Thrombocytopenia and Adverse Bleeding Events in Neonatal Lumbar Punctures in the Emergency Department.

OBJECTIVE: Lumbar punctures are performed as part of a routine evaluation of neonates with fever in the emergency department. Current recommendations regarding performing a lumbar puncture in the presence of thrombocytopenia exist for children with leukemia and other cancers; however, there are no such recommendations for the general neonatal population. This study assesses the frequency of thrombocytopenia and adverse bleeding events in neonates who undergo a lumbar puncture to determine whether a complete blood count, and specifically the platelet count, should be reviewed before performing the lumbar puncture. METHODS: This is a retrospective chart review of neonates 30 days or younger presenting to a single freestanding pediatric emergency department who received a lumbar puncture over the course of 11 years. The complete blood count was reviewed for thrombocytopenia, determined to be platelet count of less than 150,000/µL. The chart was reviewed for any documented adverse bleeding events associated with the lumbar puncture. RESULTS: A total population of 2145 was studied with 56 patients determined to be thrombocytopenic. Seven total bleeding events were identified: 1 in the thrombocytopenic group and 6 in the nonthrombocytopenic group. All bleeding events were deemed to be clinically significant, either resulting in prolonged hospital stay or required further workup and medical intervention. The percentage of clinically adverse bleeding events that were related to the lumbar puncture was 0 (0.0%; 95% confidence interval, 0.0%-6.4%) and 2 (0.1%; 95% confidence interval, 0.0%-0.3%) ( P = 1.0) in the thrombocytopenic and nonthrombocytopenic groups, respectively. CONCLUSIONS: Our results demonstrated a very low risk of bleeding events associated with lumbar punctures in neonates, with no increased risk in the thrombocytopenic group. As such, we conclude that waiting for the results of a complete blood count before performing the lumbar puncture in neonates without a known bleeding disorder is unnecessary.

Do Parents of Discharged Pediatric Emergency Department Patients Read Discharge Instructions?

OBJECTIVES: The percentage of discharged emergency department (ED) patients who read discharge instructions (DCIs) is unknown. In this study of parents of pediatric ED patients, we attempt to quantify the DCI readership rate and identify variables associated with readership. We hypothesized that few families would read their child's DCIs. METHODS: We conducted a prospective, randomized study of parents of pediatric patients who were discharged home from the ED. We randomized participants to receive a study invitation as either the second or the second to last page of their DCIs. We incentivized study participation with a $10 gift card and then used the invitation response rate as a proxy for DCI readership. We utilized logistic regression to identify predictor variables showing significant association with readership. RESULTS: One thousand patients were randomized; 963 were included in the final analysis. Eighty-four subjects, 8.8% (95% confidence interval, 7.0%-10.7%), responded to investigators. In the final regression model, private insurance (adjusted odds ratio, 1.76; P = 0.036), placement of the study invitation early within DCIs (adjusted odds ratio, 1.93; P = 0.011), and laceration diagnosis (adjusted odds ratio, 2.97; P = 0.012) predicted readership, whereas parents of Hispanic children were less likely to respond, even after adjustment for language spoken (adjusted odds ratio, 0.57; P = 0.028). CONCLUSIONS: A minority of parents of patients discharged from the pediatric ED appear to read through their child's DCIs, with Hispanic families and those without private insurance least likely to read. Future research can explore how best to reach these particularly vulnerable families.

Safety and effectiveness of intranasal midazolam and fentanyl used in combination in the pediatric emergency department.

OBJECTIVE: To examine the safety and effectiveness of intranasal midazolam and fentanyl used in combination for laceration repair in the pediatric emergency department. METHODS: We performed a retrospective chart review of a random sample of 546 children less than 18 years of age who received both intranasal midazolam and fentanyl for laceration repair in the pediatric emergency department at a large, urban children's hospital. Records were reviewed from April 1, 2012 to June 31, 2015. The primary outcome measures were adverse events and failed laceration repair. RESULTS: Of the 546 subjects analyzed, 5.1% had multiple lacerations. Facial lacerations were the most common site representing 70.3%, followed by lacerations to the hand (9.9%) and leg (7.0%). The median length of lacerations was 1.5 cm [1.0-2.5]. The median dose of fentanyl was 2.0 µg/kg [1.9-2.0] and midazolam was 0.2 mg/kg [0.19-0.20]. There were no serious adverse events reported. The rate of minor side effects was 0.7% (95% CI 0.2% to 1.9%); 0.5% (95% CI 0.1% to 1.6%) experienced anxiety and 0.2% (95% CI 0.0% to 1.0%) vomited. No patients developed hypotension or hypoxia. Of the 546 patients, 2.4% (95% CI 1.3% to 4.0%) experienced a treatment failure. 2.0% (95% CI 1.3% to 4.0%) required IV sedation and 0.4% (95% CI 0.0% to 1.3%) were repaired in the operating room. CONCLUSIONS: Our results suggest that the combination of INM and INF may be a safe and effective strategy for procedural sedation in young children undergoing simple laceration repair.

Persistent Pneumonia: Time to Take a Closer Look.

Primary pulmonary tumors are rare in pediatrics. When they are encountered, they are usually carcinoid tumors or mucoepidermoid carcinomas. We present a patient who presented to both his primary care physician and the pediatric emergency department with recurrent bouts of wheezing and pneumonia, none of which ever completely resolved despite appropriate treatment. The patient had multiple chest films, which demonstrated the persistence of what appeared to be a right-sided infiltrate/atelectasis. Ultimately, the patient underwent a diagnostic workup that included a computed tomography scan and bronchoscopy. These studies revealed the presence of a bronchial mucoepidermoid carcinoma. The patient was successfully treated with photoablation of the lesion through the involvement of multiple subspecialists, including pediatric pulmonology, pediatric surgery, pediatric otolaryngology, and pediatric oncology. We discuss the incidence and epidemiology of pediatric bronchial tumors in general and mucoepidermoid carcinoma in particular as well as diagnosis, treatment options, and prognosis. Emergency physicians must maintain a high index of suspicion for alternate diagnoses in patients whose disease fails to respond to traditionally accepted therapy.