Not Just for Urine: A Versatile Tool for Foreign Body Removal.

The swallowed or aspirated foreign body is a common pediatric emergency medicine complaint for which emergency providers must be familiar with the intricacies of management. Most swallowed foreign bodies will harmlessly pass through the GI tract, but children with GI tract abnormalities may have an increased risk of object impaction. There are few reported cases of foreign object ingestion in children with GI tract abnormalities, specifically ostomies. The Foley catheter is a versatile tool that is easily accessible in the ED setting. We present a novel case of foreign body ingestion in an infant with a colostomy secondary to Hirschsprung's disease managed with Foley catheter retrieval through an ileostomy stoma. A 17-month-old infant presented to the ED with a chief complaint of an episode of bloody vomiting. He had a two-day history of increased irritability and intolerance of feeds with emesis after every feed. The child's medical history is pertinent for Hirschsprung's disease, for which the patient had a pull-through procedure shortly after birth and a revision of the pull-through. On physical examination, the patient's ostomy was found to contain brown-green liquid stool. A small ovular mass was visualized at the stoma during crying episodes. Supine posteroanterior radiograph of the abdomen showed an oval-shaped radiolucency consistent with a metallic ingested foreign body at the site of the stoma. The foreign object was removed using a Foley catheter and forceps and was found to be a penny. The patient was observed and discharged without complications later that day. Treatment of a symptomatic ingested foreign object requires careful consideration of the type of object present and its location in the body. In this case report, we discussed the removal of an ingested coin in a symptomatic 17-month-old infant with a history of ileostomy secondary to Hirschsprung's disease using a Foley catheter. In children with ostomies, prompt imaging and non-surgical removal may be an option to manage retrieval of these objects if the patient is stable and symptoms are not severe.

Early Experience with a Novel Strategy for Assessment of Sepsis Risk: The Shock Huddle.

INTRODUCTION: Severe sepsis/septic shock (SS), a leading cause of death in children, is a complex clinical syndrome that can be challenging to diagnose. To assist with the early and accurate diagnosis of this illness, we instituted an electronic scoring tool and developed a novel strategy for the assessment of currently hospitalized children at risk for SS. METHODS: The Shock Tool was created to alert providers to children at risk for SS. Above a threshold score of 45, patients were evaluated by a team from the pediatric intensive care unit (PICU), led by the Shock Nurse (RN), a specially trained PICU nurse, to assess their need for further therapies. Data related to this evaluation, termed a Shock Huddle, were collected and reviewed with the intensivist fellow on service. RESULTS: Over 1 year, 9,241 hospitalized patients were screened using the Shock Score. There were 206 Shock Huddles on 109 unique patients. Nearly 40% of Shock Huddles included a diagnostic or therapeutic intervention at the time of patient assessment, with the most frequent intervention being a fluid bolus. Shock Huddles resulted in a patient transfer to the PICU 10% of the time. CONCLUSION: Implementation of an electronic medical record-based sepsis recognition tool paired with a novel strategy for rapid assessment of at-risk patients by a Shock RN is feasible and offers an alternative strategy to a traditional medical emergency team for the delivery of sepsis-related care. Further study is needed to describe the impact of this process on patient outcomes.

Emergency Department Triage of the "Incessantly Crying" Baby.

Incessant crying is one of the most common caregiver complaints during emergency department (ED) visits in the first few months of the child's life. Although the majority of cases are attributed to normal infant behavior, the differential diagnosis remains broad. Moreover, the potential for the negative impact of incessant crying on the mental well-being of caregivers as well as the infants necessitates that complaints be taken seriously and that "red flags" for underlying organic causes be ruled out and caregiver anxiety quelled. In addition, the apparent triviality of incessant crying in the face of the life-threatening illnesses or injuries that confront practitioners in the ED necessitates a high level of due diligence in the evaluation of these infants and their families. Ensuring the availability of family support is essential in the discharge planning. Families should also perceive the empathy of the physician and feel reassured about their safe discharge home. Although it is a challenge to examine an incessantly crying infant in all care settings, the failure to recognize the small percentage of infants that present with incessant crying as a manifestation of an underlying organic illness may have grave consequences. [Pediatr Ann. 2016;45(11):e394-e398.].

Emergency department use after pediatric pharmaceutical ingestion: comparison of two national databases.

BACKGROUND: As no "gold standard" measure exists for the number of children evaluated in emergency departments (EDs) for medication-related injuries, the public health impact is based on estimates. In January 2006 the Morbidity and Mortality Weekly Report published a National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) estimate on unintentional pediatric medication exposure to children < or =4 years of age that resulted in an ED visit: 53,517 per year for the period 2001-2003. We sought to generate a parallel estimate using American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS) to see how these estimates compare. METHODS: To match data reported from the NEISS-AIP, NPDS was searched for the electronic medical records of children < or =4 years of age whose call type was an unintentional exposure to a pharmaceutical that involved presenting to a health care facility (HCF) in 2001-2003. RESULTS: 178,513 met all of the criteria: 57,100 in 2001; 60,098 in 2002; and 61,315 in 2003. Comparing NEISS-AIP to NPDS: 10% versus 13% were hospitalized; 72% versus 68% were either 1 or 2 years of age; and the substance distribution was acetaminophen (8.1%, 6.8%), cough/cold (7.5%, 9.6%), cardiovascular (7.8%, 11.0%), anticonvulsant (3.6%, 3.2%), and vitamins (4.5%, 3.4%). CONCLUSION: These results are close suggesting that the actual number is near these numbers. The NPDS number is greater than NEISS-AIP point estimate but within the 95% confidence interval. As NPDS is an actual count and NEISS-AIP is an extrapolation from a sample, to the extent that every child presenting to an ED following a medication exposure is not reported to a poison center, both databases may underestimate the problem. The NEISS-AIP extrapolation tool may need to be reassessed.

Adolescent prescription ADHD medication abuse is rising along with prescriptions for these medications.

OBJECTIVE: We sought to better understand the trend for prescription attention-deficit/hyperactivity disorder (ADHD) medication abuse by teenagers. METHODS: We queried the American Association of Poison Control Center's National Poison Data System for the years of 1998-2005 for all cases involving people aged 13 to 19 years, for which the reason was intentional abuse or intentional misuse and the substance was a prescription medication used for ADHD treatment. For trend comparison, we sought data on the total number of exposures. In addition, we used teen and preteen ADHD medication sales data from IMS Health's National Disease and Therapeutic Index database to compare poison center call trends with likely availability. RESULTS: Calls related to teenaged victims of prescription ADHD medication abuse rose 76%, which is faster than calls for victims of substance abuse generally and teen substance abuse. The annual rate of total and teen exposures was unchanged. Over the 8 years, estimated prescriptions for teenagers and preteenagers increased 133% for amphetamine products, 52% for methylphenidate products, and 80% for both together. Reports of exposure to methylphenidate fell from 78% to 30%, whereas methylphenidate as a percentage of ADHD prescriptions decreased from 66% to 56%. Substance-related abuse calls per million adolescent prescriptions rose 140%. CONCLUSIONS: The sharp increase, out of proportion to other poison center calls, suggests a rising problem with teen ADHD stimulant medication abuse. Case severity increased over time. Sales data of ADHD medications suggest that the use and call-volume increase reflects availability, but the increase disproportionately involves amphetamines.

Parental holding and positioning to decrease IV distress in young children: a randomized controlled trial.

Young children are generally restrained in supine position for IV starts, a position that creates fear but is presumed necessary. This study randomly assigned children of ages 9 months to 4 years (N = 118) to being held upright by a parent or lying flat on an exam table for their IV procedure. Distress scores as rated by the Procedure Behavior Rating Scale were significantly lower in the upright positioning group (p = .000); parents were more satisfied with the upright position, and the upright position did not significantly alter the number of IV attempts needed. The upright position appears to be an effective way to decrease IV distress in young children.