Trauma Visits to a Pediatric Emergency Department During the COVID-19 Quarantine and "Stay at Home" Period.

BACKGROUND: Impact of social distancing on pediatric injuries is unknown. METHODS: We retrospectively compared injury visits to a pediatric emergency department by individuals ≤21 years during "Stay at Home" (SHO) period to the same period in 2019 (non-SHO). Demographics, types, and outcomes of injuries were noted. RESULTS: Although, there was a 35.6% reduction in trauma-related emergency department visits during SHO period (1226 vs 1904), the proportion of injury visits increased (15.5% vs 8.1%, P < .001) and mean age was lower (5.8 yrs ±4.5 vs 8.4 yrs ± 5.2, P < .001). There were significant increases in visits related to child physical abuse (CPA), firearms, and dog bites. Further, significant increases in trauma alerts (P < .01), injury severity (P < .01), critical care admissions (P < .001), and deaths (P < .01) occurred during the SHO period. CONCLUSIONS: Although overall trauma-related visits decreased during SHO, the proportion of these visits and their severity increased. Trauma visits related to child physical abuse, dog bites, and firearms increased. Further studies are required to assess the long-term impact of pandemic on pediatric trauma epidemiology.

Multisystem inflammatory syndrome in children associated with novel coronavirus SARS-CoV-2: Presentations to a pediatric emergency department in Michigan.

The SARS-CoV-2 is a respiratory virus of the coronavirus family responsible for a global pandemic since December 2019. More than 35 million people have been affected with the novel coronavirus disease (COVID-19), with more than one million deaths worldwide. Michigan was one of the top three states in the United States that was severely affected by the SAR-CoV-2 pandemic with more than 7000 deaths in adults and greater than 145,000 confirmed infections. However, compared to adults, the majority of children until recently were either asymptomatic or had a mild illness with SARS-CoV-2. Recently, a rare but potentially serious presentation associated with SARS-CoV-2 called multisystem inflammatory syndrome in children (MIS-C) has been recently reported and the Centers for Disease Control (CDC) released a case definition for the same. We report the clinical and laboratory presentations and outcomes of 34 children with MIS-C who were evaluated within a 12 week period at a pediatric emergency department (PED) of single institution in Michigan. These cases presented approximately three weeks after the peak of adult SAR-CoV-2 related deaths occurred in the state. While many children presented with clinical characteristics similar to incomplete Kawasaki disease (KD), they also exhibited certain unique features which differentiated MIS-C from KD. The information presented below will aid clinicians with early recognition, evaluation and management of MIS-C in the emergency department.

A National Patient Safety Curriculum in Pediatric Emergency Medicine.

BACKGROUND: Patient safety has become an important and required topic in medical education. A needs assessment showed that pediatric emergency medicine program directors were interested in a common pediatric emergency-specific safety curriculum. OBJECTIVE: The objective of this study was to describe the development and performance of a web-based patient safety curriculum in pediatric emergency medicine. METHODS: A web-based curriculum was created by the Committee on Quality Transformation of the Section of Emergency Medicine for the American Academy of Pediatrics. The curriculum consisted of emergency-specific safety topic didactic sessions with a pretest and posttest assessment. Vignette-based scenarios were also included and were discussed locally by the program directors. RESULTS: Fifty-two percent (37/71) of US Pediatric Emergency Medicine fellowship programs enrolled their fellows in the patient safety curriculum. Overall, 183 Pediatric Emergency Medicine fellows participated in the curriculum. Only 22% (40/183) of fellow participants completed the entire curriculum. The curriculum showed significant improved safety knowledge based upon the pretest and posttest results. Sixty-five percent of responders thought more about safety topics after the curriculum was completed, and 85% witnessed a safety event in the past month, whereas only 48% reported them. CONCLUSIONS: An online centralized curriculum is an effective platform for teaching content in quality and safety to a national group of physicians. Local oversight by program directors may improve compliance with curriculum completion.

Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities.

This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

Visual Diagnosis: A 2-month-old Boy With an Unusual Rash.

Congenital syphilis should be considered in the differential diagnosis of common newborn rashes, especially if the palms and soles are involved. As soon as the diagnosis is confirmed, a lumbar puncture should be performed to rule out neurosyphilis and intravenous antibiotics started pending confirmatory testing.

Prevalence of serious bacterial infections in return visits to the emergency department among infants aged 90 days or younger.

OBJECTIVE: The main objective of this study was to describe the epidemiology of return visits (RVs) in well-appearing infants to an urban emergency department (ED) who were evaluated for serious bacterial infection (SBI) at their index ED visit. METHODS: We conducted a retrospective chart review on infants aged 90 days and younger who were evaluated for SBI at their initial ED visit from 2003 through 2009. A parent database of all febrile infants evaluated for SBI was queried to identify patients who had an RV within 7 days of the index visit. We collected demographic variables including age, sex, and past medical history as well as laboratory test results including white blood cell count, blood, urine, and cerebrospinal fluid cultures and viral studies. RESULTS: Of eligible febrile infants, 10.8% (350/3220) had an RV to the ED within 7 days. The prevalence of SBI in the RV cohort was 6.0% (21/350), which included 1.7% (6/350) bacteremia, 3.7% (13/350) urinary tract infection, and 0.6% (2/350) combined urinary tract infection and bacteremia. The blood culture contamination rate was 88%. CONCLUSIONS: Infants aged 90 days or younger who are evaluated for SBI have high RV rates. A substantial number of RVs are due to contaminated blood cultures. Future studies should be conducted to identify predictors for false-positive blood cultures.

Patient safety training in pediatric emergency medicine: a national survey of program directors.

OBJECTIVES: The Accreditation Council for Graduate Medical Education requires training in patient safety and medical errors but does not provide specification for content or methods. Pediatric emergency medicine (EM) fellowship directors were surveyed to characterize current training of pediatric EM fellows in patient safety and to determine the need for additional training. METHODS: From June 2013 to August 2013, pediatric EM fellowship directors were surveyed via e-mail. RESULTS: Of the 71 eligible survey respondents, 57 (80.3%) completed surveys. A formal curriculum was present in 24.6% of programs, with a median of 6 hours (range = 1 to 18 hours) dedicated to the curriculum. One program evaluated the efficacy of the curriculum. Nearly 91% of respondents without formal programs identified lack of local faculty expertise or interest as the primary barrier to implementing patient safety curricula. Of programs without formal curricula, 93.6% included at least one component of patient safety training in their fellowship programs. The majority of respondents would implement a standardized patient safety curriculum for pediatric EM if one was available. CONCLUSIONS: Despite the importance of patient safety training and requirements to train pediatric EM fellows in patient safety and medical errors, there is a lack of formal curriculum and local faculty expertise. The majority of programs have introduced components of patient safety training and desire a standardized curriculum.

Rapunzel syndrome: diagnosis via radiograph and history.

Rapunzel syndrome is defined as a gastric trichobezoar with a tail that extends distally into the small intestine. It is extremely rare and found more often in premenarchal girls with psychiatric comorbidities. Symptoms can be vague and linger for years. However, prolonged intake of indigestible material can lead to gastric outlet obstruction, which may present similarly to a small bowel obstruction. The standard imaging modality of choice to make a presurgical diagnosis is via computed tomography (CT) scan of the abdomen. However, the risk of radiation-induced malignancy associated with a CT scan is an important consideration when managing children. We report a case of Rapunzel syndrome in a 6-year-old girl who was diagnosed presurgically without the use of a CT scan.

Listeria and enterococcal infections in neonates 28 days of age and younger: is empiric parenteral ampicillin still indicated?

INTRODUCTION: Empiric parenteral ampicillin has traditionally been used to treat listeria and enterococcal serious bacterial infections (SBI) in neonates 28 days of age or younger. Anecdotal experience suggests that these infections are rare. Existing data suggest an increasing resistance to ampicillin. Guidelines advocating the routine use of empiric ampicillin may need to be revisited. OBJECTIVE: This study aimed to describe the epidemiology and ampicillin sensitivity of listeria and enterococcal infections in neonates 28 days of age and younger who presented to 2 pediatric emergency departments (ED) in Michigan. METHODS: We conducted a 2-center, retrospective chart review (2006-2010) of neonates 28 days of age or younger who were evaluated for SBI in the ED. We abstracted and compared relevant demographic, historical and physical details, laboratory test results, and antibiotic sensitivity patterns to ampicillin from the eligible patient records. RESULTS: We identified SBI in 6% (72/1192) of neonates 28 days of age or younger who were evaluated for SBI, of which 0.08% (1/1192) neonates had enterococcal bacteremia and 0.08% (1/1192) neonates had listeria bacteremia. A total of 1.4% (15/1192) of patients had enterococcal urinary tract infection (UTI). Urinalysis is less helpful as a screening tool for enterococcal UTI when compared with Escherichia coli UTI (P < 0.001). Seventy-three percent (11/15) of urine isolates had an increase of minimal inhibitory concentrations, which indicate gradual development of resistance to ampicillin. CONCLUSIONS: Listeria is an uncommon cause of neonatal SBI in febrile neonates who presented to the ED. Empiric use of ampicillin may need to be reconsidered if national data confirm very low listeria and enterococcal prevalence and high ampicillin resistance patterns.

Are routine pelvic radiographs in major pediatric blunt trauma necessary?

BACKGROUND: Screening pelvic radiographs to rule out pelvic fractures are routinely used for the initial evaluation of pediatric blunt trauma. Recently, the utility of routine pelvic radiographs in certain subsets of patients with blunt trauma has been questioned. There is a growing amount of evidence that shows the clinical exam is reliable enough to obviate the need for routine screening pelvic radiographs in children. OBJECTIVE: To identify variables that help predict the presence or absence of pelvic fractures in pediatric blunt trauma. MATERIALS AND METHODS: We conducted a retrospective study from January 2005 to January 2010 using the trauma registry at a level 1 pediatric trauma center. We analyzed all level 1 and level 2 trauma victims, evaluating history, exam and mechanism of injury for association with the presence or absence of a pelvic fracture. RESULTS: Of 553 level 1 and 2 trauma patients who presented during the study period, 504 were included in the study. Most of these children, 486/504 (96.4%), showed no evidence of a pelvic fracture while 18/504 (3.6%) had a pelvic fracture. No factors were found to be predictive of a pelvic fracture. However, we developed a pelvic fracture screening tool that accurately rules out the presence of a pelvic fracture P = 0.008, NPV 99, sensitivity 96, 8.98 (1.52-52.8). This screening tool combines eight high-risk clinical findings (pelvic tenderness, laceration, ecchymosis, abrasion, GCS <14, positive urinalysis, abdominal pain/tenderness, femur fracture) and five high-risk mechanisms of injury (unrestrained motor vehicle collision [MVC], MVC with ejection, MVC rollover, auto vs. pedestrian, auto vs. bicycle). CONCLUSION: Pelvic fractures in pediatric major blunt trauma can reliably be ruled out by using our pelvic trauma screening tool. Although no findings accurately identified the presence of a pelvic fracture, the screening tool accurately identified the absence of a fracture, suggesting that pelvic radiographs are not warranted in this subset of patients.

Factors associated with cervical spine injury in children after blunt trauma.

STUDY OBJECTIVE: Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. METHODS: We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity. RESULTS: We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. CONCLUSION: We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.

Bioterrorism: Evaluating the preparedness of pediatricians in Michigan.

OBJECTIVE: There is a paucity of literature in the United States regarding preparedness for a bioterrorist attack on children. The main objective of this study was to assess the self-reported level of bioterrorism preparedness of pediatricians practicing in Michigan. METHODS: We conducted a survey that was mailed to 1000 pediatricians practicing in Michigan from July through December 2006. Survey questions were designed to evaluate the overall level of preparedness, as defined by the American Academy of Pediatrics, in dealing with a possible biological event and to describe key demographic variables. RESULTS: Of the 590 pediatricians who responded (59%), a majority (80%) were general pediatricians, whereas 20% were pediatric subspecialists. Sixty percent of responders believe terrorism is a threat, with biological agents (52%; 95% confidence interval (CI), 48.00-56.12) as the most likely cause of an event. Half of the pediatricians who responded had a workplace disaster plan, but only 12% feel their preparedness for a biological attack/event was good. Sixty-six percent (392/590) were not currently Pediatric Advanced Life Support certified, 38% (95% CI,34.63-42.51) have never attended a lecture based on bioterrorism, 85% (95% CI, 82.00-87.78) have never participated in a bioterrorism training exercise, and 89% (95% CI, 87.00-91.95) do not provide disaster-oriented anticipatory guidance to their patients. Seventy-six percent (95% CI, 73.10-79.98) of all responders indicated their desire for more bioterrorism training, with 42% preferring diagnostic algorithms and 37% (95% CI, 32.79-40.59) preferring a prepared lecture on video format. CONCLUSIONS: Surveyed pediatricians in Michigan consider bioterrorism a significant threat but are overwhelmingly underprepared to deal with an event. There is a perceived need for a coordinated educational program to improve level of preparedness.

Epidemiologic findings of cancer detected in a pediatric emergency department.

This study describes epidemiologic findings of pediatric cancer diagnosed in the emergency department (ED) setting. Medical records are retrospectively reviewed on all patients in the hospital's cancer database between 2000 and 2004 who were diagnosed as having cancer or whose oncologic diagnosis was missed during their ED presentation. Of 427 patients identified in the cancer database, 18% (77 of 427) are analyzed. Oncologic diagnosis was missed in 5% (4 of 77) of the eligible patients initially presenting to the ED. The incidence of cancer in the ED is 22.8 cases per 100,000 ED visits. The most prevalent cancer is related to the hematologic system (37.7%), followed by the central nervous system (31.2%) and the abdomen (22.1%). Hematologic, central nervous system, and abdominal cancers constitute approximately 90% of all childhood cancers. Cancer is diagnosed frequently in our ED patient population. Based on the prevalence of certain tumors, the diagnostic approach to children with hematologic, neurologic, or abdominal complaints should include evaluation for any underlying cancer.

A 16-year-old boy with acute urinary retention.

Urinary retention can be described as the inability to void volitionally despite an adequate volume of urine in the bladder. It is a common complaint in adults, especially among elderly males with benign prostatic hyperplasia. Children, in contrast, are more likely to have voluntary retention of urine due to urethral irritation or dysuria. Gently massaging the suprapubic region while the child is in a warm bath often relieves the retention in these cases. Other patients described as lazy voiders can present with acute urinary retention. These patients are typically young girls who are embarrassed to void at school. Retraining or timed voiding is often successful managing lazy voiders. However, these benign disorders should only be diagnosed after anatomical or organic causes for their symptoms have been considered and ruled out.

Methicillin-resistant Staphylococcus aureus as a cause of community-acquired pneumonia.

New pathogens have emerged that now complicate the management of community-acquired pneumonia (CAP). Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a potential cause of CAP, particularly complicated CAP. In this literature review, the incidence, invasiveness, and antimicrobial management of CA-MRSA is discussed. Based on existing data and the rising incidence of CA-MRSA, we recommend a change in antibiotic selection for complicated CAP.

Healthy children with invasive community-acquired methicillin-resistant Staphylococcus aureus infections.

Reports of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in the pediatric community have exploded during the past decade. These infections typically result in mild skin and soft tissue infections that can be managed simply with oral antimicrobials. Recently, there have been reports of invasive CA-MRSA infecting children without risk factors, with isolated cases of life-threatening disease. We report 2 atypical cases of invasive CA-MRSA infecting previously healthy children.