Incidence of Bacteremia and Serious Bacterial Infections in Hyperpyrexic Infants Offered Universal Pneumococcal Conjugate Vaccine 13 and Haemophilus influenzae B Immunization.

BACKGROUND: High fevers, especially in young children, often alarm clinicians and prompt extensive evaluation based on perceptions of increased risk of serious bacterial infection (SBI), and even brain damage or seizure disorders. OBJECTIVE: The aim of this study was to determine the prevalence of SBI in infants aged 3-36 months with fever ≥40.5°C in a population of infants offered universal pneumococcal conjugate vaccine 13 and Haemophilus influenzae B immunization. METHODS: This study is a retrospective review of all infants aged 3-36 months with temperature ≥40.5°C presenting to a tertiary care pediatric emergency department over a 30-month period in an era of universal pneumococcal conjugate 13 and H. influenzae B immunization. RESULTS: SBI was recorded in 54 (21.8%) of 247 study infants, most commonly pneumonia 30 patients (12.1%) and urinary tract infection 16 patients (6.5%). Two patients had positive blood cultures, yielding a bacteremia rate of 0.8%. Patients with SBI had a significantly higher WBC count (P < 0.0001) and C-reactive protein levels (P < 0.0001), and were significantly more likely to be hospitalized (P < 0.0001). DISCUSSION: Although SBI was common (21.8%) in our cohort of hyperpyrexic infants universally offered vaccination with pneumococcal conjugate 13 and H. influenzae B vaccines, bacteremia was a rare finding (0.8%).

Assessing the impact of a new medical toxicology service on the treatment of paracetamol overdose at a large tertiary care hospital.

BACKGROUND: Paracetamol overdose is the most common cause of acute liver failure in the United States. Administration of acetylcysteine is the standard of care for this intoxication. Laboratory values and clinical criteria are used to guide treatment duration, but decision-making is nuanced and often complex and difficult. The purpose of this study was to evaluate the effect of the introduction of a medical toxicology service on the rate of errors in the management of paracetamol overdose. METHODS: This was a single center, retrospective, cohort evaluation. Patients with suspected paracetamol overdose were divided into two groups: those attending in the 1 year period before and those in the 1 year after the introduction of the medical toxicology service. The primary outcome was the frequency of deviations from the established management of paracetamol intoxication, using international guidelines as a reference. RESULTS: Fifty-four patients were eligible for the study (20 pre-toxicology-service, 34 post-toxicology-service). The frequency of incorrect therapeutic decisions was significantly lower in the post-toxicology service implementation versus the pre-implementation group (P = 0.005). DISCUSSION: Our study suggests that a medical toxicology service reduces the incidence of management errors, including the number of missed acetylcysteine doses in patients with paracetamol overdose. The limitations include the retrospective study design and that the study was conducted at a single center, which may limit generalizability. CONCLUSIONS: The implementation of a medical toxicology service was associated with a decrease in the number of errors in the management of paracetamol overdose.

Patients with Altered Mental Status May Benefit from Medical Toxicology Consultation.

BACKGROUND: Presentation of intoxicated patients to hospitals is frequent, varied, and increasing. Medical toxicology expertise could lead to important changes in diagnosis and treatment, especially in patients presenting with altered mental status. OBJECTIVES: To describe and analyze clinical scenarios during a 1-year period after the establishment of a medical toxicology consultation service (MTCS). METHODS: Cases of 10 patients with altered mental status at presentation were evaluated. Medical toxicology consultation suggested major and significant changes in diagnosis and management. RESULTS: Of 973 toxicology consultations performed during the study period, bedside consultation was provided for 413 (42%) patients. Of these 413, 88 (21%) presented with some level of altered mental status. We described 10 patients in whom medical toxicology consultation brought about major and significant changes in diagnosis and management. CONCLUSIONS: Benefits may be derived from medical toxicology consultations, especially in patients with altered mental status. Medical toxicology specialists are well positioned to provide high value and expedited patient care.

Acute intoxication caused by three common synthetic cannabinoids: The experience of a large, urban, tertiary care hospital.

BACKGROUND: Synthetic cannabinoids (SC) are chemical substances, which activate cannabinoid receptors in a similar fashion to tetrahydrocannabinol, but with increased efficacy, and are used as illicit recreational drugs. OBJECTIVE: Our objective was to characterize the clinical manifestations and management of three specific, common SC exposures in a cohort of patients presenting to the emergency department of our institution. METHODS: Retrospective case series of patients admitted to an urban tertiary care center between August 1, 2018 and December 31, 2021, with confirmed SC use and positive urinary immunoassay testing for AB-FUBINACA, 4F-MDMB-BUTINACA and ACHMINACA. RESULTS: 58 patients met inclusion criteria during the 3-year study period; median age was 35 years, 60% were male, 31% patients were exposed to >1 substance, and 31% needed hospital addition. The most common physical signs were cardiovascular (54%) and neuropsychiatric (45%). Severe outcomes included coma and seizures, necessitating intubation in 4 patients, and acute renal injury in 7 patients. CONCLUSION: SC are potentially harmful drugs of abuse which can lead to life-threatening complications. Acute care personnel should be aware of the broad range of signs and symptoms of SC use. Testing with short turn around times is available to assess SC use.

C-Reactive Protein and the Outcome of a Pediatric Emergency Department 7 Days Revisit.

BACKGROUND: Pediatric emergency department (PED) return visits represent an important quality of care metric and constitute a patient-centered outcome. C-reactive protein (CRP) is an inflammatory biomarker that is commonly used as screening tool in the PED. In this study, we assessed the clinical outcomes of children whose levels of CRP are 150 mg/L or higher at the initial PED visit and if such levels could be useful in predicting outcomes at a second PED visit. METHODS: A historical cohort study of all patients who visited the PED between July 2007 and June 2017 and had a CRP value of 150 mg/L or greater in the setting of a febrile illness. Data of patients with a return visit to the PED within 7 days were assessed for an association between laboratory values, diagnosis and clinical outcome. RESULTS: One hundred thirty-six index visits were included in this study. One hundred fifteen (84.6%) of the revisits were discharged after their second visit, and 21 (15.4%) were admitted to the inpatient unit. Admitted patients did not differ from patients who were discharged home in diagnosis and CRP levels, but a difference in white blood cell and absolute neutrophil counts was observed. CONCLUSIONS: The intensity of the inflammatory response, as expressed by the high concentrations of CRP in children, does not seem to predict the outcome at a repeat PED visit within 7 days.

Outcomes of children presenting to the emergency department with fever and bulging fontanelle.

BACKGROUND: In infants aged 3-18 months presenting with a bulging fontanelle and fever it is often necessary to exclude central nervous system infection by performing a lumbar puncture. Several studies have shown that well-appearing infants with normal clinical, laboratory and imaging studies have a benign (non-bacterial) disease. At our institution, we often observe such infants and withhold lumbar puncture. OBJECTIVE: To determine the clinical characteristics and outcomes of well-appearing, febrile infants with a bulging fontanelle, whether they did or did not undergo lumbar puncture. DESIGN: A retrospective chart review of the medical records of all febrile infants with a bulging fontanelle seen between March 2018 and March 2020 at Dana Children's Hospital. The following data were extracted: age of the patient, gender, previous medical history, general appearance, vomiting, appetite, fever, blood test results and CSF results (when taken), final diagnosis, disposition status, and whether or not the patient returned to our ER. Stats: Descriptive statistics were used to describe the study population. RESULTS: The study group included 40 children, 22 males, and 18 females. Their age ranged from 3 to 13 months. Only 8 of the patients in the study group were admitted and 32 were discharged. Only 13 (32.5%) had an LP performed, three of which had elevated levels of WBC in the CSF, two of them had a positive culture. None of the patients who were discharged returned to the ED. CONCLUSIONS: Our study, combined with previous works, supports the assumption that management of well-appearing infants with normal medical history who present with fever and bulging fontanelle could be done without a lumbar puncture. Larger and prospective studies are needed to support this observation.

Echis coloratus envenomation in children: a retrospective case series.

BACKGROUND: Antivenom has been used successfully to treat systemic and progressive, local manifestations of envenomations inflicted by Echis coloratus, the second most common cause of snake envenomation in Israel. There is a paucity of published data regarding the use of monovalent (equine) immunoglobulin G antivenom in children. This study describes outcomes from the regimen used in two large, tertiary care pediatric centers. METHODS: A retrospective chart review of children admitted with definite or probable signs of Echis coloratus envenomation to Sourasky (Tel Aviv) and Soroka (Be'er Sheva) Medical Centers from January 1st 2008-to June 1st 2019. Extracted data included age, location of bite, time to hospital arrival, laboratory test results, complications, time to antivenom administration if indicated, adverse effects of the antivenom, and outcomes. Indications for antivenom were: diagnosis of Echis coloratus as the etiology of envenomation, local and systemic signs e.g. skin puncture wounds, swelling of the involved limb, local hematoma, and abnormal coagulation blood test results. RESULTS: During the study period, 11 children were treated with intravenous Echis coloratus antivenom. Median age was 9 years and 10 of 11 patients were male. Two patients underwent fasciotomy; in one, compartment syndrome was diagnosed by pressure measurement, and in the second, clinically. One patient developed mild urticaria 30 min after initiation of the antivenom; the treatment was stopped and then restarted at a slower rate after he was treated with hydrocortisone and diphenhydramine. No further adverse reactions were observed. CONCLUSIONS: In children, Echis coloratus antivenom appeared to be effective and safe for the treatment of systemic and progressive local manifestations of envenomation by Echis coloratus.

Bradycardia Without Hypertension: Is It a Common Clinical Presentation of Ventriculoperitoneal Shunt Malfunction in Pediatric Patients?

BACKGROUND: Mechanical shunting of cerebrospinal fluid is an effective treatment for hydrocephalus. Some studies suggest that bradycardia without hypertension may also be observed in ventriculoperitoneal (VP) shunt malfunction; however, in our experience, this is not a common presenting sign. OBJECTIVE: The aim of this study was to evaluate whether bradycardia without hypertension was a common sign in patients presenting to the pediatric emergency department (ED) with a VP shunt malfunction. METHODS: A retrospective observational study, from May 2006 to April 2015, which included a random sample of children admitted to the ED with clinical features suggestive of possible VP shunt malfunction. Control patients were defined as those who arrived at our ED with suspected VP shunt malfunction that was later ruled out on further workup. RESULTS: A total of 65 patients were included in this study. A significantly greater number of patients with a confirmed shunt pathology presented with vomiting (P = 0.01) and lethargy/apathy (P = 0.01). In the control group, a significantly greater number of patients presented with fever (P = 0.004) and seizures (P = 0.02). The number of patients presenting with bradycardia was not significantly different between the shunt pathology and control groups (P > 0.05). CONCLUSIONS: Bradycardia is not a common presentation in patients with VP shunt malfunction. Bradycardia is often recognized as a significant sign; however, it is one of the last presenting signs. Educating patients about the early signs must be considered as part of the treatment for VP shunt malfunction.

The importance of skull impact site for minor mechanism head injury requiring neurosurgical intervention.

PURPOSE: The most frequent impact sites for head injury patients who require surgical intervention are the temporo-parietal regions. However, most recent guidelines for indication of neuroimaging for head injury sparsely address the impact site as a risk factor. Our purpose was to determine the association between the site of impact in a minor mechanism pediatric head injury and neurosurgical intervention. METHOD: A retrospective cohort study of head injury patients seen between 2000 and 2016 in a large trauma center was carried out. We looked at all children ages 0-18 years who underwent neurosurgical intervention for head traumas. A major mechanism was defined as a fall of >1 m, being struck by a fast-flying object, or a motor collision involving an estimated speed of >40 kph. All other mechanisms were classified as minor. RESULTS: Out of 533 patients, we excluded patients with non-accidental trauma, patients with a relevant chronic illness, patients with a major mechanism of injury, and patients with missing important data, leaving 43 as the study group. Of the 43 patients with a minor mechanism, none had a site of impact that was outside the temporo-parietal region. CONCLUSION: We studied one of the largest cohorts of pediatric patients undergoing neurosurgical intervention for a head injury. In our cohort, none of the children who sustained a minor mechanism of injury suffered a site of impact in the occipital or frontal bone regions outside the temple region. These data suggest that injury location should be considered in assessing the need for neuroimaging in minor mechanism head trauma patients.

Publication outcomes of abstracts presented at 2013 North American Congress of Clinical Toxicology (NACCT) conference.

Introduction: Scientific conferences are useful in disseminating medical research and advancing the medical and scientific fields. An important measure of the success of such conferences is the proportion of research that is published in peer-reviewed journals. The conversion rates for toxicology abstracts to full-text publications at previous North American toxicology meetings were low. No study has assessed the publication rate from the 2013 North American Congress of Clinical Toxicology (NACCT) conference.Methods: We reviewed 316 abstracts presented at the 2013 NACCT Conference. We searched the PubMed, EMBASE, and Medline databases using the authors' names and keywords, through September 2019. We then identified and excluded cases and case reports to reanalyze the data.Results: Thirty-three of 316 abstracts (10.4%) subsequently appeared in 17 different peer-reviewed journals, led by Clinical Toxicology (13 out of 33, 3%). Leading countries of origin for abstract submission were the USA (285), Canada (9), and the UK (8). Excluding case reports, 25 out of 207 abstracts (12.0%) achieved publication in peer-reviewed journals.Conclusions: Fewer than one in eight abstracts reached publication within six years of the 2013 NACCT meeting, even after accounting for and excluding case reports. This rate is lower than in other specialty medical societies.

Publication outcomes of abstracts presented at an international toxicology conference.

INTRODUCTION: The timely and formal publication of material presented at national and international meetings is critical to the dissemination of new information to the medical community. The conversion rates for toxicology abstracts to full-text publications at previous North American toxicology meetings were low. No study has assessed the publication rate from the European Association of Poisons Centers and Clinical Toxicologists (EAPCCT). METHODS: We reviewed 269 abstracts presented at the 2013 EAPCCTcongress. We searched the PubMed, EMBASE, and Medline databases using the first, second, and last authors' names and keywords, through November 2018. RESULTS: Forty-seven of 269 abstracts (17%) subsequently appeared in 29 different peer-reviewed journals, led by Clinical Toxicology (13 out of 47, 28%). Leading countries of origin were the USA (8), UK (7) and Italy (6). The proportions of publications from native English-speaking and non-native English-speaking countries were similarly low (16% vs. 19%). CONCLUSIONS: Fewer than one in six abstracts reached publication within five years of the 2013 EAPCCT meeting. This rate is lower than in other specialty medical societies.

Pediatric Electric Bicycle Injuries: The Experience of a Large Urban Tertiary Care Pediatric Hospital.

BACKGROUND: Electric bicycles (E-bikes) are one of a wide range of light electric vehicles that provide convenient local transportation and attractive recreational opportunities. The aim of this study was to report E-bike-related injuries in children presenting to a trauma center. METHODS: Retrospective observational study, from December 2014 to November 2015, which included all pediatrics patients admitted to the emergency department with an injury related to E-bike use, was performed. RESULTS: A total of 97 E-bike injuries presented to the emergency department during this period. Mean age of E-bikers was 13.7 years (range, 7.5-16 years). Injuries to the head and the upper and the lower extremities were the most common. Thirteen patients (15%) were admitted, and 4 underwent surgery. CONCLUSIONS: Children are mainly injured as riders when using E-bikes. There is a need for regulation regarding the use of E-bikes to enhance the safety of both bikers and other road and pavement users.

Comparison Between Small and Large Bowel Intussusception in Children: The Experience of a Large Tertiary Care Pediatric Hospital.

BACKGROUND: Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to serious sequelae. The objective of this study was to determine the prevalence of ileoileal intussusception and to document and compare clinical outcomes with ileocolic intussusception. METHODS: A retrospective cohort study of children with an abdominal ultrasound that diagnosed intussusception. Clinical data and diagnostic studies were retrieved, to compare ileoileal with ileocolic intussusception. RESULTS: A total of 488 patients were evaluated with an abdominal ultrasound on suspicion of intussusception; 54 (11%) had ileoileal intussusception and 30 (6%) ileocolic intussusception. The significant features distinguishing the 2 conditions were fever, more common in patients with ileoileal intussusception, and an abdominal mass, which was papable more commonly in ileocolic intussusception. None of the ileoileal intussusception patients required surgical intervention, and all were discharged without complication. CONCLUSIONS: With recent advances in abdominal ultrasound, the diagnosis of ileoileal intussusception has become easier than before. Patients presenting with small bowel intussusception may not need any immediate intervention. The presence of fever supports the diagnosis of ileoileal intussusception.

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.

A Case of Methotrexate Neurotoxicity Presented as Status Epilepticus, Encephalopathy, and High Fever.

High-dose methotrexate is used to treat a range of adult and childhood cancers including osteosarcoma. Significant neurotoxicity is reported in 1% to 4.5% of patients treated with high-dose methotrexate and can present in a wide variety of symptoms. We present a case of a 14-year-old boy with a recent diagnosis of osteosarcoma who presented to the emergency department with status epilepticus, altered mental status, and very high fever secondary to methotrexate neurotoxicity. We review current literature and discuss some controversies related to this state. We also describe high fever as one of the possible symptoms associated with this condition and suggest using specific magnetic resonance imaging sequence to uncover abnormal findings related to this state. Since high-dose methotrexate is not a rare treatment in this era, we believe that in addition to oncologists, emergency department and intensive care providers should be aware of the potential role of methotrexate in causing significant neurotoxicity and include it in the differential diagnosis when treating a patient presenting with new neurological symptoms in the setting of recent high-dose methotrexate treatment.

Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning.

Drowning is a leading cause of injury-related death worldwide, but there are limited data on the management and disposition of asymptomatic and mildly symptomatic adults and children following a drowning event. Some authors have recommended admission for all drowning victims due to the possibility of respiratory and clinical deterioration in a seemingly well patient. In order to identify predictors for admission and to establish a unified approach for management, we retrospectively collected all children ≤ 16 years old presented following a drowning event to the pediatric ED over a period of 12 years. The children were divided into two groups, those who were discharged home from the ED and those who were admitted. Seventy-one surviving and non-intubated children were asymptomatic to moderately symptomatic, and they comprised the study group. Crepitations on lung auscultation, oxygen desaturation, and respiratory distress were significantly higher in the admitted group (n = 26) compared with the discharged group (n = 45) (P < 0.05). Respiratory distress and lung crepitations were independent predictors for admission. Eventually, 30% of the hospitalized patients required oxygen therapy, but there were no cases that deteriorated and required invasive ventilation. No readmissions occurred in the group of children who were discharged from the ED.Conclusion: Children who after six hours show no respiratory distress and have normal oxygen saturation and normal auscultation can be safely discharged home. Respiratory distress and lung crepitations should both warrant the physician to consider admission of asymptomatic to moderately symptomatic children following a drowning event. An algorithm to assist patient management is proposed. What is Known: •There are few data in the literature regarding the management and disposition of asymptomatic to moderately symptomatic children after drowning. What is New: •We found that respiratory distress and lung crepitations are independent predictors for admission. An algorithm to assist patient management is proposed.

Outpatient Management of Headache after Pediatric Emergency Department Visit: Are we Missing Anything?

BACKGROUND: Headache is a common complaint in children at a pediatric emergency department (PED). The primary objective of this analysis is to describe the outcome of patients presenting with headache to the PED and discharged with neurology follow up. The secondary objective is to describe the diagnostic evaluation children with headache underwent in the PED and to evaluate headache characteristics which are more likely associated with serious, life-threatening conditions. METHODS: A retrospective chart review of children who were discharged from the PED after evaluation for headache, with a scheduled urgent neurology outpatient clinic follow up at the same institution, over a 3.5-year period. RESULTS: During the study period, we identified 300 children whose admitting diagnosis was headache and they were discharged from the PED with a scheduled follow up. None of these patients had papilledema on fundoscopy performed by an ophthalmologist during the PED visit. Following neurology outpatient clinic visit, 62 (21%) were referred to perform brain magnetic resonance imaging. None of the patients had a diagnosis of brain tumor or any anatomic abnormality that could increase intracranial pressure. CONCLUSIONS: No immediate life-threatening cases presented to the follow up neurology clinic for evaluation. A scheduled urgent neurology outpatient clinic follow up in any child with headache who is discharged from the PED, offers a safety net, even when the physical examination including fundoscopy is normal.

A Comparison of Manual versus Electric Bicycle Injuries Presenting to a Pediatric Emergency Department.

BACKGROUND: The use of electric bicycles (E-bikes) has dramatically increased over the last decade. E-bikes offer an inexpensive, alternative form of transport, but also pose a new public health challenge in terms of safety and injury prevention. OBJECTIVE: The aim of this study was to describe the epidemiology and severity of E-bike related injuries among children treated in the emergency department (ED) and to compare these to manual bicycle related injuries. METHODS: A retrospective observational study of all pediatric patients presenting to the ED between December 2014 and November 2015 with an injury related to E-bike or manual bicycle use. Data including demographics, diagnosis, injury severity score (ISS), and outcome were compared. RESULTS: A total of 196 cyclist injuries presented to the ED; 85 related to E-bike use and 111 to manual bicycle riders. The mean age of E-bikers was 13.7 years (7.5-16 years) and of manual bicycle riders was 9.9 years (3-16 years). Injuries to the head and the extremities were common in both groups. E-bikers had significantly more intra-abdominal organ injury (P=0.047). Injury severity scores were low overall, but injuries of higher severity (ISS>9) only occurred among the E-bikers. CONCLUSIONS: Pediatric E-bike injuries tend to be more severe than those sustained during manual bicycle riding. Further research into bicycle and other road and pavement users could lead to enhanced regulation regarding E-bike usage.

Severe disseminated intravascular coagulation in a child envenomated by Echis coloratus and successful treatment with monovalent equine immunoglobulin G antivenom.

BACKGROUND: Echis coloratus (Burton Carpet viper), a highly venomous snake belonging to the family Viperidae, is responsible for a large proportion of the venomous snakebites in Israel and Palestinian Authority. Procoagulant enzymes are present in Echis coloratus venom and significant coagulopathy is typical after envenomation. Here we report a case of envenomation by Echis coloratus that involved severe coagulopathy as the main systemic manifestation with severe bleeding after fasciotomy. CASE DETAILS: A 3-year-old boy was admitted to our pediatric critical care unit after a snakebite to his left hand, 2-3 hours post-bite. Based on the possibility of compartment syndrome, a fasciotomy was performed before administration of antivenom. At our hospital, he had altered prothrombin time (PT) and activated partial thromboplastin time (aPTT), with low fibrinogen levels. The snake responsible for the bite was later identified as a 38-cm long Echis coloratus. Five vials of Israeli monovalent antivenom were subsequently administered with step-wise improvement in hematological abnormalities. Other treatments included massive blood products transfusion (packed RBC, FFP, cryoprecipitate, PLT), inotropes and ventilatory support. After a prolonged hospital course the patient had a positive outcome.