Faculty Bibliography

Gastrostomy tubes (G-tubes) are frequently used in children for feeding and nutrition. Complications related to G-tubes (and G-buttons) in children represent a common presentation to the emergency department (ED). G-tube replacement is usually performed by pediatric emergency medicine physicians. Misplacement may lead to tract disruption, perforation, fistula tract formation, or feeding into the peritoneum. Contrast-enhanced radiographs are traditionally used for confirmation. In addition to a longer length-of-stay, repeat ED visits result in repeated radiation exposure. The use of point-of-care ultrasound (POCUS) instead of radiography avoids this exposure to ionizing radiation. Here, we describe three patients who presented with G-tube complications in whom POCUS alone performed by pediatricians was used for confirmation of the tubes' replacement. Two children presented to the ED with G-tube dislodgement, and one child presented with a ruptured balloon. In all three cases, a new G-tube was replaced at the bedside using POCUS guidance without the need for further radiographic studies. There were no known ED or clinic returns for G-tube complaints over the next 30 days. This is the first report of pediatricians using POCUS to guide and confirm G-tube replacement in children. The success of these cases suggests the technique's feasibility. Future prospective studies are needed to evaluate the learning curves, diagnostic accuracy, ED length-of-stay, and use of confirmatory imaging.

Background and Objectives: Medical response teams deployed by the Emergency Department (ED) may be necessary to provide care for non-hospitalized patients outside of the ED. Knowledge and consistency of the medical response flow may vary by practitioners. The impact of targeted training videos for these medical response teams has not been well studied. The objective of this study is to assess the use of a training video to provide education of the medical response workflow to ED providers in the delivery of medical care to non-hospitalized patients outside of the ED Methods: A training video was developed to address medical response flow, including coverage hours, team assignments, medical equipment accessibility, hospital coverage areas, and building entry points. The video was shown to Emergency Medicine attendings, fellows, residents, and nurse practitioners during academic conferences. A survey using a Likert scale and multiple answer questions was administered prior to showing the video to assess baseline knowledge. The same questions were surveyed upon conclusion of the video. Analysis using independent sample t-test were used to assess group responses in the pre and post training video questions. Mean scores were also stratified by provider groups Results: 64 of the 79 surveyed completed both pre and post training video questions. There were significant increases in mean scores from the groups overall between the pre and post video surveys when participants were asked who would respond to medical requests outside the ED (M=6.9, SD=2.7 vs M=8.6, SD=2.0; t(133)=-3.9, p=<0.001), knowledge of response team coverage area (M=5.8, SD=3.1 vs M=8.6, SD=2.0; t(133)=-6.2, p=<0.001), building entry points (M=5.7, SD=3.0 vs M=8.7, SD=1.8; t(133)=-4.0, p=<0.001), medical equipment accessibility (M=5.5, SD=3.2 vs M=8.9, SD=1.9; t(133)=-6.7, p=<0.001), and coverage hours (M=5.5, SD=3.2 vs M=8.9, SD=1.9; t(133)=-7.3, p=<0.001). The mean score differences were often more significant in resident groups than other provider groups on the same surveyed questions
Conclusion(s): Training video may be used as an education tool for ED providers who response to medical response team requests for non-hospitalized patients outside the ED. Future assessments should be evaluated for knowledge retention and consistency in medical response team flow among providers

OBJECTIVE:The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation. METHODS:We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression. RESULTS:Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9-15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8-15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00-1.04). CONCLUSIONS:Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.

Although systemic infections originating from skin infections caused by insect bites are uncommon, it is imperative to maintain a broad differential diagnosis should patients develop systemic symptoms. Necrotizing fasciitis is a rare diagnosis, and progression to septic pulmonary emboli is even less common. Emergent identification and aggressive treatment of these two disease processes are imperative as both carry high rates of morbidity and mortality.

BACKGROUND:Oral lacerations represent a unique challenge for anesthesia in the emergency department. Many options exist for local anesthesia, but these options are often associated with pain from injections or anxiety from anticipated needle injection. CASE SERIES:We introduce a novel and needleless approach to achieving local anesthesia for oral mucosa repair by dripping injectable lidocaine directly onto mucosal wounds prior to repair. This method is well tolerated and achieves appropriate anesthesia without undesirable side effects. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Dripped injectable lidocaine may be an alternative method for mucosal anesthesia in the pediatric population.

Tick-borne illnesses are increasing in prevalence and geographic reach. Because the presentation of these illnesses is sometimes nonspecific, they can often be misdiagnosed, especially in the early stages of illness. A detailed history with questions involving recent activities and travel and a thorough physical examination will help narrow the diagnosis. While some illnesses can be diagnosed on clinical findings alone, others require confirmatory testing, which may take days to weeks to result. This issue reviews the emergency department presentation of 9 common tick-borne illnesses and evidence-based recommendations for identification, testing, and treatment.

Vegetarian and vegan diets are gaining popularity in the United States. Although appropriately planned vegetarian diets, including vegan diets, are healthful and nutritionally adequate and may provide health benefits in the prevention and treatment of certain diseases, not all families are aware of the nutritional supplements that may be required for their children. We describe a case of a 2-year-old previously healthy child consuming a vegan diet who presented to the pediatric emergency department with an acute inability to move her legs. Ionized calcium was found to be 0.89 mmol/L, and symptoms completely resolved within 2 hours of calcium gluconate infusion.