A new clinical score to identify children at low risk for appendicitis.

BACKGROUND: Besides clinical signs and imaging, in recent years, biomarkers have proven to be a viable diagnostic resource for acute appendicitis (AA). OBJECTIVE: The objective of this study was to develop a clinical score including clinical signs and a combination of biomarkers to identify children with abdominal pain at low risk of AA. DESIGN/METHODS: We prospectively included children 2 to 14 years of age with abdominal pain suggestive of AA who presented to the emergency department between July 2016 and September 2017. A new score, the Pediatric Appendicitis Laboratory Score (PALabS) including clinical signs, leucocyte (WBC) and neutrophil (ANC) counts and plasma C-reactive protein (CRP) and calprotectin (CP) levels was developed and validated through secondary analyses of two distinct cohorts The validation sample included visits to a single pediatric emergency department from 2012 to 2013 and 2016 to 2017. RESULTS: The derivation sample included 278 children, 35.9% of whom had AA and the validation sample included 255 children, 49% of whom had AA. Using logistic regression, we created a 6-part score that consisted of nausea (3 points), history of focal right lower quadrant pain (4 points), ANC of ≥7500/µL (7 points), WBC of ≥10,000/µL (4 points), CRP ≥ 10.0 mg/L (2 points) and CP ≥ 0.50 ≥ ng/mL (3 points). This score exhibited a high discriminatory power (area under the curve: 0.88; 95% confidence interval: 0.84 to 0.92) and outperformed the PAS and Kharbanda scores (area under the curve: 0.76; 95% confidence interval: 0.71 to 0.82 and 0.82; 95% confidence interval: 0.77 to 0.87, respectively). A PALabS ≤6 had a sensitivity of 99.2% (95% confidence interval [CI]: 95.6-99.9), negative predictive value of 97.6% (95% CI: 87.7-99.6), and negative likelihood ratio of 0.03 (95% CI: 0.00-0.18) in the validation set. CONCLUSION: In our validation cohort of patients with acute abdominal pain, the new score can accurately predict which children are at low risk of appendicitis and could be safely managed with close observation.

Recomendaciones sobre la prevención de intoxicaciones / Recommendations for the prevention of poisoning

Las intoxicaciones constituyen la quinta causa de muerte por una lesión no intencionada en la región europea de la OMS, si bien España se encuentra en el grupo con una menor tasa. La mayoría de las intoxicaciones no voluntarias se dan en niños pequeños, en su casa, por la ingesta de medicamentos o productos del hogar. De estos últimos un porcentaje importante se almacena en recipientes no originales o al alcance de los niños. En el presente artículo, el Comité de Seguridad y Prevención de Lesiones No Intencionadas en la Infancia de la Asociación Española de Pediatría proporciona una serie de recomendaciones tanto educativas como legales para prevenir este tipo de lesiones

Poisoning is the fifth leading cause of death from unintentional injury in the WHO European region, while Spain is in the group with a lower rate. Most involuntary poisonings occur in young children while they are at the home, due to unintentional ingestion of therapeutic drugs or household products. Of these, a large percentage is stored in non-original containers and/or within reach of children. In this article, the Committee on Safety and Non-Intentional Injury Prevention in Childhood of the Spanish Association of Pediatrics provides a series of recommendations, educational as well as legal, to prevent such cases

Ingesta de psicofármacos: causa más frecuente de intoxicaciones pediátricas no intencionadas en España / Therapeutic psychotropic drugs: Most common cause of unintentional poisoning in children

INTRODUCCIÓN: El objetivo es conocer cuáles son los agentes más habitualmente implicados en las intoxicaciones medicamentosas no intencionadas que consultan en los Servicios de Urgencias Pediátricos (SUP) en España. MATERIAL Y MÉTODOS: Estudio descriptivo basado en un registro prospectivo de las intoxicaciones registradas en los 57 SUP participantes del Observatorio Toxicológico de la Sociedad Española de Urgencias de Pediatría entre octubre de 2008 y septiembre de 2013. RESULTADOS: En el periodo estudiado se registraron 639 intoxicaciones, de ellas 459 (71.8%) ingestas no intencionadas. Los agentes principales implicados fueron los fármacos (253, 55,1%), seguidos de los productos del hogar (137, 29,8%). Los grupos de fármacos más involucrados fueron los psicofármacos (62, 24,5%); de estos, 54 benzodiacepinas, anticatarrales (41, 16,2%) y antitérmicos (39, 15,4%). CONCLUSIONES: La causa más importante de consulta por una intoxicación no intencionada en la infancia en los SUP españoles es la ingesta de psicofármacos, sobre todo benzodiacepinas

INTRODUCTION: The aim of this article is to determine the most common substances involved in unintentional poisoning in children attending Pediatric Emergency Departments (PED) in Spain. METHODS: A descriptive study was conducted based on a prospective registry of the poisonings registered in the 57 PED participating in the Toxicology Surveillance System of the Spanish Society of Pediatric Emergencies between October 2008 and September 2013. RESULTS: A total of 639 poisoning were registered during the study period, 459 of them (71.8%) were unintentional. The most commonly involved substances were drugs (253, 55.1%) followed by household products (137, 29.8%). The drug groups most involved were psychotropic drugs (62, 24.5%), which included benzodiazepines (54), anti-catarrhal (41, 16.2%), and antipyretics (39, 15.4%). CONCLUSIONS: The most common reason for consulting Spanish PEDs is the unintentional ingestion of psychotropic drugs, mainly benzodiazepines

[Therapeutic psychotropic drugs: Most common cause of unintentional poisoning in children]. / Ingesta de psicofármacos: causa más frecuente de intoxicaciones pediátricas no intencionadas en España.

INTRODUCTION: The aim of this article is to determine the most common substances involved in unintentional poisoning in children attending Pediatric Emergency Departments (PED) in Spain. METHODS: A descriptive study was conducted based on a prospective registry of the poisonings registered in the 57 PED participating in the Toxicology Surveillance System of the Spanish Society of Pediatric Emergencies between October 2008 and September 2013. RESULTS: A total of 639 poisoning were registered during the study period, 459 of them (71.8%) were unintentional. The most commonly involved substances were drugs (253, 55.1%) followed by household products (137, 29.8%). The drug groups most involved were psychotropic drugs (62, 24.5%), which included benzodiazepines (54), anti-catarrhal (41, 16.2%), and antipyretics (39, 15.4%). CONCLUSIONS: The most common reason for consulting Spanish PEDs is the unintentional ingestion of psychotropic drugs, mainly benzodiazepines.

[Recommendations for the prevention of poisoning]. / Recomendaciones sobre la prevención de intoxicaciones.

Poisoning is the fifth leading cause of death from unintentional injury in the WHO European region, while Spain is in the group with a lower rate. Most involuntary poisonings occur in young children while they are at the home, due to unintentional ingestion of therapeutic drugs or household products. Of these, a large percentage is stored in non-original containers and/or within reach of children. In this article, the Committee on Safety and Non-Intentional Injury Prevention in Childhood of the Spanish Association of Pediatrics provides a series of recommendations, educational as well as legal, to prevent such cases.

Diferencias territoriales en las intoxicaciones agudas en menores de 14 años en España / Regional differences in acute poisoning in under 14 year-old children in Spain

INTRODUCCIÓN: La identificación de variaciones en las intoxicaciones en diferentes regiones puede facilitar una prevención más eficaz. OBJETIVOS: Analizar el perfil de las intoxicaciones agudas pediátricas en diferentes regiones españolas. MATERIAL Y MÉTODOS: Registro prospectivo de las intoxicaciones registradas en 53 servicios de urgencias pediátricos incluidos en el Observatorio Toxicológico de la Sociedad Española deUrgencias de Pediatría entre 2008 y 2013. RESULTADOS: Se registraron 566 intoxicaciones en menores de 14 años, 458 (81,1%) por ingestas no voluntarias (mecanismo principal en todas las regiones). Las intoxicaciones por errores de dosificación fueron más habituales en Madrid (12,4% del total vs. 5% en el resto; p = 0,009); confin recreacional en la región Vasconavarra y Zaragoza (14,4 vs. 3,4% en el resto; p = 0,0008); porCO en Cataluña, Madrid y Otros (7,1 vs. 0,3%; p < 0,0001). CONCLUSIONES: Los perfiles de intoxicaciones agudas en menores de 14 años varían significativamente entre las diferentes regiones españolas

INTRODUCTION: The identification of variations in different profiles of pediatric poisonings may improve the prevention of these episodes. OBJECTIVES: To analyze the profile of pediatric acute poisonings in different regions of Spain. MATERIAL AND METHODS: A study was conducted, based on a prospective registry of the acute pediatric poisonings registered in 53 Spanish pediatric emergency departments included in the Toxicology Surveillance System of the Spanish Society of Pediatric Emergencies between 2008 and 2013. The regions were defined taking into account geographic factors, and the structuring of regional pediatric societies. RESULTS: A total of 566 poisoning were recorded in children less than 14 years. Poisonings due to dosage errors were more common in Madrid (12.4% of the whole group of poisonings vs 5.0% in the other regions, P = .009); recreational poisonings were more common in the Basque-Navarre region and Zaragoza (14.4% vs 3.4% in the others, P = .0008); and CO poisoning in Catalonia, Madrid and others (7.1% vs 0.3%, P < .0001). CONCLUSIONS: The profiles of acute poisonings in children less than 14 years vary significantly between the different Spanish regions. An epidemiological Surveillance System is a good tool to collect information in order to design preventive actions

Recomendaciones sobre la prevención de ahogamientos / Recommendations for the prevention of drowning

El ahogamiento supone la segunda causa de muerte accidental en menores de 19 años en Europa. Las condiciones climáticas en España permiten un amplio periodo de contacto con el agua, aumentando el riesgo por mayor exposición y constituyendo la segunda causade mortalidad accidental en menores de 14 años. Los ahogamientos en menores de 5 años se producen sobre todo en piscinas particulares o de comunidades privadas y, en el caso de niños mayores, suelen estar ligados a actividades acuáticas de tipo lúdico en lagos, mar, ríos y canales, y, en ocasiones, asociadas al consumo de alcohol. En el presente artículo, el Comité de Seguridad y Prevención de Lesiones No Intencionadas en la Infancia de la Asociación Española de Pediatría proporciona una serie de recomendaciones para prevenir este tipo de lesiones, tanto arquitectónicas como educativas y legislativas

Drowning is the second leading cause of non-intentional death in children under the age of 19 in Europe. Weather conditions in Spain allow an extended period of contact with water, therefore increasing the risk of drowning (due to the increased exposure), and constitutes the second leading cause of accidental death in children less than 14 years of age. In childrenyounger than 5 years, drowning occurs mostly in pools belonging to private homes or communities, while in older children, drowning is often linked to aquatic recreational activities in lakes,sea, rivers and canals, and at times associated with alcohol consumption. In this article, the Committee on Safety and Non-Intentional Injury Prevention in Childhood of the Spanish Association of Pediatrics provides a series of architectonic, educational and legislative recommendations to prevent such incidents

[Recommendations for the prevention of drowning]. / Recomendaciones sobre la prevención de ahogamientos.

Drowning is the second leading cause of non-intentional death in children under the age of 19 in Europe. Weather conditions in Spain allow an extended period of contact with water, therefore increasing the risk of drowning (due to the increased exposure), and constitutes the second leading cause of accidental death in children less than 14 years of age. In children younger than 5 years, drowning occurs mostly in pools belonging to private homes or communities, while in older children, drowning is often linked to aquatic recreational activities in lakes, sea, rivers and canals, and at times associated with alcohol consumption. In this article, the Committee on Safety and Non-Intentional Injury Prevention in Childhood of the Spanish Association of Pediatrics provides a series of architectonic, educational and legislative recommendations to prevent such incidents.

Bacteremia in previously healthy children in emergency departments: clinical and microbiological characteristics and outcome.

A blood culture (BC) is frequently requested in both patients with a suspected occult bacteremia/invasive infection as well as those with certain focal infections. Few data are available on the characteristics of patients in whom a bacteremia is identified in the Pediatric Emergency Department (PED). A prospective multicenter registry was established by the Spanish Pediatric Emergency Society. Epidemiological data, complementary test results, clinical management, and final outcome were recorded. Data from the first three years of the registry were analyzed. A true bacterial pathogen grew in 932 of 65,169 BCs collected [1.43 %; 95 % confidence interval (CI) 1.34-1.51 %], with 711 of them collected in patients without previously known bacteremia risk factors. Among them, 335 (47.1 %) were younger than 1 year old and 467 (65.7 %) had a normal Pediatric Assessment Triangle (PAT) on admission. Overall, the most frequently isolated bacterial species was Streptococcus pneumoniae (27.3 %; 47.6 % among patients with an altered PAT). The main pathogens were Escherichia coli (40.3 %) and S. agalactiae (35.7 %) among patients younger than 3 months, S. pneumoniae among patients 3-60 months old (40.0 %), and S. aureus (31.9 %) among patients over 60 months of age. Neisseria meningitidis was the leading cause of sepsis in patients older than 3 months. Eight patients died; none of them had a pneumococcal bacteremia and all had abnormal PAT findings on admission. S. pneumoniae is the main cause of bacteremia in patients without bacteremia risk factors who attended Spanish PEDs. Age and general appearance influence the frequency of each bacterial species. General appearance also influences the associated mortality.

[Regional differences in acute poisoning in under 14 year-old children in Spain]. / Diferencias territoriales en las intoxicaciones agudas en menores de 14 años en España.

INTRODUCTION: The identification of variations in different profiles of pediatric poisonings may improve the prevention of these episodes. OBJECTIVES: To analyze the profile of pediatric acute poisonings in different regions of Spain. MATERIAL AND METHODS: A study was conducted, based on a prospective registry of the acute pediatric poisonings registered in 53 Spanish pediatric emergency departments included in the Toxicology Surveillance System of the Spanish Society of Pediatric Emergencies between 2008 and 2013. The regions were defined taking into account geographic factors, and the structuring of regional pediatric societies. RESULTS: A total of 566 poisoning were recorded in children less than 14 years. Poisonings due to dosage errors were more common in Madrid (12.4% of the whole group of poisonings vs 5.0% in the other regions, P=.009); recreational poisonings were more common in the Basque-Navarre region and Zaragoza (14.4% vs 3.4% in the others, P=.0008); and CO poisoning in Catalonia, Madrid and others (7.1% vs 0.3%, P<.0001). CONCLUSIONS: The profiles of acute poisonings in children less than 14 years vary significantly between the different Spanish regions. An epidemiological Surveillance System is a good tool to collect information in order to design preventive actions.

Investigación en urgencias pediátricas / Research in paediatric emergencies

No disponible

Intoxicaciones en menores de 7 años en España. Aspectos de mejora en la prevención y tratamiento / Poisoning in children under age 7 in Spain. Areas of improvement in the prevention and treatment

Introducción: La prevención de las intoxicaciones agudas pediátricas requiere conocer las circunstancias en que suceden. Objetivos: Analizar las circunstancias de las intoxicaciones en<7 años de edad y su manejo en los Servicios de Urgencias Pediátricos hospitalarios en España (SUPE). Material y métodos: Estudio prospectivo incluyendo episodios de intoxicaciones en <7 años de edad registrados en 44 hospitales entre los años 2008 y 2011. Resultados: Se registraron 400 intoxicaciones, 308 (77%) en <7 años; 23 (7,5%) referían episodios similares previos familiares. Sucedieron en domicilio familiar 230, principalmente por ingesta no intencionada (89,6%) de medicamentos (182; 59%), productos del hogar (75; 24,4%) y cosméticos (18; 5,8%). El 36,6% contactó previamente con otros servicios. En el hospital recibieron tratamiento 160 (51,9%) y el 45,4% ingresó. Ninguno falleció. En las intoxicaciones por fármacos se practicaron más frecuentemente exploraciones complementarias (48,9% vs. 32% por productos del hogar y 11,1% por cosméticos; p<0,05), tratamientos (64,8% vs. 36% y 16,6%; p<0,0001) e ingreso (54,9% vs. 37,3% y 5,5%; p=0,015) y el 12,1% no fue por ingesta accidental (vs. 2,6% y 0%; p<0,05), sobre todo errores de dosificación. Las intoxicaciones por productos del hogar se asociaron más frecuentemente a conservación en envases no originales y al alcance de los niños. Conclusiones: La mayoría de las intoxicaciones atendidas en SUPE suceden en <7 años, tras ingesta no intencionada de fármacos y productos del hogar en el domicilio. Las intoxicaciones por fármacos fueron potencialmente más peligrosas. La prevención debiera considerar la educación sobre almacenaje de medicamentos/productos del hogar, administración de medicamentos y consejos para evitar nuevos episodios (AU)

Introduction: To prevent acute poisoning in children we need to know in which circumstances they occur. Objective: To analyse the circumstances of poisoning in children under 7 years-old and the management of these children in Spanish Paediatric Emergency Departments (SPED). Material and methods: We perform a prospective study of charts of poisoned children less than 7 years admitted to 44 hospitals between 2008 and 2011. Results: A total of 400 poisoned children were recorded: 308 (77%) in children under 7 years, of whom 23 (7.5%) of them had previous episodes of poisoning in the family. More than half (230) occurred at home, mainly due to accidental ingestion (89.6%), of drugs (182, 59%), household products (75, 24.4%), and cosmetics (18, 5.8%). More than one-third (36.6%) contacted other departments before the patient reached SPED. A total of 160 (51.9%) were treated in the hospital, and 45.4% were admitted in the hospital. None of them died. Drug poisoning required complementary tests more often (48.9% vs. 32% household products, and 11.1% cosmetics, P<.05), more treatments (64.8% vs. 36% and 16.6%, P<.0001) and more admissions (54.9% vs. 37.3% and 5.5%, P=.015), and 12.1% were not due to accidental ingestion but dosage errors (vs. 2.6% and 0%, P<.05).Household product poisonings were more often related with storage in non-original packaging and being reachable by children. Conclusions: The most frequent poisonings seen in SPED were caused by the accidental ingestion of drugs and household products by children less than 7 years-old at home. Drug poisoning was potentially more risky. Drug and household product storage education, proper drug dosage and administration, and good advice are the main issues to prevent these poisonings (AU)

[Poisoning in children under age 7 in Spain. Areas of improvement in the prevention and treatment]. / Intoxicaciones en menores de 7 años en España. Aspectos de mejora en la prevención y tratamiento.

INTRODUCTION: To prevent acute poisoning in children we need to know in which circumstances they occur. OBJECTIVE: To analyse the circumstances of poisoning in children under 7 years-old and the management of these children in Spanish Paediatric Emergency Departments (SPED). MATERIAL AND METHODS: We perform a prospective study of charts of poisoned children less than 7 years admitted to 44 hospitals between 2008 and 2011. RESULTS: A total of 400 poisoned children were recorded: 308 (77%) in children under 7 years, of whom 23 (7.5%) of them had previous episodes of poisoning in the family. More than half (230) occurred at home, mainly due to accidental ingestion (89.6%), of drugs (182, 59%), household products (75, 24.4%), and cosmetics (18, 5.8%). More than one-third (36.6%) contacted other departments before the patient reached SPED. A total of 160 (51.9%) were treated in the hospital, and 45.4% were admitted in the hospital. None of them died. Drug poisoning required complementary tests more often (48.9% vs. 32% household products, and 11.1% cosmetics, P<.05), more treatments (64.8% vs. 36% and 16.6%, P<.0001) and more admissions (54.9% vs. 37.3% and 5.5%, P=.015), and 12.1% were not due to accidental ingestion but dosage errors (vs. 2.6% and 0%, P<.05). Household product poisonings were more often related with storage in non-original packaging and being reachable by children. CONCLUSIONS: The most frequent poisonings seen in SPED were caused by the accidental ingestion of drugs and household products by children less than 7 years-old at home. Drug poisoning was potentially more risky. Drug and household product storage education, proper drug dosage and administration, and good advice are the main issues to prevent these poisonings.

Estudio descriptivo de los hemocultivos positivos en un servicio de urgencias pediátrico / Positive blood cultures in a pediatric emergency department: a descriptive analysis

Se describe las patologías y los microorganismos que causan bacteriemia y la influencia del hemocultivo (HC) positivo en urgencias en el manejo posterior. Se trata de un estudio retrospectivo de los HC positivos realizados en urgencias durante 2008 y 2009. Se consideró el cambio de la actitud terapéutica, el inicio o modificación del antibiótico y/o el ingreso hospitalario. Se realizaron 7.582 HC. En 382 (5,0%) hubo crecimiento bacteriano, 88 (23,0%) fueron verdaderos positivos. La neumonía y la infección urinaria fueron las principales patologías asociadas a bacteriemia y S. pneumoniae y E. coli los microorganismos más frecuentes. El HC positivo condicionó cambio de actitud terapéutica en un tercio de los episodios, principalmente en pacientes con fiebre sin foco. Se concluye que la positividad del HC condicionó un cambio de actitud terapéutica en un número significativo de pacientes, aunque dada la baja prevalencia de bacteriemia el impacto global fue bajo (AU)

We describe the infections and microorganisms causing bacteremia in an emergency department and to analyze the influence of a positive blood culture on subsequent management. It is a retrospective study of positive blood cultures ordered in the emergency department in 2008 and 2009. A change in therapeutic approach was defined as the initiation or modification of antibiotic therapy and/or hospital admission. A total of 7582 blood cultures were ordered. Bacteria grew in 382 (5.0%); 88 (23.0%) were true positives. Pneumonia and urinary tract infection were the main diagnoses associated with bacteremia. The pathogens implicated most often were Streptococcus pneumoniae and Escherichia coli. A positive blood culture led to a change in therapeutic approach in a third of the cases, mainly in patients with fever of unknown origin. We conclude that the management changed on the basis of blood culture findings in a significant number of cases although given the low prevalence of bacteremia, the overall impact was low (AU)

Evaluación de la escala canadiense de triaje pediátrico en un servicio de urgencias de pediatría europeo / Canadian Paediatric Triage and Acuity Scale: assessment in a European pediatric emergency department

Objetivo: Evaluar el funcionamiento y fiabilidad de una versión informatizada de la Canadian Paediatric Triage and Acuity Scale (PaedCTAS) en un servicio de urgencias pediátrico(SUP) europeo. Método: Revisión retrospectiva de los episodios de pacientes valorados en el 2007, recogiendo datos sobre el nivel de gravedad, la estancia media, la tasa de hospitalización y pruebas complementarias. Evaluamos la fiabilidad que comparaba la clasificación de casos teóricos (concordancia entre diferentes evaluadores y exactitud con respecto a una valoración de referencia).Resultados: Se analizaron 57.617 episodios cuya distribución por niveles fue la siguiente: nivel I 0,1%; II 1,7%; III 43,1%; IV 50% y V 5,1%. El porcentaje de pruebas complementarias realizadas varió desde un 63,6% en el nivel I a un 8% en el nivel V(p < 0,01). El tiempo de estancia media (TEM) aumentó progresivamente desde 72 minutos para el nivel V a 373 min. para el I. Las tasas de hospitalización fueron también diferentes para cada nivel de gravedad (desde 84% en el nivel I a 1,6% en el nivel V;p < 0,001). En el estudio de fiabilidad, la valoración del triángulo de evaluación pediátrica fue exacta en el 93,6% de los casos y el índice Kappa fue de 0,77 (IC 95% 0,75-0,79). Se asignó correctamente el nivel de gravedad (o incluyó un desacuerdo irrelevante en el 80,3% de los casos), y el índice Kappa fue 0,47 (IC 95% 0,46-0,48).Conclusiones: La Paed CTAS parece aplicable en un SUP europeo aunque son mejorables determinados aspectos de la escala y de su aplicación en nuestro servicio (AU)

Objectives: To assess the functionality and reliability of a computerized version of the Canadian Paediatric Triage and Acuity Scale (PaedCTAS) in a European pediatric emergency department. Methods: Retrospective review of emergency cases in 2007. We collected data on the seriousness of each emergency mean patient stay in the department, rate of admission, and tests ordered. The reliability of the scale was estimated bycalculating the agreement between raters’ theoretical classification of cases and the reference assessment. Results: A total of 57617 emergencies were analyzed. The distribution by levels of severity were as follows: level 1,0.07%; level 2, 1.73%; level 3, 43.1%; level 4, 50%; and level 5, 5.1%. The frequency of orders for tests ranged from63.6% at level 1 to 8% at level 5 (P<.01). The mean duration of stay increased progressively from 72 minutes for level 5to 373 minutes for level 1. Admission rates also differed by severity level (from 84% at level 1 to 1.6% at level 5, P<.001).The reliability study showed that triage based on the Paediatric Assessment Triangle was exact in 93.6% of the cases; theκ index was 0.77 (95% confidence interval [CI] 0.75-0.79). The scale correctly assigned the level of severity or included only a slight discrepancy in 80.3% of the cases. The κ index was 0.47 (95% CI, 0.46-0.48).Conclusions: The PaedCTAS seems to be applicable to European pediatric emergency department use although certain features of the scale could be improved for application by our emergency department (AU)