A silent scream in the pediatric emergency department: child abuse and neglect

Child abuse and neglect includes any behavior that harms the child or hinders the child's development. The aim of this study was to determine the demographic and clinical characteristics of patients with suspected child abuse or neglect in the pediatric emergency department. Between July 2017 and July 2022, patients admitted to our pediatric emergency department and consulted to the medical social services unit with a preliminary diagnosis of neglect and/or abuse were retrospectively scanned through the registry system. The patients were divided into five groups according to their victimization: physical, sexual, and emotional abuse; neglect; and medical child abuse (MCA)-Munchausen by proxy. A total of 371 children were included in the study. Two hundred twenty-two (59.8%) of the patients were female and the median age was 161 months [IQR (46-192)]. Then, 56.3% of the patients were in the adolescent age group. The most common admission time period was between 16.00 and 24.00 (n 163, 43.9%). Then, 24.2% of the patients were exposed to physical abuse, 8.8% to sexual abuse, 26.1% to emotional abuse, 50.4% to neglect, and 3.2% to MCA. One hundred eight (29.1%) patients were followed up as inpatients in the pediatric intensive care unit. Four of the patients (1%) had out-of-hospital cardiac arrest, and the deaths were in patients under 2 years of age.  Conclusion: Pediatric emergency departments are one of the important units visited by child maltreatment patients. Victimized children may reflect their silent screams with various clinical presentations. Infants are at the greatest risk of suffering serious or fatal injuries. Health professionals working in the emergency department have an important role in detecting, treating, and preventing recurrence of child neglect and abuse. What is Known: • The pediatric emergency department is an important entry point in the health care system for children who experience maltreatment. • It has a wide spectrum of physical, sexual, emotional abuse and neglect. What is New: • A high index of suspicion is required to diagnose cases of child maltreatment. • Infants are at the greatest risk of suffering serious or fatal injuries.

Implementation of a "hypoglycemia kit" in a pediatric emergency room: A retrospective study during 2011-2019

INTRODUCTION

Hypoglycemia is a common symptom in pediatrics that can lead to neurological sequelae. The etiologies are mostly benign, but hypoglycemia can be a symptom of severe underlying disease. To streamline the etiological investigations, a "hypoglycemia kit," containing supplies needed to perform specific analyses quickly, was made available in the pediatric emergency department of the Rouen University Hospital in 2011. Since its introduction, this kit has been used to explore all cases of hypoglycemia regardless of the context. However, although very useful, these analyses are expensive. The objective of our study was to examine the cost-effectiveness of this kit and to refine its indications if necessary.

METHODS

This was a non-interventional and retrospective single-center study. Digital records of patients for whom a hypoglycemia kit was used from September 2011 to August 2019 at the pediatric emergency department of Rouen University Hospital were used to retrieve clinical characteristics, laboratory results, and the causes of hypoglycemia.

RESULTS

The study included 82 patients. The etiologic investigation concluded that 74 patients had functional hypoglycemia, and eight cases were attributed to other etiologies. In two cases, the kit led to a diagnosis, i.e., 2.4 % efficiency. A history of congenital malformations or previous hypoglycemia was significantly associated with severe etiologies. However, there was no significant association between hypoglycemia severity, age, sex, and these etiologies.

CONCLUSION

Our study reveals that the cost-effectiveness of the hypoglycemia kit is low in pediatric emergencies (2.4 %) at Rouen University Hospital, where functional hypoglycemia remains the leading cause of hypoglycemia. However, our results allow us to suggest a decision tree for refining the usability of this kit, which would considerably increase its efficiency.

Systemic review of age brackets in pediatric emergency medicine literature and the development of a universal age classification for pediatric emergency patients - the Munich Age Classification System (MACS)

Currently arbitrary, inconsistent and non-evidence-based age cutoffs are used in the literature to classify pediatric emergencies. None of these classifications have valid medical rationale. This leads to confusion and poor comparability of the different study results. To clarify this problem, this paper presents a systematic review of the commonly used age limits from 115 relevant articles. In the literature search 6226 articles were screened. To be included, the articles had to address the following three topics: "health services research in emergency medicine", "pediatrics" and "age as a differentiator". Physiologic and anatomic principles with reference to emergency medicine were used to solve the problem to create a medically based age classification for the first time.The Munich Age Classification System (MACS) presented in this paper is thus consistent with previous literature and is based on medical evidence. In the future, MAC should lead to ensure that a uniform classification is used. This will allow a better comparability of study results and enable meta-analyses across studies.

Lost in translation? Information quality in pediatric pre-hospital medical emergencies with a language barrier in Germany

BACKGROUND

In pediatric medical emergencies, paramedics and emergency physicians must often rely on the information of third parties, often caregivers, to gather information. Failing to obtain relevant information may lead to misinterpretation of symptoms and subsequent errors in decision making and clinical treatment. Thus, children and/or caregivers with limited proficiency of the locally spoken language may be at risk for medical errors. This study analyzes logs of rescue missions to determine whether paramedics could obtain essential information from German-speaking and foreign-language children and their caregivers.

METHODS

We conducted a secondary data analysis based on retrospective data on pediatric patients of four emergency medical services (EMS) stations in Northern Germany. We defined language discordance with communication difficulties as main exposure. We used documentation quality as outcome defined as existing information on (a) pre-existing conditions, (b) current medication, and (c) events prior to the medical emergency. Statistical analyses include descriptive statistics, simple regression and multivariable regression. As multivariable regression model, a logistic regression was applied with documentation quality as dependent variable and language discordance with communication difficulties as independent variable adjusted for age, sex and Glasgow Coma Scale (GCS).

RESULTS

Data from 1,430 pediatric rescue missions were analyzed with 3.1% (n = 45) having a language discordance with communication difficulties. Patients in the pediatric foreign-language group were younger compared to German-speaking patients. Thorough documentation was more frequent in German-speaking patients than in patients in the foreign-language group. Pre-existing conditions and events prior to the medical emergency were considerably more often documented in German-speaking than for foreign-language patients. Documentation of medication did not differ between these groups. The adjustment of sex, age and GCS in the multivariable analysis did not change the results.

CONCLUSION

Language barriers are hindering paramedics to obtain relevant information in pediatric pre-hospital emergencies. This jeopardizes the safe provision of paramedic care to children who themselves or their caregivers are not fluent in German language. Further research should focus on feasible ways to overcome language barriers in pre-hospital emergencies.

TRIAL REGISTRATION

This is a retrospective secondary data analysis of a study that was registered at the German Clinical Trials Register (No. DRKS00016719), 08/02/2019.

Clinical decision-making training using the Script Concordance Test and simulation: A pilot study for pediatric residents

BACKGROUND

Each year, new pediatric residents begin their shifts in the pediatric emergency room. While technical skills are often acquired during workshops, non-technical skills such as communication, professionalism, situational awareness, or decision-making are rarely tested. Simulation enables non-technical skills to be developed in situations frequently encountered in pediatric emergencies. Adopting an innovative approach, we combined two pedagogical methods: the Script Concordance Test (SCT) and simulation to improve clinical reasoning and non-technical skills of first-year pediatric residents in dealing with clinical situations involving febrile seizures. The aim of this work is to report the feasibility of such a combined training.

METHODS

The first-year pediatric residents participated in a training session on how to manage a child attending the emergency department with a febrile seizure. At the beginning of the session, the trainees had to complete the SCT (seven clinical situations) and then participated in three simulation scenarios. Student satisfaction was assessed by means of a questionnaire at the end of the session.

RESULTS

In this pilot study, 20 residents participated in the training. The SCT scores for the first-year pediatric residents were lower and more widely distributed than those of the experts with better concordance for diagnostic items compared to investigation or treatment items. All were satisfied with the teaching methods employed. Further sessions on additional topics relating to the management of pediatric emergency cases were requested.

CONCLUSION

Although limited by the small size of our study, this combination of teaching methods was possible and seemed promising for the development of non-technical skills of pediatric residents. These methods are in line with the changes being made to the third cycle of medical studies in France and can be adapted to other situations and other specialties.

Pediatric trauma smackdown: PTS vs SIPA

BACKGROUND

Different scoring tools aid prediction of pediatric trauma patients' prognosis but there's no consensus on when to apply each. Pediatric Trauma Score (PTS) was one of the first tools developed. Shock Index Pediatric Adjusted (SIPA) adapts Shock Index (SI) in predicting outcomes adjusted for age. It is unclear if either scoring tool is better at predicting outcomes.

OBJECTIVE

To compare SIPA and PTS for level I and II pediatric traumas to determine if both are equally effective in predicting outcomes for pediatric trauma patients.

DESIGN/METHODS

This is a retrospective review of patients 1-17 years with level 1 and 2 activated trauma (1/2013 - 11/2019).

OUTCOMES OF INTEREST

disposition, length of stay, ventilator use, moderate/major spleen/liver lacerations, and Index Severity Score (ISS). Patient visits were scored using both scores and placed into high/low risk category as predefined by the individual scoring tools: High risk SIPA, low risk SIPA, high risk PTS, low risk PTS.

RESULTS

There were 750 patients who met inclusion criteria, 35 visits scored high with both tools and 543 visits scored low. The odds ratio (OR) for each tool showed high risk scores were more likely to be associated with increased likelihood of outcomes. When both high-risk groups were compared, PTS had an increased OR for most outcomes. SIPA had an increased OR for receiving fluid bolus.

CONCLUSION

This study externally validates both scoring tools for the same cohort. Both tools were reliable predictors, but PTS identifies more "high risk" visits. PTS requires more variables to calculate than SIPA. SIPA may be an effective way to triage when resources are scarce. However, there's still a need for a pediatric trauma triage score that can encompass the accuracy of PTS and the convenience of SIPA.

How to incorporate telemedicine in medical residency: A Brazilian experience in pediatric emergency

INTRODUCTION

The exponential growth of telehealth services during the COVID-19 pandemic led to the implementation of a telemedicine care service in a tertiary university pediatric hospital. It brought the need to develop a training aimed at remote care within the pediatric emergency rotation program.

OBJECTIVE

To describe the implementation of a telemedicine training for pediatric residents and present the preliminary results.

METHODS

Descriptive prospective study (pre and post), with 40 resident physicians of the first year of pediatrics. Reaction Assessments were applied before and after training, in addition to a resident physician perception questionnaire at the end of the training.

RESULTS

There was a significant difference in the resident's perception of experience and safety after initial training. Most rated the proposal as good or excellent, considered teaching telemedicine relevant and that this experience contributed to their learning on the subject.

CONCLUSION

This study describes an innovative proposal for training in telemedicine. The preliminary results were encouraging, demonstrating the program's potential in training future pediatricians.

Compassion fatigue and burnout in Turkish pediatric emergency nurses during the COVID-19 pandemic

PURPOSE

This study was conducted to determine compassion fatigue and burnout in nurses working in the pediatric emergency department (PED) during the COVID-19 pandemic in Turkey.

DESIGN AND METHODS

This descriptive and cross-sectional study was conducted with 164 nurses working in the PED and following the social media platforms of the Emergency Nurses Association between September 1, 2020, and January 1, 2021. Data were collected using the online survey method with the Descriptive Data Form, Maslach Burnout Inventory (MBI), and Compassion Fatigue-Short Scale (CF-SS).

RESULTS

Pediatric emergency nurses reported that they experienced high emotional exhaustion (28.25 ± 6.05) and depersonalization (11.89 ± 2.39), low personal accomplishment (17.98 ± 3.12), and moderate compassion fatigue (4.99 ± 1.43).

CONCLUSION

Pediatric emergency nurses had high levels of burnout and moderate levels of compassion fatigue during the pandemic in Turkey. To prevent any long-term negative effects of the pandemic, addressing the physiological, psychological, and psychosocial needs of nurses should be prioritized.

PRACTICAL IMPLICATIONS

Compassion fatigue and burnout can affect the quality of care provided by nurses, but also negatively affect their well-being and quality of life during the pandemic. Therefore, the development of interventions to reduce compassion fatigue and burnout can help manage these symptoms.

Ovarian torsion: diagnosis, surgery, and fertility preservation in the pediatric population

Ovarian torsion is rare in the pediatric population. Delayed diagnosis can significantly impact fertility. The aim of this review is to highlight current knowledge regarding clinical presentation, diagnosis, surgical management, and follow-up in the pediatric population. Whilst the presentation is often very unspecific, most children will present with sudden severe unilateral pelvic pain associated with vomiting. A key diagnostic test is pelvic ultrasonography, which may help demonstrate an asymmetric enlarged ovary with peripherally displaced follicles. In the pediatric population, ovarian torsion may occur in a normal ovary. However, underlying lesions can be found in half of cases. Benign neoplasms (teratomas or cystic lesions) represent the commonest etiology, with the risk of malignancy being less than 2%. Surgical management should be focused on fertility preservation. This is achievable through ovarian detorsion ± ovarian cystectomy ± oophoropexy to avoid recurrence. Follow-up studies demonstrate excellent recovery rates of detorsed ovaries including those with ischemic appearances. What is Known: • Ovarian torsion is a rare diagnosis in the pediatric population. • Aspecific symptoms and differential diagnoses lead to missed or delayed diagnosis increasing the risk of oophoprectomy and further infertility. What is New: • Reviewing the latest knowledge about clinical presentation, diagnostic, surgical management, and follow-up of ovarian torsion in the pediatric population. • Adiponectin was negatively associated with diastolic blood pressure and HOMA-IR, and chemerin was negatively associated with glucose.

Comparison of the outcomes of testicular torsion among children presenting during the Coronavirus Disease 2019 (COVID-19) pandemic versus the pre-pandemic period: A systematic review and meta-analysis

OBJECTIVE

To evaluate whether the Coronavirus Disease 2019 (COVID-19) pandemic resulted in a prolonged duration of symptoms, a delayed presentation to the medical facility, and consequently more orchiectomy procedures among children with testicular torsion compared to the pre-COVID-19 period.

METHODS

Systematic search of four scientific databases was performed. The search terms used were (coronavirus OR novel coronavirus OR SARS-CoV-2 OR COVID-19) AND (testicular torsion OR orchidectomy OR orchiectomy OR orchidopexy OR orchiopexy). The inclusion criteria were all boys presenting with testicular torsion during the COVID-19 and pre-COVID-19 periods. A comparison of the average duration of symptoms, the proportion of children with delayed presentation (>24 h), and the proportion of children requiring orchiectomy was made among the two groups. The Downs and Black scale was used for methodological quality assessment.

RESULTS

The present meta-analysis included six comparative studies (five retrospective studies). A total of 711 patients (473 during the COVID-19 period) were included. No significant differences in the average duration of symptoms (WMD: 2.6, 95% CI -6.78 to 11.99, P = 0.59), the proportion of children with delayed presentation (RR = 1.03, 95% CI 0.52-2.02, p = 0.94), and orchiectomy rate (RR = 1.23, 95% CI 0.82-1.84, p = 0.31) were observed among the two patient groups. All studies had a moderate risk of bias.

CONCLUSION

The duration of symptoms, the proportion of children with delayed presentation, and orchiectomy rate did not significantly differ among the children with testicular torsion presenting during the COVID-19 and pre-COVID-19 periods. However, due to the moderate risk of bias, the level of evidence of the available comparative studies is limited.

Fast, cheap and feasible: Implementation of pediatric telemedicine in a public hospital during the Covid-19 pandemic

OBJECTIVE

In Brazil, telemedicine was allowed as an exception during the coronavirus disease (COVID-19) pandemic. Despite its recognized value and availability, telemedicine is not universally used, suggesting that some barriers prevent its adoption and acceptance within the community. This study aims to describe the implementation of a low-cost telemedicine service in a pediatric hospital in Brazil.

METHOD

Retrospective descriptive study reporting the first three months (April to June 2020) of the experience of implementing a low-cost telemedicine emergency care program in a public tertiary hospital. The service was available to patients up to 18 years of age enrolled in this hospital. A tool for assessing the severity of the patient was developed, the aim of standardizing the procedure, while maintaining quality and safety. Guardian's satisfaction was assessed with a questionnaire sent after teleconsultations.

RESULTS

255 teleconsultations were carried out with 140 different patients. Of the total consultations, 182 were from 99 patients that had performed the Real-Time Polymerase Chain Reaction (RT-PCR) test for the new coronavirus (SARS-Cov-2) or had direct contact with a person known to be positive for COVID-19. Only 26 (14%) were referred to an in-person consultation. No deaths, adverse events or delayed diagnosis were recorded. 86% of the patients who answered the satisfaction questionnaire were satisfied and 92% would use telemedicine again.

CONCLUSION

This study presents an innovative implementation of a telemedicine program in a public and exclusively pediatric tertiary service, serving as a reference for future implementation in other public services in Brazil and developing countries.

Epidemiology of pediatric hand surgery emergencies. Retrospective study of 245 patients seen over 10 months in two referral centers

BACKGROUND

The primary objective of this retrospective study was to analyse the epidemiology and assess the characteristics of all paediatric hand injuries requiring emergent surgery.

HYPOTHESIS

Paediatric hand emergencies that require surgical treatment have a specific epidemiological distribution.

METHODS

We conducted a multicentre retrospective descriptive epidemiological study of surgical paediatric hand emergencies seen over 10 consecutive months.

RESULTS

We included 245 patients between the 1st of January and the 31st of October 2016. Irrespective of age, most injuries (69%) occurred at home; 11% (n=26) occurred at school and 4% in a sports centre. Overall, most injuries involved the dorsal aspect and affected the fingers more often than the hand. The most common lesion was crush injury of a distal phalanx (36% of cases). Door guards were in use in only 9% of homes (n=8), and mean age of the patients in this group was 5 years Paronychia/acute infections accounted for 27% of cases. Wounds of the hands of fingers made up 23% of cases, with the palmar aspect being involved in 70% of cases. The wound was often due to the use of a sharp-edged object. Fractures/dislocations accounted for 12% of cases and bites or scratches for 2%.

DISCUSSION

This study showed that the most common hand injuries requiring emergent surgery in a paediatric population are crush injuries of the fingertip such as door-crush injuries, which most often occur at home. Reinforcing prevention strategies should be the main priority in order to decrease the incidence of hand lesions in children. Raising awareness among parents and improving the education of the public could significantly decrease the incidence of these injuries.

LEVEL OF EVIDENCE

IV; retrospective cohort.

Erratum: Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room

[This corrects the article on p. 557 in vol. 25, PMID: 34177176.].

Dazed and Confused: Altered Mental Status in an Adolescent Male

BACKGROUND

Absence status epilepticus (ASE) is a form of generalized nonconvulsive status epilepticus. ASE is characterized by impairment in consciousness, which can vary widely, making the diagnosis more difficult. The typical patient with ASE will be confused yet responsive and in a "trance-like state" with delayed speech, clumsy gait, and the ability to perform simple tasks after prompting. With treatment, typical ASE has an excellent prognosis and does not appear to be associated with significant neuronal damage.

CASE PRESENTATION

An 11-year-old boy with history of febrile seizures presented to the emergency department (ED) with altered mental status without trauma or ingestion. His vital signs and physical examination were normal, with the exception of appearing intoxicated with sparse verbalization and inappropriate emotional responses. All laboratory results and imaging were unremarkable. While in the ED, his neurologic examination trended toward normal, returning almost to baseline. He was admitted to the hospital for video electroencephalogram, which revealed status epilepticus. After benzodiazepine therapy, epileptic electrical activity ceased and the patient's symptoms resolved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ASE is a rare condition that is uncommonly described in the pediatric population. These patients are frequently misdiagnosed on initial presentation as their alteration in mental status can be easily confused with ingestion, trauma, psychiatric illness, or infectious etiologies. Overturning the long-standing emergency dogma of "if they're talking to you, it's not a seizure" is undoubtedly difficult, but both pediatric and adult providers should be aware of this clinical entity.

A rare case of anterior shoulder dislocation in 1-year- and 10-month-old toddler: case report and literature review

We report our clinical experience of a 1 year and 10 month child with traumatic anterior shoulder dislocation who underwent non-operative reduction and Desault's bandage immobilization for 10 days. No associated fractures were found and after bandage removal, full ROM of the shoulder was immediately assessed. Further research is needed to unified guideline of treatment and the time of immobilization for this type of injury in pediatric population.

Effect of budesonide on hospitalization rates among children with acute asthma attending paediatric emergency department: a systematic review and meta-analysis

INTRODUCTION

The efficacy of inhaled budesonide for managing moderate-to-severe acute exacerbations in children is not clear. Therefore, this study aimed to evaluate hospital admission rates, need for use of systemic corticosteroids, length of hospital stay and adverse events when inhaled budesonide is added to standard pediatric emergency department management of moderate-to-severe acute exacerbations of asthma.

METHODS

A systematic search was conducted in PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases. Randomized controlled trials that evaluated the effect of nebulized budesonide in moderate-to-severe acute exacerbations of asthma in pediatric patients were included for this meta-analysis. Statistical analysis was done using STATA version 13.0.

RESULTS

A total of 16 RCTs were included. Children receiving nebulized budesonide had 43% lower risk of being hospitalized (RR 0.57; 95% CI, 0.39; 0.85) and 66% lower risk of requiring systemic corticosteroids (RR 0.34; 95 % CI, 0.21; 0.55) compared with those receiving placebo. There were no differences in the length of hospital stay (Hedges's g standardized mean difference - 1.53; 95% CI, - 3.64; 0.58) and risk of adverse events (RR 0.87, 95% CI; 0.65; 1.17) between the two groups. There was no evidence of publication bias for any of the outcomes considered.

CONCLUSION

The findings of this meta-analysis support the use of inhaled budesonide in reducing risk of hospitalization and the need for systemic corticosteroids among children with acute moderate-to-severe asthma exacerbation.

Impact of novel coronavirus Disease-19 (COVID-19) pandemic in Italian pediatric emergency departments: a national survey

BACKGROUND

Coronavirus Disease-19 (COVID-19) has rapidly become a pandemic emergency, distressing health systems in each affected country. Preparation strategies for managing this pandemic have been keys to face the COVID-19 surge all over the world and all levels of care.

MATERIALS AND METHODS

During the epidemic, the Italian society of pediatric emergency-urgency (SIMEUP) promoted a national survey aiming to evaluate preparedness and response of pediatric emergency departments (PED) critical in ensuring optimal management of COVID-19 cases.

RESULTS

Our results suggest that Italian PED have promptly set a proactive approach to the present emergency. 98.9% of the hospitals have defined special pathways and assistive protocols concerning the management of pediatric COVID-19 cases. The highest percentage of application of the measures for preventive and protective for COVID-19 concerned the use of personal protective equipments.

CONCLUSIONS

Results show that the following measures for pediatric patients, admitted in PED, have been promptly implemented throughout the whole country: eg. use of protective devices, pre-triage of patients accessing the hospital. Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision algorithm and clear plans for the interventional platform teams, we can ensure optimal health care workers and patients' safety.

Injuries from alleged accidental minor head trauma in a prospective cohort of children aged 0-3 years in an emergency department

INTRODUCTION

Minor head trauma in the child, whether accidental or inflicted, is a frequent reason for seeking medical attention. Our aim is to describe the characteristics of minor head trauma in children aged 0-3 years and the resulting injuries. This in order to help the clinician to suspect and thelegal expert to confirm intentional abuse.

STUDY DESIGN

Children aged from 0 to 3 years with minor head trauma and attending the pediatric emergency department were included in the study between January 2013 and June 2014. The correlation between the characteristics of trauma and the resulting injuries was analyzed using a prospective data collection questionnaire completed by the physicians who cared for the child.

RESULTS

A total of 709 children with minor head trauma were included in the study. In nearly 90% of cases, fall height was less than 1 m. Only one-third of children aged less than 6 months had external head injury. Low-intensity trauma, such as a low-velocity fall from a height of less than 1.5 m does not cause intracranial injury. External injuries were more frequent in children who had a fall with an anterior impact, while internal injuries were found only in posterior and lateral impacts.

CONCLUSION

In the context of minor head trauma, the physician must be vigilant and must ask for a full and clear description of the trauma, its mechanisms and other characteristics, when external or internal head injuries are observed in children aged less than 6 months.

Feasibility and integration of an intensive emergency pediatric care curriculum in Armenia

Background

Emergency pediatric care curriculum (EPCC) was developed to address the need for pediatric rapid assessment and resuscitation skills among out-of-hospital emergency providers in Armenia. This study was designed to evaluate the effectiveness of EPCC in increasing physicians’ knowledge when instruction transitioned to local instructors. We hypothesize that (1) EPCC will have a positive impact on post-test knowledge, (2) this effect will be maintained when local trainers teach the course, and (3) curriculum will satisfy participants.

Methods

This is a quasi-experimental, pre-test/post-test study over a 4-year period from October 2014‑November 2017. Train-the-trainer model was used. Primary outcomes are immediate knowledge acquisition each year and comparison of knowledge acquisition between two cohorts based on North American vs local instructors. Descriptive statistics was used to summarize results. Pre-post change and differences across years were analyzed using repeated measures mixed models.

Results

Test scores improved from pretest mean of 51% (95% CI 49.6 to 53.0%) to post-test mean of 78% (95% CI 77.0 to 79.6%, p < 0.001). Average increase from pre- to post-test each year was 27% (95% CI 25.3 to 28.7%). Improvement was sustained when local instructors taught the course (p = 0.74). There was no difference in improvement when experience in critical care, EMS, and other specialties were compared (p = 0.23). Participants reported satisfaction and wanted the course repeated. In 2017, EPCC was integrated within the Emergency Medicine residency program in Armenia.

Discussion

This program was effective at impacting immediate knowledge as well as participant satisfaction and intentions to change practice. This knowledge acquisition and reported satisfaction remained constant even when the instruction was transitioned to the local instructors after 2 years. Through a partnership between the USA and Armenia, we provided OH-EPs in Armenia with an intensive educational experience to attain knowledge and skills necessary to manage acutely ill or injured children in the out-of-hospital setting.

Conclusions

EPCC resulted in significant improvement in knowledge and was well received by participants. This is a viable and sustainable model to train providers who have otherwise not had formal education in this field.

Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room

Aim and objective

To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital.

Materials and methods

The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale were to grade the extent of two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change, introduction of infection control nurse and quality improvement (QI) team formations were implement in different Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” was outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were process measures.

Result

The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9 and 96.1% to 45 and 55%, respectively, postimplementation of all PDSA cycles.

Conclusion

Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation help in sustaining the goal and attaining long-term success.

How to cite this article

Singh N, Kalyan G, Kaur S, Jayashree M, Ghai S. Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room. Indian J Crit Care Med 2021;25(5):557–565.

A study of medication errors during the prescription stage in the pediatric critical care services of a secondary-tertiary level public hospital

Background

Medication Errors (MEs) are considered the most common type of error in pediatric critical care services. Moreover, the ME rate in pediatric patients is up to three times higher than the rate for adults. Nevertheless, information in pediatric population is still limited, particularly in emergency/critical care practice. The purpose of this study was to describe and analyze MEs in the pediatric critical care services during the prescription stage in a Mexican secondary-tertiary level public hospital.

Methods

A cross-sectional study to detect MEs was performed in all pediatric critical care services [pediatric emergency care (PEC), pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and neonatal intermediate care unit (NIMCU)] of a public teaching hospital. A pharmacist identified MEs by direct observation as the error detection method and MEs were classified according to the updated classification for medication errors by the Ruíz-Jarabo 2000 working group. Thereafter, these were subclassified in clinically relevant MEs.

Results

In 2347 prescriptions from 301 patients from all critical care services, a total of 1252 potential MEs (72%) were identified, and of these 379 were considered as clinically relevant due to their potential harm. The area with the highest number of MEs was PICU (n = 867). The ME rate was > 50% in all pediatric critical care services and PICU had the highest ME/patient index (13.1). The most frequent MEs were use of abbreviations (50.9%) and wrong speed rate of administration (11.4%), and only 11.7% of the total drugs were considered as ideal medication orders.

Conclusion

Clinically relevant medication errors can range from mild skin reactions to severe conditions that place the patient’s life at risk. The role of pharmacists through the detection and timely intervention during the prescription and other stages of the medication use process can improve drug safety in pediatric critical care services.

Point-of-care ultrasound for evaluating intra-abdominal calcification in the pediatric emergency department: case series and review of literature

Background

The presence of intra-abdominal calcification in the pediatric population can be due to a wide range of conditions. Calcification in the abdomen can be seen in normal or abnormal anatomical structures. In some patients, abnormal calcification points towards the pathology; whereas in others, calcification itself is the pathology. After a thorough history and clinical examination, point-of-care ultrasound (POCUS) would complement the assessment of acute abdominal pain, based on the list of differentials generated as per the abdominal region. The main objective of this article is to review commonly encountered causes of intra-abdominal calcifications in the pediatric population and help in clinical decision-making in a Pediatric Emergency Department.

Case presentation

We describe a series of pediatric patients who presented to the Pediatric Emergency Department with acute abdominal pain, in whom point-of-care ultrasound helped expedite the diagnosis by identifying varying types of calcification and associated sonological findings. For children who present to the Pediatric Emergency Department with significant abdominal pain, a rapid distinction between emergencies and non-emergencies is vital to decrease morbidity and mortality.

Conclusions

In a child presenting to the Pediatric Emergency Department with abdominal pain, POCUS and the findings of calcifications can narrow or expand the differential diagnosis when integrated with history and physical exam, to a specific anatomic structure. Integrating these findings with additional sonological findings of an underlying pathology might raise sufficient concerns in the emergency physicians to warrant further investigations for the patient in the form of a formal radiological ultrasound and assist in the patient's early disposition. The use of POCUS might also help to categorize the type of calcification to one of the four main categories of intra-abdominal calcifications, namely concretions, conduit wall calcification, cyst wall calcification, and solid mass-type calcification. POCUS used thoughtfully can give a diagnosis and expand differential diagnosis, reduce cognitive bias, and reduce physician mental load. By integrating the use of POCUS with the history and clinical findings, it will be possible to expedite the management in children who present to the Pediatric Emergency Department with acute abdominal pain.

Referrals to a pediatric emergency department of a tertiary care teaching hospital before and after introduction of a referral education module - a quality improvement study

BACKGROUND

Provision of timely care to critically ill children is essential for good outcome. Referral from smaller peripheral hospitals to higher centers for intensive care is common. However, lack of an organized referral and feedback system compromises optimal care. We studied the quality of referral letters coming to our Emergency Department (ED) with respect to their demography, association with severity of illness and mortality before and after referral education.

METHODS

Our study was completed in three phases in the Pediatric ED; Pre-intervention, Intervention and Post intervention phases. Quality of referral letter was matched with a quality checklist proforma and graded as 'good', 'fair' and 'poor' if it scored > 7, 5-7 and < 5 points respectively. A peer reviewed referral education module was prepared using case studies, expert opinions, and lacunae observed in the first phase and administered to health care providers (HCP's) of referring hospitals. Quality of referral letter was compared between pre and post intervention phases.

RESULTS

Most referrals belonged to the neighboring states of Punjab (48.2%) and Haryana (22.4%). Major referring hospitals were from public sector (80.9%), of which the teaching hospitals topped the list (53.6%). Government run ambulance services (85.5%) was commonest mode of transport used and need for a PICU bed and/or mechanical ventilation (50.4%) was the commonest reason for referral. The post intervention phase saw a significant decline in the proportion of poor (93.2 vs.78.2%; p = 0.001) and a significant increase in the proportion of fair (6.1 vs 18%; p = 0.001) and good referral letters (0.7 vs 18%; p = 0.001). The proportion of children with physiological decompensation at triage had reduced significantly in the post intervention phase [513 out of 1403 (36.5%) vs. 310 out of 957 (32.3%); p = 0.001].

CONCLUSION

Referral education had significantly improved the quality of referral letters. Proportion of children with physiological decompensation at triage had decreased significantly after referral module. This change suggests sensitization of the peripheral hospitals towards a better referral process. Continued multifaceted approach will be required for sustained and increased benefits.

Predictors of acute metabolic decompensation in children with maple syrup urine disease at the emergency department

Acute metabolic decompensation (AMD) of maple syrup urine disease (MSUD) must be promptly recognized and treated. In this study, we aimed to identify simple variables associated with AMD in children with MSUD for use in emergency settings. Data were collected retrospectively from 115 emergency visits of 29 children with MSUD over a 4-year period in a major referral hospital. Variables in visits with and without AMD were compared using t test, Mann-Whitney U test, and chi-square test. Logistic regression was used to identify independent variables associated with decompensations. Cut-off values of laboratory variables were determined with receiver operating characteristic curves and correlations with Spearman's rank correlation. Most important variables independently associated with AMD were poor feeding, malaise, anion gap, and especially uric acid, which correlated with leucine levels. Vomiting, dehydration, neurological signs, ketonuria, and ketoaciduria were also associated with AMD. Although sodium, chloride, and glucose were lower in AMD, they had little diagnostic value.Conclusion: In children with MSUD, uric acid and anion gap are key markers for AMD. Poor feeding and malaise are clues before the onset of neurological symptoms. These simple parameters can help determine the presence of AMD in emergency settings.What is Known:• In maple syrup urine disease, acute metabolic decompensations are characterized by gastrointestinal and neurological findings.• Diagnosis requires detection of significantly elevated leucine, which may take a long time or not be available.What is New:• Poor feeding, malaise, hyperuricemia, and high anion gap are parameters that can help diagnose acute decompensations in children with maple syrup urine disease at emergency departments.• Uric acid may be a biomarker for acute decompensations because of its high sensitivity, specificity, and its strong correlation with leucine.

Reluctance to seek pediatric care during the COVID-19 pandemic and the risks of delayed diagnosis

Since the outbreak of COVID-19 pandemic, the number of cases registered worldwide has risen to over 3 million. While COVID-19 per se does not seem to represent a significant threat to the pediatric population, which generally presents a benign course and a low lethality, the current emergency might negatively affect the care of pediatric patients and overall children welfare. In particular, the fear of contracting COVID-19 may determine a delayed access to pediatric emergency facilities. Present report focuses on the experience of The Children Hospital in Alessandria (northern Italy). The authors document a drop in the number of admissions to the emergency department (A&E) during the lock-down. They will also focus on four emblematic cases of pediatric patients who were seen to our A&E in severe conditions. All these cases share a significant diagnostic delay caused by the parents’ reluctance to seek medical attention, seen as a potential risk factor for COVID-19 contagion. None was found positive to all COVID-19 swab or immunologic testing. All in all, our data strongly support the importance of promoting a direct and timely interaction between patients and medical staff, to prevent the fear of COVID-19 from causing more harm than the virus itself.

Radial head subluxation in pediatric clinics and emergency departments in China

PURPOSE

To investigate the characteristics of the onset and treatment of radial head subluxation (RHS) in pediatric clinics and emergency departments.

METHODS

A retrospective study was performed on 11, 404 RHS cases in 9827 children who visited pediatric clinics and emergency departments from January 2015 to December 2018. The patients who with history of trauma and fracture of the affected limb were excluded. The following factors were examined: the mechanisms of RHS, the type of manual reduction, the attending physician's clinical background (emergency surgeon, junior pediatric orthopedic surgeon or senior pediatric orthopedic surgeon), and the epidemiological features (gender, age, climate and location) of the injury.

RESULTS

The mean age of the patients was 27.93 ± 17.94 months (range 0.93-214.53 months), with a peak incidence of 10.73-44.53 months. Approximately two-thirds of RHS cases occurred in cold weather from January to March and from September to December. Females accounted for 53.81% (n = 6137) of the cases, and left injuries were predominant (56.87%, n = 6485) in all cases. Mechanisms of injury were classified as "pull" (90.57%, n = 10, 339), "fall" (1.56%, n = 178), "hit" (0.75%, n = 86) and "unknown" (7.02%, n = 801). The overall success rate of manual reduction was 99.47%, and the success rate of reduction was higher for senior pediatric orthopedic surgeons than for emergency surgeons and junior pediatric orthopedic surgeons (p < 0.05). However, there was still a recurrence rate of 12.16% in the 9827 patients.

CONCLUSION

Younger children are predisposed to RHS, and there is a possibility of recurrence. Trained emergency doctors can handle it well, but it is essential to refer patients to specialists when manual reduction failed.

Long-term retention assessment after simulation-based-training of pediatric procedural skills among adult emergency physicians: a multicenter observational study

BACKGROUND

One of the primary goals of simulation-based education is to enable long-term retention of training gains. However, medical literature has poorly contributed to understanding the best timing for repetition of simulation sessions. There is heterogeneity in re-training recommendations.

OBJECTIVES

This study assessed, through simulation-based training in different groups, the long-term retention of rare pediatric technical procedures.

METHODS

This multicenter observational study included 107 emergency physicians and residents. Eighty-eight were divided into four groups that were specifically trained for pediatric emergency procedures at different points in time between 2010 and 2015 (< 0.5 year prior for G1, between 0.5 and 2 years prior for G2, between 2 and 4 years prior for G3, and ≥ 4 years prior for G4). An untrained control group (C) included 19 emergency physicians. Participants were asked to manage an unconscious infant using a low-fidelity mannequin. Assessment was based on the performance at 6 specific tasks corresponding to airway (A) and ventilation (B) skills. The performance (scored on 100) was evaluated by the TAPAS scale (Team Average Performance Assessment Scale). Correlation between performance and clinical level of experience was studied.

RESULTS

There was a significant difference in performance between groups (p < 0.0001). For G1, 89% of the expected tasks were completed but resulted in longer delays before initiating actions than for the other groups. There was no difference between G4 and C with less than half of the tasks performed (47 and 43% respectively, p = 0.57). There was no correlation between clinical level of experience and performance (p = 0.39).

CONCLUSION

Performance decreased at 6 months after specific training for pediatric emergency skills, with total loss at 4 years after training, irrespective of experience. Repetition of simulation sessions should be implemented frequently after training to improve long-term retention and the optimal rate of refresher courses requires further research.

Lessons Learned from Implementing a Patient Prioritization Tool Designed with End-Users in a Pediatric Emergency Ward

INTRODUCTION

Overcrowding is a common problem in emergency departments. This is true for adult and pediatric emergency department (PED) and issues are potentially important (e.g. quality of care, financial, social, ethical). Optimum is one among several solutions implemented to fight this phenomenon. It is an electronic patient prioritization tool for PED devoted to non-vital emergencies. First usage assessments reported the tool was not used by the PED staffs despite their strong involvement during the development.

AIM

This paper aims at understanding why the PED staff did not use the Optimum system that has been designed with them and for them, through a user-centered design process.

METHOD

PED staffs answered answer a short survey about their usage of Optimum. Depending on their answer (user vs. non-user), they either underwent an individual semi-structured interview or an unstructured one. Interviews were audio-recorded and transcribed and, from each interview, meaningful semantic units representing the reasons for using/non-using Optimum were extracted and organized iteratively following a grounded approach by three ergonomics experts till a consensus was reached.

RESULTS

12 interviews have been performed with 6 physicians, 5 nurses and 1 auxiliary nurse. Overall, the prioritization tool Optimum have received a mixed response from the PED staff: Optimum display is neither understood nor trusted by users. Moreover, it is mainly used to estimate the PED attendance rate and not to prioritize patients.

DISCUSSION

This study shows how much it is difficult to implement new tool in wards despite a user-centered development and without being included in the daily used patient management tool.

Effectiveness of a Training Course on Accuracy of Triaging of Pediatric Patients

BACKGROUND:

In the context of a new but busy Pediatric Emergency Department, the risk of missing patients who need more emergent care can be reduced by timely and accurate triaging. In the emergency department of King Fahad Armed Forces Hospital, the Canadian Triage and Acuity Scale had already been implemented, including the pediatric version (PaedCTAS). However, a common observation remained that critical patients did not always receive priority with subsequent delays in management. To improve this accuracy, a training course was administered to health care professionals responsible for triaging of pediatric patients.

AIM:

To determine the effectiveness of a training course on accuracy of triaging of Pediatric Patients.

METHODS:

A triage training course was conducted over two months, with patient encounter sheets reviewed before the course for 6 months and after the course for 12 months. Accuracy was calculated by comparing it to level as determined by two pediatric emergency physicians. Also, admission rates were used as a surrogate marker to also determine accuracy.

RESULTS:

A total of 31 053 patient sheets were reviewed. There was a considerable improvement in the correct determination of all triage levels, with accuracy ranging from 56.5% to 78.3% before the course, and reaching from 79.1% to 90.8% after the course with a statistically significant difference. Triaging errors still present were mainly in the form of down-triage.

CONCLUSION:

Our training course in triage has a significant impact on the accuracy of triaging of ill pediatric patients. Further improvement can be obtained by repeated courses and direct feedback with debriefing sessions on challenges to triage level determination.

Evaluation of poisoning cases admitted to pediatric emergency department

Background

Every year, more than one million children lose their lives due to preventable accidents. Poisoning is the most common among these accidents.

Objective

In this study, we investigated the demographic and clinical characteristics of poisoning cases referred to the pediatric emergency department.

Methods

The cases (0–18 years old) related to complaints of intoxication in the pediatric emergency department between January 1, 2017, and December 31, 2017, were examined retrospectively.

Results

The study included 453 patients, with 202 (46.4%) female and 233 (53.6%) male patients. The mean age of the patients was 51.12 months. The most frequent poisoning agents were 211 (46.6%) household cleaning products and 172 (38%) drugs. When the mechanism of poisoning was examined, it was determined that 377 (83.2%) cases were accidental and 47 (10.4%) cases were suicide attempts. It was observed that 286 (45.8%) items were not in original packaging and 95% of those in original packaging were not locked.

Conclusion

To avoid childhood poisoning that may have widespread and serious consequences, the poisonous products should be sold with locked covers and kept in places where children cannot reach them.

Validation of APLS, Argall and Luscombe Formulae for Estimating Weight among Indian Children

Weight estimation in pediatric emergencies is often required for calculation of drug dosages, fluid therapy and defibrillation. The 'gold standard' of actually weighing the patient is not practically possible in emergency conditions. The aim of this study is to validate common age-based formulae (APLS, Luscombe and Argall's) and their accuracy in estimating weight of under 5-y-old Indian children by secondary data analysis from a cross-sectional study conducted by the National Nutrition Monitoring Bureau (NNMB), National Institute of Nutrition, Hyderabad, in 10 states of India in 2011-12 among under five-year-old children. Their measured weights were compared to their estimated weights as calculated using the APLS formula, the Luscombe and Argall formulae. There is a need to adjust the formulae for accurate estimation of weight among Indian children as all the three age-based weight formulae namely APLS, Argyll and Luscombe overestimated the weight among the Indian children.

Management practice-related and modifiable factors associated with paediatric emergency return visits

OBJECTIVES

We explored practice-related factors associated with preventable unscheduled return visits to an emergency department (RTED).

METHODS

We conducted a retrospective cohort study, using standardized review of health records. We included all visits with at least one RTED within 7 days of the index visit. Cases were reviewed by investigators and clinicians to identify: 1) the proportion of unscheduled RTED, 2) the proportion deemed clinically unnecessary and 3) the contribution of clinical practice pattern and system factors.

RESULTS

There were 2809 (7.3%) index visits associated with at least one RTED. Of these, 1983 (70.6%) were unscheduled, 784 (39.5%) were considered clinically unnecessary and 739 out of 784 medically unnecessary RTEDs (94.3%) were attributed to a mismatch between parental expectations and natural progression of disease that did not require Emergency Department (ED) reassessment or interventions. Eighty per cent of reviewed written discharge instructions lacked any anticipatory guidance around symptom range and duration and 21.2% contained instructions to return to the ED for signs and symptoms which do not require ED care. An administrative or system challenge was noted as the reason for the unnecessary and unscheduled RTED in 17.5%. In 3.4% of cases, nonemergency consultants were responsible for the disposition decision and discharge process.

CONCLUSIONS

Unscheduled unnecessary return visits to our ED contribute to a significant proportion of our annual volume. Providing discharge instructions that help families distinguish expected range and duration of symptoms from signs requiring ED care was identified as a potential strategy to impact the frequency of unscheduled RTED.

Pediatric apheresis emergencies and urgencies: An update

Urgency and emergency in general, and even more in the pediatric setting, remain a thematic debate not yet fully resolved. The decision to undergo a pediatric patient to an invasive treatment not free from potentially serious side effects like an apheresis procedure should be weighted with great attention. At the moment there is no unanimous consensus about the clinical pictures in which an urgency procedure in pediatrics is indicated. Each center acts according to its own experience and not infrequently to its own fears. Consequently the difficult to draw up an unequivocal shared list of pathologies needing an intervention in urgency/emergency it is confirmed as problematic. We report the experience of a big multidisciplinary hospital that has selected and shared with the specialists of different medical disciplines during the years the pediatric clinical conditions in which an urgent intervention with apheresis technology is indicated.

Common Pediatric Medical Emergencies in Office Practice

General Practitioners frequently see children with medical conditions that may evolve into an emergency if not promptly attended to. The most common emergencies encountered in pediatric office practice are respiratory distress, dehydration, anaphylaxis, seizures and trauma. Assessment of children is sometimes difficult as the signs and symptoms might be subtle and not markedly expressed. Also, normal value of vital signs vary with age, thus their interpretation requires discrete knowledge of age appropriate values. Initial approach to a sick child involves formation of initial impression, doing primary assessment, proper history taking and classifying the condition into following categories: Respiratory distress, Respiratory failure, Compensated shock, Decompensated shock and Primary brain dysfunction. Initial management of any pediatric emergency involves assessment of airway, breathing and circulation and providing relevant adequate support. Majority of cardiac arrests in pediatric practice are secondary to progressive respiratory failure and thus, if intervened timely and effectively, will prevent fatal outcome. In a child with shock, compensated state can rapidly evolve to decompensated state, thus necessitating its early recognition and rapid intervention. Anaphylaxis should be suspected in any child with sudden onset of skin or mucosal symptoms along with respiratory, circulatory or gastro-intestinal involvement and adrenaline should be given by intra-muscular route.

[Use of cognitive aids in pediatric emergency care : Interdisciplinary consensus statement]

Preclinical pediatric emergencies are rare events and are therefore often associated with stress and uncertainty for emergency medical service personnel. To ensure adequate treatment of pediatric patients a variety of different cognitive aids exist (e.g. books, apps, rulers, weight-adapted bag systems). Especially the size specifications of the medical equipment and the dosage of emergency medication are individually very different in children and are dependent on parameters, such as body height and weight. Therefore, cognitive aids often enable length measurement whereby it is possible to draw conclusions on body weight for calculating the child's medication dosage. These aids may help to avoid the wrong medication dose or the wrong therapy of children but uncritical and untrained usage of these aids carries a potential risk of mistakes. This recommendation gives an overview of the general requirements and different problems of cognitive aids and should help improve the general framework and the rational basis for the use and further development of cognitive aids in emergency medicine.

Demographic and mortality analysis of hospitalized children at a referral hospital in Addis Ababa, Ethiopia

BACKGROUND

Global childhood mortality rates remain high. Millennium Development Goal 4 focused efforts on reducing rates by two-thirds between 1990 and 2015. In Ethiopia, child mortality rates dropped 71 % from 1990 to 2015, however it is estimated that 184,000 Ethiopian children die each year. There is limited information about pediatric hospital admissions in Ethiopia. Our aims were to examine the temporal relationship of mortality to admission, describe the demographics, and identify cause mortality of children admitted to the Zewditu Memorial Hospital (ZMH).

METHODS

A four-year retrospective review of pediatric admissions was conducted at the pediatric emergency room and pediatric hospital ward at ZMH in Addis Ababa, Ethiopia. Admission entries from 2011-2014 of children age 29 days-14 years were reviewed. Age, gender, admission date, disease classification, discharge status and date were obtained. Patient gender was compared using Chi-square analysis. A descriptive analysis was used for age and cause mortality.

RESULTS

A total of 6866 patient entries were reviewed. The proportion of admissions younger than age 5 was 0.747 (95 % CI 0.736-0.757). Overall mortality was 0.042 (95 % CI, 0.037-0.047). The proportion of recorded deaths occurring within 2 days of admission was 0.437 (95 % CI 0.380-0.494). The proportion of male admissions was significantly higher than female admissions in all age groups (male 0.575, p < 0.0001, 95 % CI 0.562-0.586). The main causes of mortality were pneumonia (0.253, 95 % CI, 0.203-0.303), severe acute malnutrition (0.222, 95 % CI 0.174-0.27), HIV/AIDS-related complications (0.056, 95 % CI 0.029-0.083), spina bifida (0.049, 95 % CI 0.024-0.074), and hydrocephalus (0.045, 95 % CI 0.021-0.069).

CONCLUSIONS

Our study revealed a lower mortality rate than previously reported in Ethiopia. Despite this, 44 % of pediatric hospital mortality occurred early during hospitalization, higher than reported at other Ethiopian hospitals. This adds further evidence that systematic efforts should be dedicated to improve pediatric emergency care. Admissions included 58 % male patients, similar to other reports in Ethiopia implying that this may be a nation-wide phenomenon. The observed disparity may be due to societal factors regarding care-seeking behaviors or male predilection for respiratory illness warranting further investigation. Cause mortality patterns were similar to reports in analogous settings.

Pediatric Emergency Magnetic Resonance Imaging: Current Indications, Techniques, and Clinical Applications

MR imaging plays an important role in the detection and characterization of several pediatric disease entities that can occur in the emergent setting because of its cross-sectional imaging capability, lack of ionizing radiation exposure, and superior soft tissue contrast. In the age of as low as reasonably achievable, these advantages have made MR imaging an increasingly preferred modality for diagnostic evaluations even in time-sensitive settings. In this article, the authors discuss the current indications, techniques, and clinical applications of MR imaging in the evaluation of pediatric emergencies.

Diagnostic accuracy and prognostic utility of D Dimer in acute appendicitis in children

The objective was to determine the uselfulness of D Dimer (DD) as a diagnostic or prognostic marker in acute appendicitis (AA) in children using a prospective observational study in the pediatric emergency department of a tertiary hospital. We enrolled 135 patients aged 1-16 years presenting with abdominal pain consistent with AA, who required laboratory studies. We analyzed clinical, analytical variables and histopathology findings (when they underwent surgery). Statistical analysis was conducted using SPSS. 38.5% of the children were clinically diagnosed with AA (n = 52), confirmed by pathology in 51 patients. 55.8% were gangrenous appendicitis. Leucocyte count, C-reactive protein (CRP), and DD were higher in the AA group and in the gangrenous appendicitis group (p < 0.05), with highest values of DD in the gangrenous group. The area under the receiving operating characteristics (ROC) curve for DD in the diagnosis of AA is 0.66 (95% CI 0.56-0.75). For DD cut-off point of 230 ng/mL, sensitivity (Se) was 0.40, specificity (Sp) 0.80, positive predictive value (PPV) 0.57, and negative predictive value (NPV) 0.66. The area under the ROC curve for DD in children with gangrenous appendicitis is 0.93 (95% CI 0.87-1). A DD cut-off point of 230 ng/mL exhibited: Se = 0.69, Sp = 1, PPV = 1 and NPV = 0.72.

CONCLUSION

DD levels increase in patients with AA. Although it does not constitute a useful diagnostic marker, it could be a good prognostic marker.