Time of Observation in Xenobiotic Ingestions in Children: Is 6 Hours Too Long?

OBJECTIVES: Children endure a prolonged observation after xenobiotic ingestions, despite low associated morbidity and mortality. The primary objective was to describe the management and outcomes of acute xenobiotic exposures in asymptomatic pediatric patients presenting to the emergency department (ED). A secondary objective was to explore the impact of vital signs on the patients' management and outcomes. METHODS: We conducted a retrospective review of asymptomatic children (younger than 18 years) presenting to a pediatric ED after a toxic ingestion from 2014 to 2018. Ingestions of hydrocarbons, acetaminophen, salicylates, sulfonylureas, caustic, and/or extended release agents were excluded. Demographic and clinical data were abstracted. RESULTS: Of 2817 charts, we identified 109 asymptomatic patients with a mean age of 4.7 years. The average observation from registration to disposition was 4.06 hours. Five patients were admitted and were subsequently discharged within 24 hours. Of the discharged patients, 2 returned within 72 hours and were subsequently discharged home. A total of 321 asymptomatic patients presented with ≥1 abnormal vital signs (mean age, 6.6 years) and were observed in the ED for an average of 4.54 hours. They had a higher percentage of ingestions related to suicide attempts (odds ratio, 6.8). Twenty-two were admitted. Of those discharged home, 11 returned to the ED within 72 hours; all were subsequently discharged home. CONCLUSIONS: Prolonged observations may not be necessary after ingestions in asymptomatic children. Vital sign abnormalities at presentation did not impact disposition. Prospective studies are needed to determine the safety and efficacy of this shortened observation.

Validation of Risk Stratification Criteria to Identify Febrile Neonates at Low Risk of Serious Bacterial Infection.

Our objective was to evaluate the accuracy of risk stratification criteria for febrile neonates in the emergency department. This was a retrospective study of febrile neonates ≤56 days of age. Patients were low risk for serious bacterial infection (SBI) if all test results were within normal ranges. Three hundred thirty-eight patients were enrolled with a mean age of 32 (±14) days, and 78 (23%) had SBI: 26 (8%) with bacteremia, 48 (14%) with urinary tract infection, 3 (1%) with meningitis, and 11 (3%) with pneumonia. Risk stratification criteria identified 47 (14%) as low risk, 2 of whom had SBI (both with Group B Streptococcus bacteremia). The sensitivity was 97.4% (95% confidence interval = 91.0% to 99.7%), and the negative predictive value was 95.7% (95% confidence interval = 84.8% to 98.9%). The risk stratification criteria have high sensitivity and high negative predictive value for identifying infants at low risk for SBI. Care must be taken to assure reliable follow-up.

Poisoning with malicious or criminal intent: characteristics and outcome of patients presenting for emergency care.

Background: Poisoning is the leading cause of injury-related death in the USA. Poisoning with malicious or criminal intent is uncommon, and poorly characterized. Objectives: To explore substances, patients' demographics, clinical presentation, management and outcome in victims of malicious poisoning in the USA. Methods: Using the 47 participating sites of the Toxicology Investigators Consortium (ToxIC) Registry, a North American research consortium, we conducted an observational study of a prospectively collected cohort. We identified all patients exposed to malicious poisoning who had received medical toxicology consultation between January 2014 and June 2017. Clinical and demographic data were collected including age, sex, agents of exposure, clinical manifestations, treatment, disposition and outcome. Results: We identified 60 patients who presented to the emergency department with malicious poisoning, of whom 21 (35%) were children. Among 21 children, 17 (81%) were younger than 2 years. There was no sex dominance among patients. The main substances involved in pediatric patients were sympathomimetics (35%) and opioids (19%). In adults, a more varied panel of offending substances was used, with no specific dominant toxidrome. Children received more treatment interventions compared to adults (overall treatment 81% versus 46% [p = 0.0132]; mechanical ventilation: 29% versus 5% [p = 0.0176], respectively). Three (5%) patients died (two children, one adult). Conclusions: Poisonings with malicious intent are uncommon; they are disproportionally directed towards infants, frequently resulting in severe injury and carry relatively high mortality.

Cutaneous polyarteritis nodosa successfully treated with topical diflucortolone valerate: a case report & review of the literature.

Cutaneous Polyarteritis Nodosa (cPAN) was first described in 1931. cPAN is considered a rare disease, its true incidence is unknown. The age of onset is diverse. Most studies have shown no significant gender predominance. cPAN presents with distinct skin findings, such as a maculopapular rash, subcutaneous nodules, livedoid vasculitis, panniculitis, ischemic finger lesions, or erythematous patchy rash. Etiology is unclear. It is still believed to be an immune complex-mediated disease, although a possible mechanism recently proposed relates a familial form of the disease to impaired activity of Adenosine Deaminase 2. cPAN may reflect an underlying disease, infection or medical treatment. There is no consensus as to initial treatment, dosage and length of treatment. Patients with constitutional symptoms, visceral involvement, a more severe course of the disease, or high acute phase reactants, were treated mainly with systemic corticosteroids and/or cytotoxic agents for varying durations. However, persistence of cutaneous lesions has been documented. We describe a 14 year old male suffering from persistent cPAN, with no constitutional symptoms or involvement of internal organs. The patient was treated with a local corticosteroid-based ointment during exacerbations, until complete remission. Although reported in only one study, treatment with topical corticosteroid compound may result in significant improvement or complete regression of skin lesions in cPAN patients.

Overview of obstructive sleep apnea in children: exploring the role of dentists in diagnosis and treatment.

Among the many factors important in children"s development is sleep. Sleep disorders can impair children"s sleep and lead to negative consequences. Obstructive sleep apnea (OSA), which involves blockage of the airway during sleep, can affect development and behaviour; thus, OSA in children should be diagnosed and treated at an early stage. One of the main causes of childhood OSA is enlargement of the tonsil tissues and, in most cases, their removal serves as an ultimate treatment of OSA. However, it remains unclear what proportion of children with enlarged tonsil tissue suffer from OSA. Dentists are becoming increasingly aware of the issue of OSA as they are sometimes involved in treatment of this condition using oral appliances. Moreover, as dentists often look into children"s mouths, they can play an active role in identifying those with enlarged tonsils and referring them for sleep assessment.