Pediatric lateral patellar dislocation: is there a role for plain radiography in the emergency department?

BACKGROUND: Osteochondral fractures are reported to complicate patellar dislocations in 5-95% of patients. For this reason, post-reduction radiographs are recommended for the routine evaluation of patellar dislocations in all patients. To date, no data have been reported regarding the impact plain radiography has on the Emergency Department (ED) management of pediatric patients with lateral patellar dislocations. STUDY OBJECTIVES: To estimate the incidence of fractures detected by post-reduction plain radiographs in pediatric patients presenting with unreduced lateral patellar dislocations and to examine differences in ED management between patients with and without radiographically apparent fractures. METHODS: Retrospective review of records for pediatric patients who presented to an ED, received a diagnosis of lateral patellar dislocation, and underwent a reduction procedure. RESULTS: Of 80 patients who met criteria for inclusion in the study, 8 patients (10%; 95% CI 3-17) had a fracture identified. All patients, regardless of their radiographic findings, had their dislocation reduced uneventfully and were discharged with knee immobilization and a plan for outpatient follow-up. There were no statistically significant differences between those patients who had a detected fracture as compared to those without in terms of intravenous line placement (p = 1.000), parenteral analgesic administration (p = 0.965), procedural sedation administration (p = 0.922), ED length of stay (p = 0.706), or provision of a prescription for an oral analgesic upon discharge (p = 0.103). CONCLUSION: Osteochondral fractures were detected by plain radiography in 10% of patients presenting with lateral patellar dislocation and did not alter ED management. Pediatric patients with lateral patellar dislocations may be candidates for discharge from the ED after reduction without plain radiography. The modality by which to best determine the presence of a complicating osteochondral fracture (i.e., plain radiography, computed tomography, magnetic resonance imaging, or arthroscopy) may be left to the discretion of the orthopedic surgeon accepting the child in follow-up. Further study is needed to determine if forgoing plain radiographs in the ED decreases length of stay and reduces patient costs.

Nondepressed linear skull fractures in children younger than 2 years: is computed tomography always necessary?

BACKGROUND: Current recommendations are that young children with a skull fracture following head injury undergo computed tomography (CT) examination of their head to exclude significant intracranial injury. Recent reports, however, have raised concern that radiation exposure from CT scanning may cause malignancies. OBJECTIVE: To estimate the proportion of children with nondisplaced linear skull fractures who have clinically significant intracranial injury. METHODS: Retrospective review of patients younger than 2 years who presented to an emergency department and received a diagnosis of skull fracture. RESULTS: Ninety-two patients met the criteria for inclusion in the study; all had a head CT scan performed. None suffered a clinically significant intracranial injury. CONCLUSION: Observation, rather than CT, may be a reasonable management option for head-injured children younger than 2 years who have a nondisplaced linear skull fracture on plain radiography but no clinical signs of intracranial injury.

How well does serum bicarbonate concentration predict the venous pH in children being evaluated for diabetic ketoacidosis?

OBJECTIVE: The objective of the study was to determine whether serum bicarbonate (HCO3) concentration can accurately predict venous pH in the evaluation of diabetic ketoacidosis (DKA). METHODS: A retrospective review of patients who presented to a children's hospital emergency department and received an International Classification of Diseases, Ninth Revision code related to DKA or diabetes mellitus was performed. To be eligible for inclusion and data abstraction, patients had blood sampled simultaneously for venous blood gas and metabolic panel. A linear regression model was created using pH (dependent variable) and HCO3 (predictor). The diagnostic performance and accuracy of HCO3 to discriminate abnormal pH were evaluated using receiver operating characteristic curve analysis. RESULTS: Three hundred patients met the inclusion criteria. The linear relationship between pH and HCO3 using the Pearson correlation coefficient was found to be R = 0.89 (confidence interval [CI], 0.83-0.95; R = 0.79). Receiver operating characteristic curve analysis that maximized sensitivity and specificity demonstrated that a HCO3 18.5 or less predicts pH less than 7.3 (area under the curve = 0.97; CI, 0.94-0.99; sensitivity, 93%; specificity, 91%), and a HCO3 10.5 or less predicts pH less than 7.1 (area under the curve = 0.97; CI, 0.95-0.99; sensitivity, 97%; specificity, 88%). CONCLUSIONS: Serum bicarbonate accurately predicts abnormal venous pH in children with DKA. Venous pH determination may not be necessary for all patients being evaluated for DKA.

Utilization of emergency ultrasound in pediatric emergency departments.

OBJECTIVES: This study aimed to determine the utilization of emergency ultrasound (EUS) in pediatric emergency departments (EDs) and in pediatric emergency medicine (PEM) fellowship training programs and to assess if PEM fellowship programs provided formal training in EUS. METHODS: A Web-based survey was administered to pediatric emergency medical directors, fellowship directors, and graduating fellows. RESULTS: A response was received from 60% of individuals and 68% of institutions. Of the responders, 27% reported that their institution had a EUS program. Also, 96% of the responders reported having a dedicated US machine in the ED, but only 61% reported using EUS for managing ED patients. Responders reported using EUS for the focused assessment by sonography for trauma examination (93%), abscess management (82%), vascular access (78%), bladder scanning (70%), cardiac activity confirmation (59%), and pericardial effusion detection (59%). For pediatric emergency staff physicians, 63% of the responders reported obtaining EUS training from general emergency physicians and 59% from a commercial ultrasound course and from pediatric emergency physicians. For PEM fellows, 34% reported having a standardized EUS training program. Of the responders, 69% reported receiving training from general emergency physicians during adult ED rotations and 38% reported receiving training from pediatric emergency physicians. Only 28% of programs reported using criteria established by the American College of Emergency Physicians for the number of scans performed to attain competence. CONCLUSIONS: In our study sample, there is wide variation in the uses of EUS and the training pediatric emergency physicians receive in its use.

Rehydration: role for early use of intravenous dextrose.

Acute gastroenteritis is a common reason for children to seek health care. Among the potential complications of acute gastroenteritis, the most common is dehydration. For mild to moderate dehydration, treatment options include oral and intravenous rehydration. Outpatient treatment failure for either method, when it occurs, is often due to persistent nausea and vomiting. Some authorities have suggested that the early administration of dextrose to patients receiving intravenous rehydration may help terminate vomiting and result in fewer outpatient treatment failures. The purpose of this report was to review the evidence supporting the effectiveness of early intravenous dextrose administration in the outpatient management of dehydration in children with acute gastroenteritis.

Temporal bone rhabdomyosarcoma presenting as acute peripheral facial nerve paralysis.

Facial palsy is not an uncommon presentation to an emergency department. Whereas most patients will ultimately receive a diagnosis of Bell palsy (idiopathic peripheral seventh cranial nerve palsy), a subset will have an identifiable cause for their facial paralysis. Children are more likely to have an identifiable cause than are adults. We present a case in which a child presented with acute peripheral facial nerve palsy and was found to have temporal bone rhabdomyosarcoma. The key clinical finding was the presence of both 7th and 12th cranial nerve palsy.

Survey of academic pediatric emergency departments regarding use of evaluation and management codes.

OBJECTIVE: The aims of the study were to determine the frequency at which each emergency medicine evaluation and management (E/M) code is used, to identify factors associated with their use by academic pediatric emergency departments (PEDs), and to compare PED E/M code utilization rates with rates reported by Centers for Medicare and Medicaid Services for general emergency departments (EDs). METHOD: A 24-question survey was sent to 42 academic PED medical directors. Questions pertained to PED demographics, physician staff, records/documentation, billing education, and E/M coding data for 1 year. The general ED E/M code utilization rates were obtained from the published Centers for Medicare and Medicaid Services database. Descriptive statistics and odds ratios were used to report and compare the data. RESULTS: Twenty (48%) of the surveys were returned, and 9 (21%) completed the E/M coding data questions. From these 9 departments, the mean PED annual census was 46,065 (range, 23,531-92,910). The methods of PED medical record documentation were template (6), handwritten (2), and dictation/transcription (1). Charge documents were completed by the PED physician (3), professional service coders (4), and hospital coders (2). Coding/documentation in-services were provided to the physicians of 7 PEDs, and billing audits were performed in 5 PEDs. The total number of charges for the 9 PEDs was 325,129, 78.4% of the census. Multiple reasons were given for the discrepancy between census and charges. The percentage of each of the 5 levels of service billed was calculated for each of the 9 PEDs. The 2 lowest levels of service were used 38.3% of the time, whereas the 2 highest were used 19.2% of the time. The range for the highest level of service varied widely from 5.3% to 53.3%. Approximately 65% of E/M codes used by general EDs were for the 2 highest levels of service. The PED with the highest percentage of upper level charges (53.4%) was the only PED that used dictation/transcription for documentation. CONCLUSION: Although the response rate was low, and thus the validity of the results was limited, the findings may serve as a benchmark for E/M code utilization in PEDs. The large variation in use of the E/M codes among the PED in our study and the lower rate of using the highest E/M codes by the PEDs compared with the general EDs suggest potential opportunities for academic PEDs to improve billing practices.

Hypoglycemia complicating dehydration in children with acute gastroenteritis.

A study was done to estimate the prevalence of hypoglycemia among children with dehydration due to acute gastroenteritis, and to identify clinical variables associated with hypoglycemia in these children. A retrospective case series of children older than 1 month of age and younger than 5 years of age who presented to an urban children's hospital Emergency Department with acute gastroenteritis and dehydration was performed. Medical records were reviewed; demographic and clinical data, including pretreatment serum glucose concentrations, were recorded. There were 196 children comprising the study population. Eighteen children (9.2%) were hypoglycemic. The duration of vomiting was longer for the children with hypoglycemia (2.6 days, SD +/- 1.5) than for those without hypoglycemia (1.6, SD +/- 1.8), 95% CI 0.13 to 1.88. Hypoglycemia may complicate dehydration due to acute gastroenteritis in young children. Clinicians should examine the serum glucose concentration in these children.