastly underdiagnosed.

Data on epidemiology and prognosticators of persistent post-concussion syndrome (PPCS) after mild traumatic brain injury (mTBI) in the pediatric population is scarce. The aim of this study was to evaluate the prevalence of PPCS in children after mTBI and to identify clinical variables in children who are at high risk for developing PPCS. A multicenter, retrospective matched cohort in which PPCS symptoms were evaluated in children 8-15-year-old, 6-60 months after being admitted to the emergency department because of mTBI. The control group included children admitted to the emergency department because of uncomplicated distal radius fractures. The children's guardians were interviewed for the presence of PPCS symptoms using the "Rivermead Post-Concussion Questionnaire". A multivariable logistic regression model was used to identify predictors of PPCS. Two-hundred and five children were included in the mTBI group and 205 in the control. The median time from the injury was 33.5 months in the mTBI group and 33.8 in the control. The prevalence of PPCS in the mTBI group was 25.3% and PPCS like symptoms in the control was 2.4%, p < 0.001. Within the 6-60 months period, the PPCS prevalence was not influenced by the time that elapsed from the injury. In the mTBI group, motor vehicle accidents and adolescence were found to be risk factors for PPCS. PPCS is underdiagnosed in the pediatric population and 25% of children admitted to the ED due to mTBI may suffer from PPCS. Screening guidelines should be implemented to identify and properly treat these children.

Use of Point-of-Care Ultrasound to Identify Occult Fractures of the Tibia in the Pediatric Emergency Department: A Case Series.

BACKGROUND: Although point-of-care ultrasound (POCUS) has been shown to be useful in the identification of both pediatric and adult long-bone fractures in the emergency setting, radiography remains the standard of care. Emergency physicians are often faced with the dilemma of how to evaluate and treat the child with lower leg injury and physical examination concerning for fracture but no readily identifiable fracture line on radiography. CASE REPORTS: We present four cases in which POCUS was used to diagnose a radiographically occult fracture of the proximal tibia in young children. This is the first case series of occult fracture of the tibia diagnosed with POCUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS can demonstrate evidence of fracture even after unremarkable radiography is obtained, and POCUS findings consistent with fracture might allow for more effective guidance on discharge.

Point-of-Care Ultrasound-Guided Drainage of Joint Effusions in the Pediatric Emergency Setting: A Case Series.

Literature supporting the use of point-of-care ultrasound (POCUS) for both identification and aspiration of effusions in large joints in the pediatric emergency department (PED) is sparse. We collected a case series of five patients who presented to the PED from August 2020 to December 2020 with an effusion in the hip, shoulder, knee, or elbow identified and aspirated under POCUS performed by pediatric emergency medicine (PEM) physicians. POCUS confirms effusion location and size and visualization of a completely evacuated effusion. POCUS can also guide the decision to start antibiotics earlier in the course of illness, can prevent unnecessary transfers for formal sonographic imaging or for potentially unnecessary radiographic imaging. This series supports the role of a PEM physician and POCUS guidance in the identification and aspiration of large-joint effusions.

Ultrasound-Guided Distal Forearm Fracture Reduction by Pediatric Emergency Physicians: A Single Center Retrospective Study.

INTRODUCTION: Fracture reduction under point-of-care ultrasound (POCUS) guidance facilitates measurement of residual angulation or displacement that may not be apparent on examination. Point-of-care ultrasound is without patient or staff exposure to ionizing radiation and enlists no additional staffing resources or patient transfer. METHODS: We conducted a chart review of all children who underwent reduction of a distal forearm fracture in the pediatric emergency department over a 2-year period, from September 2018 to September 2020. We compared length of stay (LOS) with that for orthopedist-performed distal forearm reductions during the study period. We allowed a 6-week lag period to ensure no missed rereduction before analyzing the data. After reduction, children were instructed to follow up with an orthopedist within 1 week. Children with loss of reduction on orthopedic follow-up are referred back through our emergency department for operative reduction. RESULTS: A total of 74 children with 75 distal forearm fractures were identified. Average LOS was 179 minutes for the pediatric emergency medicine physician reductions and 215 minutes for the orthopedist reductions (P < 0.001). Ninety-six percent of reductions were completed with POCUS assistance, and 61% had less than 5 degrees of angulation on postreduction radiography. Only 2.7% of children underwent rereduction. CONCLUSIONS: Distal forearm fracture reductions by a pediatric emergency medicine physician under POCUS guidance have a high rate of excellent alignment, low rate of failed reduction, and significantly shorter LOS (P < 0.001) than reductions performed by orthopedists.

Contamination rates of different methods of urine culture collection in children: A retrospective cohort study.

AIM: Urinary tract infection is a common cause of paediatric morbidity. However, there is no consensus on the default method for urine culture collection in children. This study aimed to examine the contamination rates of different urine collection methods. METHODS: This was a retrospective cohort study in a paediatric emergency department. Data were collected from electronic health records on all children whose urine culture samples were obtained in the paediatric emergency department between March 2018 and March 2019. Different methods of urine collection included the midstream (MS) method, clean catch (CC), transurethral bladder catheterisation and suprapubic aspiration. Contamination rates and positive urine culture rates were calculated and compared for sex, age, and collection method. RESULTS: Urine culture samples were collected from 1507 children. There were 284 (18.8%) cultures that were positive with significant growth and 52 (3.5%) that were defined as 'contaminated'. The contamination rates for the midstream method in toilet-trained children were 1.6% (10/609), 4.9% (17/348) for CC in pre-continent children, 4.9% (25/515) for transurethral bladder catheterisation and 0% (0/35) (P = 0.006) for suprapubic aspiration. There was no significant difference in contamination rates of urine cultures collected by CC and catheterisation in the compared groups. The rates of positive cultures in the subgroup of children with high suspicion for Urinary tract infection were also found to be similar. CONCLUSIONS: Our study shows that CC is non-inferior to catheterisation for collecting urine cultures in young children.

The Child With a Painful Arm: A POCUS Screening Protocol to Identify Fracture in Children With Upper Extremity Injury.

BACKGROUND: Young children present frequently to the emergency department with an immobile, painful arm. It is often difficult to discern a point of tenderness in a frightened, injured child. Common approaches included sending the child for x-ray studies of the extremity or empirically attempting reduction of radial head subluxation. We created a step-by-step point-of-care ultrasound screening protocol of the upper extremity to increase or decrease the probability of fracture before x-ray study or reduction. CASE REPORT: We present the cases of 6 children younger than 4 years without a clear history of pulled elbow and without swelling or deformity on examination, for whom this protocol revealed fracture or lowered the probability of fracture, thereby increasing the safety of radial head reduction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In most cases, identification of a single fracture on ultrasound allows for focused x-ray study on the area of fracture. Children with a normal ultrasound screen can undergo reduction of radial head subluxation safely.

Listening to Hospital Personnel's Narratives during the COVID-19 Outbreak.

Healthcare workers (HCWs) facing the COVID-19 pandemic are required to deal with unexpectedly traumatic situations, concern about contamination, and mounting patient deaths. As a means to address the changing needs of our hospital's HCWs, we conducted a narrative analysis study in the early stages of the covid-19 outbreak. A focus group of medical experts, conducted as the initial step, recommended that a bottom-up research tool be used for exploring HCWs' traumatic experiences and needs. We therefore conducted 450 semi-structured in-depth interviews with hospital personnel. The interviews were based on Maslow's Pyramid of Needs model, and the narratives were analyzed by applying the Listening Guide methodology. The interviewees expressed a need for physical and psychological security in the battle against Covid-19, in addition to the need for attachment and meaning. Importantly, we also found that the interview itself may serve as a therapeutic tool. In light of our findings, we recommended changes in hospital practices, which were subsequently implemented. Further research on HCWs' traumatic experiences and needs will provide evidence-based knowledge and may enable novel approaches in the battle against Covid-19. To conclude, the knowledge generated by listening to HCWs' narratives may provide suitable support programs for professionals.

Could It Be Pneumonia? Lung Ultrasound in Children With Low Clinical Suspicion for Pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a significant cause of pediatric morbidity and mortality worldwide. Emergency department point of care ultrasound (POCUS) is a first-line modality for diagnosis of CAP. The current coronavirus disease 2019 pandemic creates a unique opportunity to incorporate lung POCUS into the evaluation of a broader range of children. It has increased the utility of lung POCUS in both evaluation and follow-up of pediatric coronavirus cases. An increased use of lung POCUS creates an opportunity for earlier diagnosis while allowing the opportunity for overdiagnosis of small infiltrates and atelectasis. We collated a case series to demonstrate the benefit of lung POCUS in a very broad range of children. METHODS: We collected a case series of 5 patients between December 2018 and December 2019 who presented nonclassically and were diagnosed with CAP on POCUS by a pediatric emergency physician. CONCLUSION: Routine lung POCUS in ill children will allow treating physicians to identify and follow a pulmonary infiltrate consistent with CAP quickly. We anticipate that early and more frequent use of POCUS and earlier diagnosis of CAP may improve outcomes by decreasing healthcare encounters within the same illness and by reducing the incidence of late sequelae of pneumonia such as empyema and effusions. However, we acknowledge that this may come at the expense of the overtreatment of viral infiltrates and atelectasis. Further study is required to improve the specificity of lung POCUS in the evaluation of CAP.

Identifying Retrocecal Appendicitis on Point-of-Care Ultrasound (POCUS).

BACKGROUND: Retrocecal appendicitis may be challenging to find. We present the first case series in which retrocecal appendicitis was found on point-of-care ultrasound (POCUS). CASE REPORTS: In each of the five cases, appendicitis was found by a pediatric emergency physician in the right periumbilical region or right upper quadrant. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The POCUS practitioner should scan both the right upper and right lower quadrant of the abdomen in search of appendicitis, as well as in search of signs of perforation.

Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic.

AIM: To present seven paediatric patients with appendicitis, all with late diagnosis resulting from different aspects of the fear from the current global COVID-19 pandemic. METHODS: Cases were collected from three paediatric surgical wards. Comparison between complicated appendicitis rates in the COVID-19 era and similar period in previous year was performed. RESULTS: All seven children presented with complicated appendicitis. Main reasons for the delayed diagnosis during the COVID-19 era were parental concern, telemedicine use and insufficient evaluation. Higher complication rates were found during the COVID-19 era compared to similar period in previous year (22% vs 11%, P-value .06). CONCLUSION: The fear from COVID-19 pandemic may result in delayed diagnosis and higher complication rates in common paediatric medical conditions. We believe caregivers and healthcare providers should not withhold necessary medical care since delay in diagnosis and treatment in these routinely seen medical emergencies may become as big of a threat as COVID-19 itself.

Childhood Drowning: Review of Patients Presenting to the Emergency Departments of 2 Large Tertiary Care Pediatric Hospitals Near and Distant From the Sea Coast.

OBJECTIVE: Drowning is a leading cause of death among infants and toddlers. Unique physiological and behavioral factors contribute to high mortality rates. Drowning incidents predominantly occur during warmer months and holidays. The aim of this study was to describe the characteristics of pediatric drowning victims who attended 2 different emergency departments (EDs), 1 near and 1 distant from the sea coast, to recognize risk factors, complications, causes of death, and the educational needs of families and caregivers. METHODS: Retrospective cohort analysis of incident history, clinical presentation, treatments, and outcomes of drowning victims was performed. Data were analyzed both by age group and proximity of institution to the sea coast. RESULTS: From 2005 to 2015, 70 drowning patients presented to the 2 institutions; there was no difference in incident history or outcomes based on proximity to the sea coast. Fifty-six percent of patients were younger than 6 years, the majority drowning in pools. More of the older children drowned in the sea (48% vs 23%). Half of all patients were treated and followed in the ED or ward, and the other half were treated in the pediatric intensive care unit; 12 suffered severe complications, including 5 diagnosed with brain death. Cardiopulmonary resuscitation was performed in 80% of the fatal group and 23% of the nonfatal group (P = 0.006). Seven children who experienced a cardiac arrest with hypothermia were treated before arrival in the ED, and 5 had ongoing cardiac arrest upon arrival in the ED (these were the 5 suffering brain death). DISCUSSION: Most of patients younger than 6 years drowned in swimming pools, suggesting that parents are perhaps less vigilant in these circumstances, even though they may remain in close proximity. Active adult supervision entails attention, proximity, and continuity. Educational efforts should be aimed at reminding parents of this, especially in the summer months.

Beyond Point-of-Care Ultrasound: Bedside Ultrasound in the Diagnosis of Soft Tissue Mass.

Cancer is diagnosed in 1 in 7000 children annually. Here, we report 6 cases of a mass identified by the author, a novice sonographer in a pediatric emergency medicine fellowship, using point-of-care ultrasound, from January of 2017 to May of 2018. Identification of these cases early in presentation allowed for earlier involvement of the relevant specialist and shorter time to diagnosis and treatment, and might be expected to increase parent satisfaction as well.