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73


Pediatric Croup Due to Omicron Infection Is More Severe Than Non-COVID Croup

Scribner, Camille; Patel, Kavita I; Tunik, Michael
OBJECTIVE:Croup due to infection with the omicron variant of COVID is an emerging clinical entity, but distinguishing features of omicron croup have not yet been characterized. We designed a study to compare the clinical features of croup patients presenting to the pediatric emergency department pre-COVID pandemic with COVID-positive croup patients who presented during the initial omicron surge. METHODS:This was a retrospective observational cohort study of children 0 to 18 years old who presented to our urban, tertiary care pediatric emergency department with symptoms of croup. The study compared a cohort of croup patients who presented in the year before the onset of the COVID pandemic to a cohort of COVID-positive croup patients who presented during the initial omicron surge. The primary outcomes included illness severity and treatments required in the emergency department. The secondary outcome was hospital admission rate. RESULTS:There were 499 patients enrolled in the study, 88 in the omicron croup cohort and 411 in the classic croup cohort. Compared with the classic croup patients, omicron croup patients were more likely to present with stridor at rest (45.4% vs 31.4%; odds ratio [OR], 1.82; confidence interval [CI], 1.14-2.91) and hypoxia (3.4% vs 0.5%; OR, 7.22; CI, 1.19-43.86). Omicron croup patients required repeat dosing of inhaled epinephrine in the emergency department more often (20.4% vs 6.8%; OR, 3.51; CI, 1.85-6.70), and they were more likely to require respiratory support (9.1% vs 1.0%; OR, 10.18; CI, 2.99-34.60). Admission rates were significantly higher for omicron croup patients than for classic croup patients (22.7% vs 3.9%; OR, 7.26; CI, 3.58-14.71), and omicron croup patients required intensive care more frequently (5.7% vs 1.5%; OR, 4.07; CI, 1.21-13.64). CONCLUSIONS:Pediatric patients with omicron croup develop more severe disease than do children with classic croup. They are more likely to require additional emergency department treatments and hospital admission than patients with croup before the COVID pandemic.
PMID: 36729063
ISSN: 1535-1815
CID: 5420282

Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results

Mahajan, Prashant; VanBuren, John M; Tzimenatos, Leah; Cruz, Andrea T; Vitale, Melissa; Powell, Elizabeth C; Leetch, Aaron N; Pickett, Michelle L; Brayer, Anne; Nigrovic, Lise E; Dayan, Peter S; Atabaki, Shireen M; Ruddy, Richard M; Rogers, Alexander J; Greenberg, Richard; Alpern, Elizabeth R; Tunik, Michael G; Saunders, Mary; Muenzer, Jared; Levine, Deborah A; Hoyle, John D; Lillis, Kathleen Grisanti; Gattu, Rajender; Crain, Ellen F; Borgialli, Dominic; Bonsu, Bema; Blumberg, Stephen; Anders, Jennifer; Roosevelt, Genie; Browne, Lorin R; Cohen, Daniel M; Linakis, James G; Jaffe, David M; Bennett, Jonathan E; Schnadower, David; Park, Grace; Mistry, Rakesh D; Glissmeyer, Eric W; Cator, Allison; Bogie, Amanda; Quayle, Kimberly S; Ellison, Angela; Balamuth, Fran; Richards, Rachel; Ramilo, Octavio; Kuppermann, Nathan
It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis.
PMID: 36097858
ISSN: 1098-4275
CID: 5336162

Intentional Asphyxiation Using Baby Wipes: A Case Report and Review of the Literature

Gerber, Nicole; Iyer, Shweta; Parra, Didier Murillo; Legano, Lori; Tunik, Michael
Abusive suffocation with foreign bodies is an uncommon form of child abuse. We present the case of a 2-month-old infant with colic who was forcibly suffocated with a baby wipe by a female babysitter. He presented to the emergency department in respiratory distress, and the foreign body was removed in the operating room by otorhinolaryngology. He was found to have intraoral lacerations and a left diaphyseal humeral fracture. To our knowledge, there is only 1 other collection of case reports of abusive suffocation with baby wipes. This case highlights the importance of considering abuse in cases of oral injury and foreign body aspiration in pediatric patients.
PMID: 32618904
ISSN: 1535-1815
CID: 4537452

Are We Doing Enough to Reduce Ionizing Radiation Exposure in Children?: An Analysis of Current Approaches to Pediatric Appendicitis Imaging at a Major Urban Medical Center

Iyer, Shweta; Patel, Juhee; Moscatelli, Marc; Narayanan, Nisha; Brunsting, Ella; Laub, Daniel; Hooley, Gwen; Tunik, Michael; Foltin, Jessica Cooper
OBJECTIVE:The aim of this study was to evaluate current imaging approaches in children with suspected appendicitis (AP) in the pediatric emergency department (ED) of a major urban medical center. METHODS:Children aged 6 to 18 years who presented to a pediatric ED in 2016 with possible AP were identified by a keyword search. Charts were reviewed for the following: age, sex, time of evaluation, imaging study, results of imaging study, disposition, and outcome. RESULTS:We calculated mean values and SD for continuous data. Initially, 503 charts were identified. Of these 503, 292 children were identified as having possible AP. Mean age was 10.7 years (SD, 2.7); 50.6% presented between 5:00 PM and 8:00 AM the next morning. Of the 287 US studies performed, 114 (39.7%) were definitively positive or negative. Of these, 46 (16.0%) were negative for AP and 68 (23.7%) were positive. There were 173 (60.3%) ultrasounds that were equivocal. Computed tomography scans were performed in 41 (13.9%) of the total 292 patients, and 2 (0.7%) of the 292 received magnetic resonance imaging. Patient dispositions were as follows: discharged home, 163 (55.8%); admitted for appendectomy, 69 (23.6%); admitted for observation, 37 (12.7%); and extended observation in ED, 10 (3.4%). There were 83 (28.4%) total surgical and interventional radiology cases and 209 (71.6%) nonsurgical cases. Of the 81 appendectomies, 79 (97.5%) had an abnormal appendix, and 2 (2.5%) had no AP. Of the 79 abnormal appendices, 22 (27.8%) were perforated, 55 (69.6%) were not, and 2 (2.6%) were unclear. CONCLUSIONS:Computed tomography scans were performed in 13.9% of patients with suspected AP. The overall AP rate was 28.4%. We plan to increase the use of magnetic resonance imaging and other modalities to reduce overall computed tomography usage.
PMID: 31274826
ISSN: 1535-1815
CID: 4100672

A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections

Kuppermann, Nathan; Dayan, Peter S; Levine, Deborah A; Vitale, Melissa; Tzimenatos, Leah; Tunik, Michael G; Saunders, Mary; Ruddy, Richard M; Roosevelt, Genie; Rogers, Alexander J; Powell, Elizabeth C; Nigrovic, Lise E; Muenzer, Jared; Linakis, James G; Grisanti, Kathleen; Jaffe, David M; Hoyle, John D; Greenberg, Richard; Gattu, Rajender; Cruz, Andrea T; Crain, Ellen F; Cohen, Daniel M; Brayer, Anne; Borgialli, Dominic; Bonsu, Bema; Browne, Lorin; Blumberg, Stephen; Bennett, Jonathan E; Atabaki, Shireen M; Anders, Jennifer; Alpern, Elizabeth R; Miller, Benjamin; Casper, T Charles; Dean, J Michael; Ramilo, Octavio; Mahajan, Prashant
Importance/UNASSIGNED:In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. Objective/UNASSIGNED:To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Design, Setting, and Participants/UNASSIGNED:Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. Exposures/UNASSIGNED:Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures/UNASSIGNED:Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Results/UNASSIGNED:We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Conclusions and Relevance/UNASSIGNED:We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.
PMID: 30776077
ISSN: 2168-6211
CID: 3685742

Epidemiology of paediatric trauma presenting to US emergency departments: 2006-2012

Avraham, Jacob B; Bhandari, Misha; Frangos, Spiros G; Levine, Deborah A; Tunik, Michael G; DiMaggio, Charles J
BACKGROUND: Traumatic injury is the leading cause of paediatric morbidity and mortality in the USA. We present updated national data on emergency department (ED) discharges for traumatic injury for a recent 7-year period. METHODS: We conducted a descriptive epidemiological analysis of the Nationwide Emergency Department Sample Survey, the largest and most comprehensive database in the USA, for 2006-2012. Among children and adolescents, we tracked changes in injury mechanism and severity, cost of care, injury intent and the role of trauma centres. RESULTS: There was an 8.3% (95% CI 7.7 to 8.9) decrease in the annual number of ED visits for traumatic injury in children and adolescents over the study period, from 8 557 904 (SE=5861) in 2006 to 7 846 912 (SE=5191) in 2012. The case-fatality rate was 0.04% for all injuries and 3.2% for severely injured children. Children and adolescents with high-mortality injury mechanisms were more than three times more likely to be treated at a level 1 trauma centre (OR=3.5, 95% CI 3.3 to 3.7), but were more no more likely to die (OR=0.96, 95% CI 0.93 to 1.00). Traumatic brain injury diagnoses increased 22.2% (95% CI 20.6 to 23.9) during the study period. Intentional assault accounted for 3% (SE=0.1) of all child and adolescent ED injury discharges and 7.2% (SE=0.3) of discharges among 15-19 year-olds. There was an 11.3% (95% CI 10.0 to 12.6) decline in motor vehicle injuries from 2009 to 2012. The total cost of care was $23 billion (SE=0.01), a 78% increase from 2006 to 2012. CONCLUSIONS: This analysis presents a recent portrait of paediatric trauma across the USA. These analyses indicate the important role and value of trauma centre care for injured children and adolescents, and that the most common causes and mechanisms of injury are preventable.
PMID: 29056586
ISSN: 1475-5785
CID: 2757522

Food poisoning

Chapter by: Fil, Laura J; Tunik, Michael G
in: Goldfrank's toxicologic emergencies by Nelson, Lewis; et al (Ed)
New York : McGraw-Hill Education, [2019]
pp. ?-?
ISBN: 1259859614
CID: 3699822

Prevalence of Brain Injuries and Recurrence of Seizures in Children with Post Traumatic Seizures

Badawy, Mohamed K; Dayan, Peter S; Tunik, Michael G; Nadel, Frances M; Lillis, Kathleen A; Miskin, Michelle; Borgialli, Dominic A; Bachman, Michael C; Atabaki, Shireen M; Hoyle, John D Jr; Holmes, James F; Kuppermann, Nathan
OBJECTIVES: Computed tomography (CT) is often used in the emergency department (ED) evaluation of children with post-traumatic seizures (PTS); however, the frequency of traumatic brain injuries (TBI) and short-term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBI on CT and short-term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED. METHODS: This was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 emergency departments (ED) in the Pediatric Emergency Care Applied Research Network (PECARN). We evaluated children <18 years with head trauma and PTS between June 2004 and September 2006. We assessed TBI on CT, neurosurgical interventions and recurrent seizures within one week. Patients discharged from the ED were contacted by telephone 1 week-3 months later. RESULTS: Of 42,424 children enrolled, 536 (1.3%, 95% CI 1.2, 1.4%) had PTS. 466 of 536 (86.9%, 95% CI 83.8, 89.7%) underwent CT in the ED. TBIs on CT were identified in 72 (15.5%, 95% CI 12.3, 19.1%), of whom 20 (27.8%, 95% CI 17.9, 39.6%) underwent neurosurgical intervention, and 15 (20.8%, 95% CI 12.2, 32.0%) had recurrent seizures. Of the 464 without TBIs on CT (or no CTs performed), 457 had recurrent seizure status known, and 5 (1.1%, 95 CI 0.4, 2.5%) had recurrent seizures; 4 of 5 presented with GCS scores <15. None of the 464 underwent neurosurgical intervention. We found significant associations between likelihood of TBI on CT with longer time until the PTS after the traumatic event (p=0.006) and longer duration of PTS (p<0.001). CONCLUSIONS: Children with PTS have a high likelihood of TBI on CT, and those with TBI on CT frequently require neurosurgical interventions and frequently have recurrent seizures. Those without TBI on CT, however, are at low risk of short-term recurrent seizures, and none required neurosurgical interventions. Therefore, if CT-negative and neurologically normal, patients with PTS may be safely considered for discharge from the ED
PMID: 28170143
ISSN: 1553-2712
CID: 2437412

Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma

Tunik, Michael G; Powell, Elizabeth C; Mahajan, Prashant; Schunk, Jeff E; Jacobs, Elizabeth; Miskin, Michelle; Zuspan, Sally Jo; Wootton-Gorges, Sandra; Atabaki, Shireen M; Hoyle, John D Jr; Holmes, James F Jr; Dayan, Peter S; Kuppermann, Nathan
STUDY OBJECTIVE: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. METHODS: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for >/=2 nights with intracranial injury on CT). RESULTS: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. CONCLUSION: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.
PMID: 27471139
ISSN: 1097-6760
CID: 2191702

Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children with Blunt Head Trauma

Borgialli, Dominic A; Mahajan, Prashant; Hoyle, John D Jr; Powell, Elizabeth C; Nadel, Frances M; Tunik, Michael G; Foerster, Adele; Dong, Lydia; Miskin, Michelle; Dayan, Peter S; Holmes, James F; Kuppermann, Nathan
OBJECTIVE: To compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma. METHODS: This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial ED evaluation. The pediatric GCS was used for children <2 years and the standard GCS for those >/=2 years. Outcomes were TBI visible on CT and clinically-important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver-operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes. RESULTS: We enrolled 42,041 patients of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%; 95% CI 8.4, 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%; 95% CI 1.2, 1.6%) had ciTBIs. In patients >2 years, 773/11,977 (6.5%; 95% CI 6.0, 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%; 95% CI 1.7, 2.0%) had ciTBIs. For the pediatric GCS in children <2 years, the area under the ROC curve was 0.61 (95% CI 0.59, 0.64) for TBI on CT and 0.77 (95% CI 0.73, 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI 0.70, 0.73) for TBI on CT scan and 0.81 (95% CI 0.79, 0.83) for ciTBI. CONCLUSIONS: The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI
PMID: 27197686
ISSN: 1553-2712
CID: 2112342