Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region

OBJECTIVES

Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock.

METHODS

We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors.

RESULTS

Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]).

CONCLUSIONS

Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

Cardiopulmonary resuscitation skill training and retention in teens (CPR START): A randomized control trial in high school students

Aim

High school students are currently the largest group of individuals in the US receiving CPR training every year. This study examines the effect of adding a real-time visual feedback device to a standard instructor-led CPR course on skill acquisition and retention in high school students.

Methods

All study participants underwent baseline CPR skill testing and received a standard instructor-led compression-only CPR course. We then randomized students to a ‘Feedback Group’, consisting of 2 min of CPR training using a real-time visual feedback device, or ‘Standard Group’ that continued to practice on the inflatable manikin. CPR skills for all students were tested afterwards using the feedback device and reported as a compression score (CS) derived from their chest compression depth, rate, hand position, and full chest recoil. We compared the CS at baseline, week-0 (immediately post-intervention), week-10, week-28, and week-52 between groups.

Results

A total of 220 students were included in the analyses (Feedback Group = 110, Standard Group = 110). Both groups showed similar CPR performance at baseline. At week-0, the Feedback Group had a significantly higher CS compared to the Standard Group (adjusted difference: 20% [95% CI: 11%–29%; p < 0.001]). This difference attenuated over time but remained significant at the week-10 and week-28 follow-up; however, by the week-52 follow-up, there was no significant difference between groups.

Conclusions

Using a real-time visual feedback device during CPR training significantly improves skill acquisition and retention in high school students and should be integrated into the high school CPR curriculum.

An Unusual Cause of Persistent Crying in a Toddler

BACKGROUND

Excessive or persistent crying is a common presentation to the pediatric emergency department, and often poses a diagnostic dilemma to emergency physicians. There are several reasons for excessive or persistent crying in children, ranging from benign causes like hunger, to life-threatening causes such as intussusception.

CASE REPORT

We report an interesting case of a toddler whose cause of excess crying, with no detectable clinical clues, was eventually attributed to a foreign body in the esophagus. A brief review of diagnostic approach to excess crying and management of ingested foreign bodies is presented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ingested foreign body is a potential cause of persistent crying, and early recognition can result in definitive treatment and prevention of potential mortality and morbidity.

Visual Diagnosis: Pinpoint, Nonfollicular, Sterile Pustules on Edematous Erythema in a 15-year-old

AGEP is a rare skin reaction that causes the formation of numerous aseptic pustules on an erythematous base. In most cases, it presents after exposure to drugs, more often antibiotics. Fever and leukocytosis are common. The history, clinical appearance, and histology of the pustules confirm the diagnosis of AGEP. Pustular psoriasis, SJM, and EM must be ruled out. The lesions heal spontaneously within 2 weeks after discontinuation of the offending agent, an occurrence that further supports the diagnosis. Immediate withdrawal of the causative agent and supportive therapy is the mainstay of treatment for AGEP.