Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region.

OBJECTIVES: Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock. METHODS: We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors. RESULTS: Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]). CONCLUSIONS: Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease.

STUDY OBJECTIVE: We evaluate the additive value of pelvic examinations in predicting sexually transmitted infection for young female patients with suspected cervicitis or pelvic inflammatory disease in a pediatric emergency department (ED). METHODS: This was a prospective observational study of female patients aged 14 to 20 years who presented to an urban academic pediatric ED with a complaint of vaginal discharge or lower abdominal pain. Enrolled patients provided a urine sample for chlamydia, gonorrhea, and trichomonas testing, which served as the criterion standard for diagnosis. A practitioner (pediatric ED attending physician, emergency medicine or pediatric resident, pediatric ED fellow, or advanced practice provider) obtained a standardized history from the patient to assess for cervicitis or pelvic inflammatory disease according to the Centers for Disease Control and Prevention criteria. They then recorded the likelihood of cervicitis or pelvic inflammatory disease on a 100-mm visual analog scale. The same practitioner then performed a pelvic examination and again recorded the likelihood of cervicitis or pelvic inflammatory disease on a visual analog scale with this additional information. Using the results of the urine sexually transmitted infection tests, the practitioner calculated and compared the test characteristics of history alone and history with pelvic examination. RESULTS: Two hundred eighty-eight patients were enrolled, of whom 79 had positive urine test results for chlamydia, gonorrhea, or trichomonas, with a sexually transmitted infection rate of 27.4% (95% confidence interval [CI] 22.6% to 32.8%). The sensitivity of history alone in diagnosis of cervicitis or pelvic inflammatory disease was 54.4% (95% CI 42.8% to 65.5%), whereas the specificity was 59.8% (95% CI 52.8% to 66.4%). The sensitivity of history with pelvic examination in diagnosis of cervicitis or pelvic inflammatory disease was 48.1% (95% CI 36.8% to 59.5%), whereas the specificity was 60.7% (95% CI 53.8% to 67.3%). The information from the pelvic examination changed management in 71 cases; 35 of those cases correlated with the sexually transmitted infection test and 36 did not. CONCLUSION: For young female patients with suspected cervicitis or pelvic inflammatory disease, the pelvic examination does not increase the sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomonas compared with taking a history alone. Because the test characteristics for the pelvic examination are not adequate, its routine performance should be reconsidered.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence.

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Point-of-Care Ultrasound in Pediatric Clinical Care.

IMPORTANCE: Point-of-care (POC) ultrasound has been used by a variety of nonradiologist physicians. Recently, POC ultrasound use by pediatricians has received increased attention with the practice of both established and novel applications. OBJECTIVES: To review various uses of ultrasound by pediatricians, discuss challenges and potential pitfalls as pediatric physicians seek to use ultrasound in their practices, and consider various areas of research needs and opportunities. EVIDENCE REVIEW: Available English-language publications from 1970 through December 31, 2014. FINDINGS: Limited research supports the notion that many POC ultrasound applications practiced by nonradiologist pediatricians can assist in clinical decision making and procedural success. Future challenges include the need for institutions to train and credential large numbers of health care professionals in the use of pediatric POC ultrasound, as well as the necessity of diverse research efforts, including the establishment of pediatric-specific norms, consideration of optimal educational strategies, and inquiry intended to identify best practices for clinical effectiveness and efficiency. CONCLUSIONS AND RELEVANCE: Although considerable effort needs to be devoted to the continued development of pediatric POC ultrasound, there is potential for useful application in a variety of clinical and educational settings.

A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures.

OBJECTIVES: The primary objective was to compare the cosmetic outcomes of traumatic trunk and extremity lacerations repaired using absorbable versus nonabsorbable sutures. The secondary objective was to compare complication rates between the two groups. METHODS: This was a randomized controlled trial comparing wounds repaired with Vicryl Rapide and Prolene sutures. Pediatric and adult patients with lacerations were enrolled in the study. At a 10-day follow-up, the wounds were evaluated for infection and dehiscence. After 3 months, patients returned to have the wounds photographed. Two plastic surgeons blinded to the method of closure rated the cosmetic outcome of each wound using a 100-mm visual analog scale (VAS). Using a noninferiority design, a VAS score of 13 mm or greater was considered to be a clinically significant difference. We used a Student's t-test to compare differences between mean VAS scores and odds ratios (ORs) to compare differences in complication rates between the two groups. RESULTS: Of the 115 patients enrolled, 73 completed the study including 35 in the Vicryl Rapide group and 38 in the Prolene group. The mean (±SD) age of patients who completed the study was 22.1 (±15.5) years, and 39 were male. We found no significant differences in the age, race, sex, length of wound, number of sutures, or layers of repair in the two groups. The observer's mean VAS for the Vicryl Rapide group was 54.1 mm (95% confidence interval [CI] = 44.5 to 67.0 mm) and for the Prolene group was 54.5 mm (95% CI = 45.7 to 66.3 mm). The resulting mean difference was 0.5 mm (95% CI = -12.1 to 17.2 mm; p = 0.9); thus noninferiority was established. Statistical testing showed no differences in the rates of complications between the two groups, but a higher percentage of the Vicryl Rapide wounds developed complications. CONCLUSIONS: The use of absorbable sutures for the repair of simple lacerations on the trunk and extremities should be considered as an alternative to nonabsorbable suture repair.

Evaluation of acute appendicitis by pediatric emergency physician sonography.

STUDY OBJECTIVE: We investigate the accuracy of pediatric emergency physician sonography for acute appendicitis in children. METHODS: We prospectively enrolled children requiring surgical or radiology consultation for suspected acute appendicitis at an urban pediatric emergency department. Pediatric emergency physicians performed focused right lower-quadrant sonography after didactics and hands-on training with a structured scanning algorithm, including the graded-compression technique. We compared their sonographic interpretations with clinical and radiologic findings, as well as clinical outcomes as defined by follow-up or pathologic findings. RESULTS: Thirteen pediatric emergency medicine sonographers performed 264 ultrasonographic studies, including 85 (32%) in children with pathology-verified appendicitis. Bedside sonography had a sensitivity of 85% (95% confidence interval [CI] 75% to 95%), specificity of 93% (95% CI 85% to 100%), positive likelihood ratio of 11.7 (95% CI 6.9 to 20), and negative likelihood ratio of 0.17 (95% CI 0.1 to 0.28). CONCLUSION: With focused ultrasonographic training, pediatric emergency physicians can diagnose acute appendicitis with substantial accuracy.

Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one?

OBJECTIVES: Our primary objective was to investigate whether urine drug screen (UDS) results affected the medical management of pediatric psychiatric patients presenting to the pediatric emergency department (ED) for psychiatric evaluation and whether it affected the final disposition of these patients. METHODS: This was a retrospective chart review of patients who presented to an urban pediatric ED in Newark, NJ, with psychiatric or behavior problems for medical clearance before psychiatric evaluation between June 3, 2008, and June 3, 2009. Inclusion criteria were any patient between the ages of 0 to 20 years who presented to the pediatric ED and had a UDS performed. Exclusion criteria were if the UDS was obtained for a primary medical workup such as altered mental status, known or admitted overdose, or accidental ingestions, or no psychiatric consultation was made from the ED. Abstracted descriptive data include patient's age, sex, race, and insurance status. Visit-specific data include patient's reason for visit, results of the UDS, psychiatric diagnosis if any, history of substance abuse if any, and management decisions other than psychiatric evaluation after medical clearance. RESULTS: A total of 875 charts were identified from laboratory records; 539 of those patients presented to the pediatric ED for psychiatric evaluation. A total of 62 patients had at least 1 substance detected on the UDS and were referred to psychiatry. All of the patients who had presented for psychiatric evaluation, including those with a positive result on the UDS, were medically cleared with no documented change in management or medical intervention in the pediatric ED. CONCLUSIONS: Obtaining a UDS on patients who presented to the pediatric ED for medical clearance before psychiatric evaluation did not alter medical decision for clearance nor necessitate any change in management or interventions before psychiatric evaluation.

Evaluation of hypertrophic pyloric stenosis by pediatric emergency physician sonography.

OBJECTIVES: The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS). METHODS: This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS. RESULTS: Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively). CONCLUSIONS: Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.

Implementing routine HIV screening in an urban pediatric emergency department.

OBJECTIVE: In 2006, the Centers for Disease Control and Prevention recommended that all outpatient health care settings offer routine, opt-out HIV screening for patients aged 13 to 64 years, except where the prevalence of undiagnosed HIV infection is known to be less than 0.1%. Most emergency departments (EDs) lack routine HIV screening. The objective of this investigation was to describe the results of the implementation of routine, nontargeted opt-in HIV screening for patients aged 13 to 20 years in an urban pediatric ED (PED) in a city in which 1 of 30 residents has HIV/AIDS. METHODS: This was a retrospective chart review from an urban, academic PED. The implementation of routine HIV screening in the ED was funded by the New Jersey Department of Health and Senior Services and planned independently of the study investigator. Patients aged 13 to 64 years were offered HIV screening by nursing staff, physicians, and/or HIV counselors. Patients who accepted were screened with rapid HIV fingerstick testing performed via Clearview HIV 1/2 STAT-PAK by HIV counselors as per the New Jersey Department of Health and Senior Services protocol. Data collected by the study investigator were done by chart review from October through December 2009, the first 3 months after implementation of routine HIV screening. Data were collected from patients aged 13 to 20 years presenting to the PED. Primary outcomes measured included the proportion of patients offered and accepted screening, newly diagnosed HIV cases, and the rate of linking newly diagnosed HIV patients to treatment. Demographic data collected included patient age, sex, and ethnicity. Results from the first 3 months of routine, nontargeted screening were compared with the HIV screening results of October through December 2008, during which time rapid HIV screening was provided to patients in the ED based on clinical indication. Patients who were not offered testing or who refused testing were measured by forms that were placed in every chart and collected by physicians. Emergency department census data were queried to identify the total number of patients seen in the ED within age range and time frame studied. RESULTS: Three hundred (11%) of the 2645 patients aged 13 to 20 years were offered routine HIV screening in the PED from October through December 2009. Two hundred twenty-four patients (74%) accepted HIV testing. No new cases of HIV were identified. There was an increase in acceptance of HIV testing that correlated with increasing age (P < 0.05). There was no significant difference between male and female acceptance rates (P < 0.05). Eleven (4.9%) of the patients accepting testing did not have testing performed because of unavailability of the counselor and/or the patient could not wait. Review of HIV testing performed in the PED from October through December 2008 showed 39 patients aged 13 to 20 years were tested. Routine testing increased the number of patients tested by 446%. CONCLUSIONS: Pediatric patients in this urban setting are very accepting of HIV testing. HIV screening is increased when routine screening is offered.

Effect of bedside ultrasound on management of pediatric soft-tissue infection.

BACKGROUND: Superficial soft-tissue infections (SSTI) are frequently managed in the emergency department (ED). Soft-tissue bedside ultrasound (BUS) for SSTI has not been specifically studied in the pediatric ED setting. OBJECTIVE: To evaluate the effect of a soft-tissue BUS evaluation on the clinical diagnosis and management of pediatric superficial soft-tissue infection. METHODS: We conducted a prospective observational study in two urban academic pediatric EDs. Eligible patients were aged < 18 years presenting with suspected SSTI. Before BUS, treating physicians were asked to assess the likelihood of subcutaneous fluid collection and whether further treatment would require medical management or invasive management. A trained emergency physician then performed a BUS of the lesion(s). A post-test questionnaire assessed whether the physician changed the initial management plan based on the results of the BUS. RESULTS: BUS changed management in 11/50 cases. After initial clinical assessment, 20 patients were designated to receive invasive management, whereas the remaining 30 patients were designated to receive medical management. Management changed in 6/20 in the invasive group. In the medical group, 5/30 patients changed management. BUS had a sensitivity of 90% (95% confidence interval [CI] 77-100%) and specificity of 83% (05% CI 70-97%), whereas clinical suspicion had a sensitivity of 75% (95% CI 56-94%) and specificity of 80% (95% CI 66-94%) in detecting fluid collections requiring drainage. CONCLUSIONS: BUS evaluation of pediatric SSTI may be a useful clinical adjunct for the emergency physician. It changed management in 22% of cases by detecting subclinical abscesses or avoiding unnecessary invasive procedures.