Shear Stress Causing Hemolytic Anemia and Congestive Heart Failure as an Initial Presentation of Cor Triatriatum in an Infant.

Among congenital cardiac defects, cor triatriatum sinistrum is a rare formation of 3 distinct atrial chambers in the heart. Depending on the size of the defect in the membranous septum, the symptoms can range from asymptomatic to severe pulmonary hypertension. Individuals can go years, sometimes to the second and third decades of life, before presenting with symptoms. Although it is well known to be associated with pulmonary veno-occlusive disease, the association with hemolytic anemia is much less well known. Identifying the subtle signs and symptoms of cor triatriatum in the emergency department can save a life. Here, we present the case of a 6-month-old infant with hemolytic anemia in the setting of right-sided congestive heart failure leading to the diagnosis of cor triatriatum. Anemia developed secondary to shearing stress caused by the heart defect itself. Complete resolution of symptoms occurred status post septectomy and repair of the defect.

Novel Transfer of Care Sign-out Assessment Tool in a Pediatric Emergency Department.

OBJECTIVE: Transfer of care sign-outs (TOCS) for admissions from a pediatric emergency department have unique challenges. Standardized and reliable assessment tools for TOCS remain elusive. We describe the development, reliability, and validity of a TOCS assessment tool. METHODS: Video recordings of resident TOCS were assessed to capture 4 domains: completeness, synopsis, foresight, and professionalism. In phase 1, 56 TOCS were used to modify the tool and improve reliability. In phase 2, 91 TOCS were used to examine validity. Analyses included Cronbach's alpha for internal structure, intraclass correlation and Cohen's kappa for interrater reliability, Pearson's correlation for relationships between variables, and 95% confidence interval of the mean for resident group comparisons. RESULTS: Cronbach's alpha was 0.52 for internal structure of the tool's subjective rating scale. Intraclass correlation for the subjective rating scale items ranged from 0.70 to 0.80. Cohen's kappa for most objective checklist items ranged from 0.43 to 1. Content completeness was significantly correlated with synopsis, foresight, and professionalism (Pearson's r ranged from 0.36 to 0.62, P values were <0.001). House staff senior residents scored higher (on average) than interns and rotating senior residents in synopsis and foresight. Also, house staff interns scored higher (on average) than rotating senior residents in professionalism. House staff senior residents scored higher (on average) than rotating senior residents in content completeness. CONCLUSIONS: We provide validity evidence to support using scores from the TOCS tool to assess higher-level transfer of care comprehension and communication by pediatric emergency department residents and to test interventions to improve TOCS.

Clinical Utility of Noninvasive Method to Measure Specific Gravity in the Pediatric Population.

BACKGROUND: Clinicians rely on any combination of signs and symptoms, clinical scores, or invasive procedures to assess the hydration status in children. Noninvasive tests to evaluate for dehydration in the pediatric population are appealing. OBJECTIVE: The objective of our study is to assess the utility of measuring specific gravity of tears compared to specific gravity of urine and the clinical assessment of dehydration. METHODS: We conducted a prospective cohort convenience sample study, in a pediatric emergency department at a tertiary care children's hospital. We approached parents/guardians of children aged 6 months to 4 years undergoing transurethral catheterization for evaluation of urinary tract infection for enrollment. We collected tears and urine for measurement of tear specific gravity (TSG) and urine specific gravity (USG), respectively. Treating physicians completed dehydration assessment forms to assess for hydration status. RESULTS: Among the 60 participants included, the mean TSG was 1.0183 (SD = 0.007); the mean USG was 1.0186 (SD = 0.0083). TSG and USG were positively correlated with each other (Pearson Correlation = 0.423, p = 0.001). Clinical dehydration scores ranged from 0 to 3, with 87% assigned a score of 0, by physician assessment. Mean number of episodes of vomiting and diarrhea in a 24-hour period were 2.2 (SD = 3.9) and 1.5 (SD = 3.2), respectively. Sixty-two percent of parents reported decreased oral intake. CONCLUSION: TSG measurements yielded similar results compared with USG. Further studies are needed to determine if TSG can be used as a noninvasive method of dehydration assessment in children.

A Toddler With Uncontrollable Shaking After a Minor Fall.

A toddler with a closed head injury six days prior to admission, recently diagnosed with post-concussive syndrome and acute otitis media presented to our emergency department with complaint of uncontrollable shaking of the head and extremities. Physical examination demonstrated dancing movements of the eyes and truncal ataxia, concerning for the diagnosis of opsoclonus-myoclonus syndrome. Magnetic resonance imaging study was consistent with a retroperitoneal mass that was confirmed as neuroblastoma by metaiodobenzylguanidine scan and later surgical resection. We present this case, accompanied by a video of the patient, to help the emergency physician recognize this rare and often misdiagnosed syndrome.

The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study.

OBJECTIVE: There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure. METHODS: This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004. RESULTS: Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems. CONCLUSIONS: This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.

Investigation of afebrile neonates with a history of fever.

OBJECTIVE: Our objective was to describe clinically significant infections in a cohort of afebrile neonates who underwent an emergency department (ED) septic workup because of the history of a measured fever at home. METHODS: Retrospective medical record review of all infants (3/4)28 days of age who presented to our tertiary care pediatric ED between Jan. 1, 1999, and Aug. 22, 2002, underwent lumbar puncture in the ED, had a reported temperature at home of >or=38 degrees C, and an ED triage temperature of <38 degrees C. Laboratory and radiographic results were tabulated. RESULTS: During the study period, 206 neonates underwent lumbar puncture in our ED. Of these, 108 were excluded because their home temperature was not documented, and 71 were excluded because they were still febrile on presentation to the ED. The study group consisted of the remaining 27 subjects, 4 of whom had received acetaminophen prior to ED arrival. Infections were confirmed in 10 (37%) subjects (3 urinary tract infections, 2 aseptic meningitis, 1 enterovirus meningitis, 1 respiratory syncytial virus bronchiolitis, 1 rotavirus enteritis and 2 pneumonias). CONCLUSIONS: Clinically important infections are not uncommon among afebrile neonates undergoing ED septic workup because of a measured fever at home. Some diagnostic testing is warranted in this group, although the clinical utility and indications for specific test modalities remain unclear.