Faculty Bibliography

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.

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.

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.

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.

Study Objectives: To evaluate clinical decisionmaking by emergency physicians using IVC US in children undergoing ED evaluation of dehydration from GI losses. Dehydration from gastroenteritis is a leading cause of death in children <5 years worldwide. US assessment of the IVC may correlate with severity of dehydration and assist in clinical decision making. Methods: We conducted a prospective cohort study of US imaging of the IVC in pediatric patients with suspected dehydration from vomiting and/or diarrhea. The IVC was imaged in the sagittal plane at the junction of the right atrium and along the length of the IVC extending into the liver, assessing for 100% collapse of the walls of the IVC with tidal breathing. Patients < 21 yrs. presenting with vomiting requiring ondansetron or diarrhea with concern for dehydration were eligible for study inclusion. Patients enrolled from 10/2015-12/2016. Clinical dehydration scores, pre-test (before IVC US) and post-test (after IVC US) probabilities of dehydration requiring IV fluids were recorded by 5 treating sonologists that enrolled patients into the study. Primary outcomes assessed included: IV vs PO fluid rehydration, ED length of stay (LOS) and disposition (admission or discharge). Results: One hundred twelve patients were enrolled, median age was 5 years (S.D +/-6), and 49.1% were female. By clinical dehydration score, 61.6% (n/N=69/112; 95% CI: 51.9-70.6%), 36.6% (n/N=41/112; 95% CI: 27.7-46.2%), and 0.01% (n/N=2/112; 95% CI: 0.0-0.06%) were minimally, moderately and severely dehydrated respectively. The majority of patients received oral rehydration 79.4% (n/N 89/112; 95 CI: 70.8-86.5%) and 20.5% (n/N=23/112; 95% CI: 13.5-29.2%) received IV fluid rehydration. Only 4.4% (n/N=5/112; 95% CI: 0.1-8.3%) were admitted and no discharged patient returned to the ED for failure to rehydrate. The distribution of pre-test to post-test probabilities in children with suspected dehydration requiring IV fluids is presented in matrix Figure 1. Overall, IVC US altered pre-test probabilities for requiring IV fluid rehydration by decreasing in 51.8% (n/N=58/112; 95% CI: 42.1-61.3%), increasing in 25% (n/N=26/112; 95% CI: 17.3-34.1), and left unchanged in 23.2% (n/N=28/112; 95% CI: 15.8-32.1%). IVC US was attributed to changing management in 15.2% (n/N=17/112; 95% CI: 9.1-23.2%) patients; from PO to IV fluid rehydration in 6.3% (n/N=7/112) children and from IV to PO rehydration in 8.9% (n/N=10/112) patients. Conclusions: US changes pre-test to post-test probabilities for requiring IV fluid rehydration in the majority of children with suspected dehydration, but in a population of mildly to moderately dehydrated children actual management change with respect to IV vs PO rehydration was infrequent. [Image Presented]

Background/UNASSIGNED:Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation. Objective/UNASSIGNED:To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis. Methods/UNASSIGNED:We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy. Results/UNASSIGNED:In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and shorter triage-to-incision time (p = 0.003). Conclusion/UNASSIGNED:Children with suspected appendicitis receiving ultrasound scan as the initial diagnostic imaging modality do not have increased risk of perforation compared to those receiving computed tomography scan first. We recommend that children <12 years of age receive ultrasound scan first.

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

A well-appearing 3-year-old boy presented to the pediatric emergency department 2 hours after a presumed hydrocarbon ingestion. He was referred to the emergency department by his pediatrician after consultation with the local poison control center after possibly ingesting ylang ylang (Cananga odorata) fragrance oil. The child was asymptomatic with a normal physical examination. Point-of-care lung ultrasound identified focal hydrocarbon pneumonitis in the right lung and demonstrated resolution of these findings. Utilization of point-of-care ultrasound resulted in a shorter emergency department length of stay and the avoidance of radiation exposure from serial chest x-rays.