Endotracheal Administered Epinephrine Is Effective in Return of Spontaneous Circulation Within a Pediatric Swine Hypovolemic Cardiac Arrest Model.

OBJECTIVE: Early administration of epinephrine increases the incidence of return of spontaneous circulation (ROSC) and improves outcomes among pediatric cardiac arrest victims. Rapid endotracheal (ET) intubation can facilitate early administration of epinephrine to pediatric victims. To date, no studies have evaluated the use of ET epinephrine in a pediatric hypovolemic cardiac arrest model to determine the incidence of ROSC. METHODS: This prospective, experimental study evaluated the pharmacokinetics and/or incidence of ROSC following ET administered epinephrine and compared it to these experimental groups: intravenous (IV) administered epinephrine, cardiopulmonary resuscitation only (CPR), and CPR + defibrillation (CPR + Defib). RESULTS: Endotracheal administered epinephrine, at the Pediatric Advanced Life Support (PALS) recommended dose, was not significantly different than IV administered epinephrine in maximum plasma concentrations, time to maximum plasma concentration, area under the curve, or ROSC, or mean plasma concentrations at various time points (P > 0.05). The odds of ROSC in the ET group were 2.4 times greater than the IV group. The onset to ROSC in the ET group was significantly shorter than the IV group (P < 0.0001). CONCLUSIONS: These data support that ET epinephrine administration remains an alternative to IV administered epinephrine and faster at restoring ROSC among pediatric hypovolemic cardiac arrest victims in the acute setting when an endotracheal tube is present. Although further research is required to determine long-term outcomes of high-dose ET epinephrine administration, these data reinforce the therapeutic potential of ET administration of epinephrine to restore ROSC before IV access.

Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model.

OBJECTIVE: We compared the efficacy of tibial intraosseous (TIO) administration of epinephrine in a pediatric normovolemic versus hypovolemic cardiac arrest model to determine the incidence of return of spontaneous circulation (ROSC) and plasma epinephrine concentrations over time. METHODS: This experimental study evaluated the pharmacokinetics of epinephrine and/or incidence of ROSC after TIO administration in either a normovolemic or hypovolemic pediatric swine model. RESULTS: All subjects in the TIO normovolemia cardiac arrest group experienced ROSC after TIO administration of epinephrine. In contrast, subjects experiencing hypovolemia and cardiac arrest were significantly less likely to experience ROSC when epinephrine was administered TIO versus intravenous (TIO hypovolemia: 14% [1/7] vs IV hypovolemia: 71% [5/7]; P = 0.031). The TIO hypovolemia group exhibited significantly lower plasma epinephrine concentrations versus IV hypovolemia at 60, 90, 120, and 150 seconds (P < 0.05). Although the maximum concentration of plasma epinephrine was similar, the TIO hypovolemia group exhibited significantly slower time to maximum concentration times versus TIO normovolemia subjects (P = 0.004). CONCLUSIONS: Tibial intraosseous administration of epinephrine reliably facilitated ROSC among normovolemic cardiac arrest pediatric patients, which is consistent with published reports. However, TIO administration of epinephrine was ineffective in restoring ROSC among subjects experiencing hypovolemia and cardiac arrest. Tibial intraosseous-administered epinephrine during hypovolemia and cardiac arrest may have resulted in a potential sequestration of epinephrine in the tibia. Central or peripheral intravascular access attempts should not be abandoned after successful TIO placement in the resuscitation of patients experiencing concurrent hypovolemia and cardiac arrest.

Vaping-Associated Lung Injury During COVID-19 Multisystem Inflammatory Syndrome Outbreak.

BACKGROUND: E-cigarette or vaping product use-associated lung injury (EVALI) is a complex inflammatory syndrome predominantly seen in adolescents and young adults. The clinical and laboratory profile can easily mimic infectious and noninfectious conditions. The exclusion of these conditions is essential to establish the diagnosis. Recently, the novel coronavirus disease 2019 (COVID-19) pandemic introduced the multisystem inflammatory syndrome in children (MIS-C). MIS-C knowledge is evolving. The current criteria to establish the diagnosis are not specific and have overlapping features with EVALI, making the accurate diagnosis a clinical challenge during continued COVID-19 transmission within the community. CASE REPORT: Three young adults evaluated at our emergency department for prolonged fever and gastrointestinal and respiratory symptoms were initially assessed for possible MIS-C due to epidemiologic links to COVID-19 and were eventually diagnosed with EVALI. The clinical, laboratory, and radiologic characteristics of both entities are explored, as well as the appropriate medical management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Physician awareness of overlapping and differentiating EVALI and MIS-C features is essential to direct appropriate diagnostic evaluation and medical management of adolescents and young adults presenting with systemic inflammatory response during the unfolding pandemic of COVID-19.

A Novel Pediatric Multisystem Inflammatory Syndrome During the COVID-19 Pandemic.

In late March and early April, New York City was an epicenter of the COVID-19 pandemic. Citizens were ordered to stay at home to flatten the curve. The adult population was affected with a severe respiratory illness as well as acute kidney injury, cardiomyopathy, arrhythmia, and thromboembolism. Although children were not affected in the same manner, weeks after the peak, reports from other countries emerged about cases of pediatric patients presenting with a novel inflammatory syndrome. We present 4 patients along with their emergency department course, so providers will have a better understanding of the identification and workup of these patients. Currently, it is unclear when this inflammatory syndrome develops in respect to a COVID-19 infection. The clinical features of this syndrome seem to overlap between Kawasaki disease, toxic shock syndrome, and myocarditis. All patients presenting to our emergency department had fever, variable rash, abdominal pain, vomiting, and/or diarrhea. Patients remained persistently tachycardic and febrile despite being given proper doses of antipyretics. Severity of presentations varied among the 4 cases. All 4 patients were found to have antibodies to COVID-19. All patients required admission, but 2 required the pediatric intensive care unit for cardiac and/or respiratory support or closer monitoring. Upon follow-up on our patients, it seems that most patients are recovering with treatment, and overall, there is a low reported mortality rate.

Acute gastroenteritis: evidence-based management of pediatric patients.

Although most cases of acute gastroenteritis require minimal medical intervention, severe dehydration and hypoglycemia may develop in cases of prolonged vomiting and diarrhea. The mainstay of treatment for mild-to-moderately dehydrated patients with acute gastroenteritis should be oral rehydration solution. Antiemetics allow for improved tolerance of oral rehydration solution, and, when used appropriately, can decrease the need for intravenous fluids and hospitalization. This issue reviews the common etiologies of acute gastroenteritis, discusses more-severe conditions that should be considered in the differential diagnosis, and provides evidence-based recommendations for management of acute gastroenteritis in patients with mild-to-moderate dehydration, severe dehydration, and hypoglycemia.

Value of Focused Appendicitis Ultrasound and Alvarado Score in Predicting Appendicitis in Children: Can We Reduce the Use of CT?

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of focused appendicitis ultrasound combined with Alvarado score to accurately identify appendicitis in children in whom it is suspected, thereby reducing unnecessary CT examinations and associated radiation exposure. MATERIALS AND METHODS: We retrospectively evaluated the focused appendicitis ultrasound, CT, clinical, and laboratory findings of 522 consecutively registered children (231 boys, 291 girls; mean age, 13.04 [SD, 5.02] years; range, 0.74 months-21 years) who underwent focused appendicitis ultrasound for abdominal pain in a pediatric emergency department from January 2008 through October 2009. All children underwent surgery or clinical follow-up to exclude missed appendicitis. Sonographic findings were characterized as positive, negative, or inconclusive (appendix not visualized). Alternative diagnoses were noted. Alvarado score (0-10 points based on multiple clinical criteria) was determined. Focused appendicitis ultrasound and Alvarado score results were compared with surgical and pathologic reports. RESULTS: Both focused appendicitis ultrasound results and Alvarado score were associated with likelihood of surgery for appendicitis (p = 0.0001). Focused appendicitis ultrasound had conclusive results: 105 positive and 27 negative in 132 of 522 (25.2%) children. In the 390 of 522 (74.7%) children with inconclusive focused appendicitis ultrasound findings, 43 of 390 (11.0%) eventually had a diagnosis of appendicitis with CT (n = 26) or Alvarado score (n = 17). Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score less than 5 (241/522, 46.1%), only one patient had appendicitis. The negative predictive value (NPV) of inconclusive ultrasound findings and low Alvarado score combined was 99.6%. Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score of 5-8, the NPV decreased to 89.7%. CONCLUSION: Children with inconclusive focused appendicitis ultrasound findings and a low Alvarado score are extremely unlikely to have appendicitis (NPV, 99.6%). Avoiding unnecessary CT of these patients is a safe approach to diagnosis.

Low-risk criteria for pelvic radiography in pediatric blunt trauma patients.

CONTEXT: The American College of Surgeons recommends that any patient with blunt trauma undergoes radiographic evaluation, including a radiograph of the pelvis. Studies have questioned the use of such routine pelvic radiographs (PXR) in pediatrics. Selective elimination of PXR would save time, money and unshielded radiation exposure to the gonads. OBJECTIVE: To determine if a defined set of historical and clinical factors could predict low risk for pelvic fracture and incorporate these factors into a clinical decision guideline. DESIGN, SETTING, AND PATIENTS: A retrospective chart review of all blunt trauma patients 25 years or younger in whom a PXR was obtained from January 2002 to June 2006 presenting to an urban level 1 trauma center. A total of 579 patients underwent 580 trauma evaluations. MAIN OUTCOME MEASURES: Variables including sex, mechanism of injury, Glascow Coma Score, Pediatric Trauma Score, fall height, lower extremity injury, blood on rectal examination, blood at meatus, and clinical need for computed tomography (CT) were compared with outcomes of pelvic fracture and pelvic fracture requiring surgical intervention. RESULTS: There were 22 pelvic fractures identified, resulting in a fracture rate of 4%. The negative predictive value for pelvic fracture was 98.3% (95% confidence interval [95% CI], 96.9%-99.2%) if no lower extremity injury was present, 99% (95% CI, 98.2%-99.6%) if physical examination of the pelvis was normal, and 99.5% (95% CI, 98.6%-99.9%) if there was no need for abdominopelvic CT. The negative predictive value was 100% (95% CI, 98.8%-100%) if any one of these 3 factors is present. CONCLUSIONS: Using the clinical findings of (1) lack of lower extremity injury, (2) lack of an abnormal physical examination of the pelvis, and (3) no need for abdominopelvic CT, pelvic fracture can be reliably excluded. Pelvic radiography can be eliminated in the evaluation of these patients, potentially decreasing time expenditure, radiation exposure, and cost.

Perception and attitude of providers toward pain and anxiety associated with pediatric vaccine injection.

Despite the many options available for control of the pain and anxiety during vaccine injections, they are not often used. A total of 70 primary care providers (PCPs) were asked to rate their perception of pain and anxiety associated with vaccine injection in an average 4- to 6-year-old using a visual analog scale-0 (no pain/anxiety) to 10 (very severe pain/anxiety)-as well as perceived barriers. The mean PCPs' perception of pain associated with vaccine injection was 5.7 (95% confidence interval [CI] = 5.3-6.1), and perceived anxiety was 7.7 (95% CI = 7.2-8.1). Trainees recorded higher perceived anxiety than attending physicians (8.0 vs 6.9; P = .03)]. Of the respondents, 63 (90%) felt that pain and anxiety control is achievable in their office setting. Nevertheless, only 8 (11%) PCPs had ordered any pain and anxiety control measures during vaccine injection. There is a gap between the PCPs' perception of pain and anxiety and practice of pain and anxiety control measures during vaccine injection.