Management of the child after enema-reduced intussusception: hospital or home?

BACKGROUND: Standard practice has been to admit children for an observation period after enema-reduced intussusception. However, the utility of such routine practice has not been clearly justified. STUDY OBJECTIVES: The main objective was to determine the rate and timing of recurrent intussusception after successful enema reduction and describe any associated complications. METHODS: The study was a retrospective chart review identifying children with enema-reduced intussusception during a 7-year period from 2002 through 2008. Subjects were children ages 0 to 17 years presenting to the Emergency Department (ED) of a tertiary care, free-standing children's hospital with confirmed and uncomplicated enema-reduced intussusception. RESULTS: During the study period there were 98 children with successful enema reduction of intussusception. There were 10 episodes of recurrence in 7 patients, for an overall recurrence rate of 7.1%. Three patients had two recurrences each, and the remainder had single recurrences. Two patients had early recurrences (<48 h) at 3 and 5 h, for an early recurrence rate of 2.0%. The late recurrence rate (>48 h) was 5.1%. No adverse events were noted in any of the recurrences. CONCLUSIONS: Given the low early recurrence rate for enema-reduced intussusception and the minimal risk of adverse outcomes, ED observation for a 6-h period seems to be a safe alternative to inpatient management. These results support previous work and suggest that these patients can be managed on an outpatient basis.

Intussusception: clinical presentations and imaging characteristics.

OBJECTIVE: The objectives of this study were to determine the prevalence of clinical findings associated with intussusception based on age and to evaluate the test characteristics of the presence of air in the ascending colon on abdominal radiographs and the effectiveness of ultrasound in diagnosing intussusception. METHODS: This was a retrospective cohort study via chart review at a tertiary care center from January 2002 to December 2008. All children, aged 0 to 17 years, were identified with intussusception by International Classification of Diseases, Ninth Revision diagnostic coding. Charts were reviewed for clinical signs and symptoms at presentation, and all diagnostic studies were retrieved. A pediatric radiologist reviewed all films and ultrasounds. RESULTS: A total of 219 patients were identified with intussusception. One hundred thirty-two (60%) of patients were male; 127 (60%) were younger than 1 year (median, 7 months), 59 (27%) were 13 to 35 months (median, 23 months), and 33 (15%) were 3 years or older (median, 5 years). Children younger than 12 months were more likely to present with emesis, irritability, and guaiac-positive or grossly bloody stools compared with children older than 12 months (P < 0.05). In children older than 12 months, abdominal pain was the most common symptom (>96%). Plain films were performed in 192 children, and of these, 163 (85%) had no air present in the ascending colon. Abdominal ultrasound was performed on 63 patients, with 58 (92%) having findings consistent with intussusception. CONCLUSIONS: Abdominal pain is the most common complaint in all ages for children presenting with intussusception. In children younger than 12 months, the strongest clinical predictors are emesis, irritability, and blood in the stool. For diagnosing intussusceptions, radiographs of the abdomen performed well, but ultrasound performed better, diagnosing intussusception in 92% of the cases.

Practice variability in the management of complex febrile seizures by pediatric emergency physicians and fellows.

OBJECTIVE: Febrile seizures are the most common type of childhood seizure and are categorized as simple or complex. Complex febrile seizures (CFSs) are defined as events that are focal, prolonged (> 15 minutes), or recurrent. The management of CFS is poorly defined. The objective of this study was to determine the degree of variability in the emergency department evaluation of children with CFSs. METHODS: An online survey questionnaire was developed and sent to physicians identified via the listserv of the emergency medicine section of the American Academy of Pediatrics and the pediatric emergency medicine discussion list. The questionnaire consisted of five hypothetical case vignettes describing children under 5 years of age presenting with a CFS. Following review of the first four vignettes, participants were asked if they would (1) obtain blood and urine for evaluation; (2) perform a lumbar puncture; (3) perform neurologic imaging while the child was in the emergency department; (4) admit the child to the hospital; or (5) discharge with follow-up as an outpatient, with either the primary care provider or a neurologist. The final vignette determined if antiepileptic medication would be prescribed by the physician on discharge. RESULTS: Of the 353 physicians who participated, 293 (83%) were pediatric emergency medicine attending physicians and 60 (17%) were pediatric emergency medicine fellows. Overall, 54% of participants indicated that they would obtain blood for evaluation, 62% would obtain urine, 34% would perform a lumbar puncture, and 36% would perform neurologic imaging. The overall hypothetical admission rate for the case vignettes was 42%. CONCLUSIONS: This study indicates that extensive variability exists in the emergency department approach to patients with CFS. Our findings suggest that optimal management for CFS remains unclear and support the potential benefit of future prospective studies on this subject.

Recombinant human hyaluronidase-enabled subcutaneous pediatric rehydration.

OBJECTIVES: The Increased Flow Utilizing Subcutaneously-Enabled (INFUSE)-Pediatric Rehydration Study was designed to assess efficacy, safety, and clinical utility of recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous rehydration in children 2 months to 10 years of age. METHODS: Patients with mild/moderate dehydration requiring parenteral treatment in US emergency departments were eligible for this phase IV, multicenter, single-arm study. They received subcutaneous injection of 1 mL rHuPH20 (150 U), followed by subcutaneous infusion of 20 mL/kg isotonic fluid over the first hour. Subcutaneous rehydration was continued as needed for up to 72 hours. Rehydration was deemed successful if it was attributed by the investigator primarily to subcutaneous fluid infusion and the child was discharged without requiring an alternative method of rehydration. RESULTS: Efficacy was evaluated in 51 patients (mean age: 1.9 years; mean weight: 11.2 kg). Initial subcutaneous catheter placement was achieved with 1 attempt for 46/51 (90.2%) of patients. Rehydration was successful for 43/51 (84.3%) of patients. Five patients (9.8%) were hospitalized but deemed to be rehydrated primarily through subcutaneous therapy, for a total of 48/51 (94.1%) of patients. No treatment-related systemic adverse events were reported, but 1 serious adverse event occurred (cellulitis at infusion site). Investigators found the procedure easy to perform for 96% of patients (49/51 patients), and 90% of parents (43/48 parents) were satisfied or very satisfied. CONCLUSIONS: rHuPH20-facilitated subcutaneous hydration seems to be safe and effective for young children with mild/moderate dehydration. Subcutaneous access is achieved easily, and the procedure is well accepted by clinicians and parents.

Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION: Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.

STUDY OBJECTIVE: Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS: We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS: In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION: Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Use of noninvasive positive-pressure ventilation in the emergency department.

To optimize the successful use of noninvasive positive-pressure ventilation (NPPV) in the emergency department (ED), clinicians must acquire the necessary knowledge, experience, and skill in its proper application. The purpose of this article is to provide a concise but thorough review of the current state of knowledge relating to the proper application of NPPV pertaining to its use in the ED.

What is community-associated methicillin-resistant Staphylococcus aureus?

BACKGROUND: A community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection has been defined as an MRSA infection in a patient who lacks specific risk factors for healthcare exposure. We sought to determine whether the absence or presence of these risk factors still predicts the phenotypic or genotypic characteristics of MRSA strains. METHODS: All clinical MRSA isolates were prospectively collected at the University of Chicago Hospitals from July 2004 through June 2005. Patients were interviewed and/or their medical records were reviewed. Isolates underwent genotyping and susceptibility testing. Data on patients and isolates were stratified in accordance with 8 frequently cited criteria for the identification of CA-MRSA and compared for concordance. RESULTS: Among 616 unique patients from whom MRSA isolates were recovered, 404 (65.6%) had risk factors for healthcare exposure. Of the 404 isolates recovered from these patients, 166 (41.1%) were clindamycin susceptible, 190 (47.0%) carried staphylococcal cassette chromosome mec (SCCmec) type IV, 145 (35.9%) carried the Panton-Valentine leukocidin genes (PVL+), and 162 (40.1%) were identified as sequence type (ST) 8 by multilocus sequence typing (MLST), all of which are characteristics commonly attributed to CA-MRSA strains. CONCLUSIONS: Association with the healthcare environment now has little predictive value for distinguishing patients with infection due to multidrug resistant MRSA isolates from those infected by CA-MRSA isolates, that is, isolates that are clindamycin-susceptible, PVL+, ST8, and/or contain SCCmec type IV. Defining CA-MRSA by the absence of risk factors for healthcare exposure greatly underestimates the burden of epidemic CA-MRSA disease.

Emergency department overcrowding and children.

Emergency department (ED) overcrowding has been a serious issue on the national agenda for the past 2 decades and is rapidly becoming an increasingly significant problem for children. The goal of this report is to focus on the issues of overcrowding that directly impact children. Our findings reveal that although overcrowding seems to affect children in ways similar to those of adults, there are several important ways in which they differ. Recent reports document that more than 90% of academic emergency medicine EDs are overcrowded. Although inner-city, urban, and university hospitals have historically been the first to feel the brunt of overcrowding, community and suburban EDs are now also being affected. The overwhelming majority of children (92%) are seen in general community EDs, with only a minority (less than 10%) treated in dedicated pediatric EDs. With the exception of patients older than 65 years, children have higher visit rates than any other age group. Children may be at particularly increased risk for medical errors because of their inherent variability in size and the need for age-specific and weight-based dosing. We strongly recommend that pediatric issues be actively included in all future aspects of research and policy planning issues related to ED overcrowding. These include the development of triage protocols, clinical guidelines, research proposals, and computerized data monitoring systems.

Contrasting pediatric and adult methicillin-resistant Staphylococcus aureus isolates.

We performed a prospective study of all inpatient and outpatient methicillin-resistant Staphylococcus aureus (MRSA) isolates identified at the University of Chicago Hospitals from November 2003 through November 2004. Differences in resistance to non-beta-lactam antimicrobial drugs were determined after stratification of the 578 MRSA isolates into 4 groups by patient age (pediatric vs. adult) and onset location (community vs. hospital). Non-beta-lactam resistance was significantly greater among the 288 adult than the 177 pediatric community-associated isolates for erythromycin (93.2 vs. 87.0%, p = 0.03), clindamycin (51.8 vs. 7.3%, p<0.001), ciprofloxacin (62.1 vs. 10.7%, p<0.001), gentamicin (11.1 vs. 1.1%, p<0.001), and tetracycline (19.9 vs. 6.4%, p<0.001). In contrast, hospital-associated MRSA isolates from children and adults had similar rates of non-beta-lactam antimicrobial drug resistance. In our region, clindamycin is an appropriate empiric therapy of community-associated MRSA infection in children but should be used with caution in adults.

Sudden unexplained hemolysis occurring in an infant due to presumed Loxosceles envenomation.

We report the case of a 3-week-old infant referred for evaluation of sudden onset jaundice and unexplained hemolysis. After an exhaustive workup, the most likely etiology was found to be envenomation by a brown recluse spider, Loxosceles reclusa. This case underscores the fact that severe loxoscelism may occur in the absence of the classically described necrotic cutaneous lesion, and represents one of the youngest presumed cases of loxoscelism. We present the case to illustrate the importance of considering loxoscelism in the differential diagnosis of sudden massive hemolysis in children, particularly in endemic areas of the midwestern and southern United States.

Parental expectations of care and charges in a tertiary care pediatric ED.

Our objective was to assess parental expectations of diagnostic testing, time, and charges in a pediatric emergency department (PED) using a prospective survey-based study. Parents on arrival estimated the amount of testing, time, and charges expected to occur. A total of 266 of 294 (90.5%) of the questionnaires were completed and returned. Parents correctly predicted the need for radiographic evaluation in 185 of 258 (71.7%), laboratory evaluation in 179 of 257 (69.6%), and medication in 144 of 259 (55.6%). The average length of stay was 2 hours and 36 minutes and was correctly estimated within preset ranges by 86 of 253 (34.0%) and underestimated by 112 of 253 (44.3%). The mean total charge was $964 per visit and was correctly estimated within preset ranges by 91 of 260 (35.0%) and underestimated by 139 of 260 (53.3%). Despite being relatively accurate about the need for medications and radiographic and laboratory studies, parents are still more likely than not to underestimate the total charges and time associated with a PED visit.

Prospective age-based comparison of behavioral reactions occurring after ketamine sedation in the ED.

The study objective was to prospectively evaluate the frequency and severity of behavioral reactions occurring in children receiving ketamine sedation in the emergency department (ED). A behavioral observational study was conducted. Ketamine was given in a standardized protocol with midazolam, atropine, and a prehypnotic suggestion. Descriptions of behavioral reactions were recorded immediately after the procedure, and longitudinal follow-up was made in 1 day, 1 week, and 1 month. A total of 301 patients were enrolled. Mild reactions described as not unpleasant occurred in 7/205 (3.4%, 95% CI 0.9-5.9%) of the younger age group, and 2/96 (2.1%, 95% CI 0-5.0%) of the older age group. Unpleasant reactions occurred in 2/205 (1.0%, 95% CI 0-2.4%) of the younger age group, and 4/96 (4.2%, 95% CI 0-8.2%) of the older age group. We observed no clinically important difference in the proportion of older versus younger children experiencing behavioral reactions after IV ketamine sedation.

Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992-1997.

This article describes parenteral analgesic and sedative (PAS) use among patients treated in US emergency departments (EDs). Data representing 6 consecutive years (1992-1997) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined and analyzed. Patients were identified as having received PAS if they received fentanyl, ketamine, meperidine, methohexital, midazolam, morphine, nitrous oxide, or propofol. Patients were stratified according to age (pediatric <18 yrs), race, sex, insurance, type of hospital, urgency of visit, and ICD-9 (International Classification of Diseases, 9th revision) diagnostic codes. Logistic regression was performed to determine independent associations and calculate odds ratios (OR) for receiving analgesia or sedation. A total of 43,725 pediatric and 114,207 adult ED encounters were analyzed and represented a weighted sample of 555.3 million ED visits. For patients with orthopedic fractures, African-American children covered by Medicaid insurance were the least likely to receive PAS (OR 0.2, 95% confidence interval [CI] 0.1-0.6). These results suggest that variations may be occurring among ED patients receiving PAS.

Research training among pediatric emergency medicine fellows.

This study examined research training characteristics among pediatric emergency medicine (PEM) fellows. A 45-question survey was mailed to all registrants of the 1998 National PEM Fellows' Conference. Descriptions of curricular design and administrative support components, perceived barriers, and subjective stress related to research were obtained. Surveys were returned by 67 of 79 fellows (85%). A total of 92.5% reported didactic instruction relating to research with relatively higher amounts in research design and biostatistics, and lower amounts in electronic review of the literature, applying to the institutional review board, ethics, and applying for grants. The most commonly cited barriers to more active participation in research were inadequate experience, inadequate time, and lack of administrative help. Stress in relationship to research was high (5.1 on a 1-7 Likert scale). PEM fellows report increasing levels of didactic exposure and administrative support for conducting research, however, PEM fellows still report experiencing significant amounts of stress and a number of perceived barriers.

Unilateral facial paralysis occurring in an infant with enteroviral otitis media and aseptic meningitis.

We report the case of a four month old infant presenting to the Emergency Department (ED) with irritability and facial asymmetry following a recent bout of gastroenteritis. Physical examination revealed a unilateral peripheral facial nerve paralysis. Common in older children and adults, facial nerve palsy has rarely been described in infancy. Although historically associated with a variety of inflammatory and infectious causes, the pathogenesis remains unclear. In this infant we were able to successfully identify an underlying acute enteroviral infection. Coxsackie B5 was isolated from the middle ear fluid, cerebrospinal fluid (CSF), nasopharyngeal and rectal swabs. After myringotomy drainage of the middle ear fluid and placement of pneumatic equalization tubes, there was rapid and complete resolution of facial paralysis.

Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992-1997.

The objective of the study was to describe parenteral analgesic and sedative (PAS) use among patients treated in US emergency departments (EDs). Data representing 6 consecutive years (1992-1997) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined and analyzed. Patients were identified as having received PAS if they received fentanyl, ketamine, meperidine, methohexital, midazolam, morphine, nitrous oxide, or propofol. Patients were stratified according to age (pediatric <18 years), race, gender, insurance, type of hospital, urgency of visit, and ICD-9 diagnostic codes. Logistic regression was performed to determine independent associations and calculate odds ratios (OR) for receiving analgesia or sedation. A total of 43,725 pediatric and 114,207 adult ED encounters were analyzed and represented a weighted sample of 555.3 million ED visits. For patients with orthopedic fractures, African American children covered by Medicaid insurance were the least likely to receive PAS (OR 0.2, 95% confidence interval 0.1-0.6). These results suggest that variations may be occurring among ED patients receiving PAS.

Removal of esophageal foreign bodies in the pediatric ED: is ketamine an option?

The objective of the study was to evaluate our experience with esophageal foreign body (EFB) removal comparing the use of ketamine-midazolam (K-M) and fentanyl-midazolam (F-M) in the emergency department (ED), to admission and general anesthesia (GA) in the operating room (OR). A retrospective review of all children undergoing EFB removal at our institution during a 2-year period was conducted. A total of 93 patients were identified: K-M 57/93 (61.2%), F-M 28/93 (30.1%), GA 5/93 (5.4%), and 3/93 (3.2%) by other means. Mean procedure durations were 4.8 min for K-M and 7.0 min for F-M. Mean lengths of stay (LOS) for ED procedures were 3.6 hrs for K-M and 5.7 hrs for F-M, versus 17.7 hrs if admitted. Transient hypoxemia occurred in 10.7% of K-M and 15.4% of F-M. Removal of EFBs in the ED may obviate the need for admission. In our experience, the use of K-M is associated with fewer airway complications, shorter removal times, and an overall shorter LOS.