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Objective: Substantial practice variation exists in the management of children with nonsevere traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification., Methods: We conducted a single-center retrospective cohort study of children aged younger than 18 years evaluated in the emergency department (ED) from May 1, 2014 to February 28, 2020 with tICH and initial Glasgow Coma Scale (GCS) score of higher than 8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models., Results: Our sample included 135 children. Clinically important tICH was observed in 13.3% (n = 18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n = 127) presented with an initial GCS ≥ 14, including all children who later deteriorated. Initial GCS ( P = 0.001) and nonaccidental trauma ( P = 0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥ 14, isolated, nonepidural hemorrhage after accidental injury developed clinically important tICH., Conclusions: Clinically important tICH occurred in 13% of children with nonsevere tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS ≥ 14. However, a subgroup of children was identified as low risk based on clinical and neuroradiographic characteristics., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Diabetic ketoacidosis (DKA) is a common emergency department presentation of both new-onset and established diabetes mellitus (DM). β-Hydroxybutyrate (BOHB) provides a direct measure of the pathophysiologic derangement in DKA as compared with the nonspecific measurements of blood pH and bicarbonate. Our objective was to characterize the relationship between BOHB and DKA., Methods: This is a cross-sectional retrospective study of pediatric patients with DM presenting to an urban pediatric emergency department between January 1, 2016, and September 30, 2018. Analyses were performed on each patient's initial, simultaneous BOHB and pH. Diagnostic test characteristics of BOHB were calculated, and logistic regression was performed to investigate the effects of age and other key clinical factors., Results: Among 594 patients with DM, with median age of 12.3 years (interquartile range, 8.7-15.9 years), 176 (29.6%) presented with DKA. The inclusion of age, transfer status, and new-onset in the statistical model did not improve the prediction of DKA beyond BOHB alone. β-Hydroxybutyrate demonstrated strong discrimination for DKA, with an area under the curve of 0.95 (95% confidence interval, 0.93-0.97). A BOHB value of 5.3 mmol/L predicted DKA with optimal accuracy (90.6% of patients were correctly classified). The sensitivity, specificity, and positive and negative predictive values of this cut point were 76.7% (95% confidence interval, 69.8%-82.7%), 96.4% (94.2%-98.0%), 90.0% (84.0%-94.3%), and 90.8% (87.7%-93.3%), respectively., Conclusions: β-Hydroxybutyrate accurately predicts DKA in children and adolescents. More importantly, because plasma BOHB is the ideal biochemical marker of DKA, BOHB may provide a more optimal definition of DKA for management decisions and treatment targets., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To estimate rates of critical medical and neurosurgical interventions and resource utilization for children with traumatic intracranial hemorrhage (ICH)., Methods: This was a retrospective study of children younger than 18 years hospitalized in 1 of 35 hospitals in the Pediatric Health Information System from 2009 to 2019 for ICH. We defined critical intervention as a critical medical (hyperosmotic agents and intubation) or neurosurgical intervention. We determined rates of critical interventions, intensive care unit (ICU) admission, and repeat neuroimaging. We used hierarchical logistic regression to identify high-level factors associated with undergoing critical interventions, controlling for hospital-level effects., Results: There were 12,714 children with ICH included in the study. Median (interquartile range) age was 4.3 (0.7-11.0) years. Twelve percent (n = 1470) of children underwent a critical clinical intervention. Critical medical interventions occurred in 10% (n = 1219), and neurosurgical interventions occurred in 3% (n = 419). Intensive care unit admission occurred in 44% (n = 5565), whereas repeat neuroimaging occurred in 40% (n = 5072). Among ICU patients, 79% (n = 4366) did not undergo a critical intervention. Of the 11,244 children with no critical interventions, 39% (n = 4366) underwent ICU admission, and 37% (n = 4099) repeat neuroimaging. After controlling for hospital, children with isolated subdural (P = 0.013) and isolated subarachnoid (P < 0.001) hemorrhage were less likely to receive critical interventions., Conclusions: Critical medical interventions occurred in 10% of children with ICH, and neurosurgical interventions occurred in 3%. Intensive care unit admission and repeat neuroimaging are common, even among those who did not undergo critical interventions. Selective utilization of ICU admission and repeat neuroimaging in children who are at low risk of requiring critical interventions could improve overall quality of care and decrease unnecessary resource utilization., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Vascular endothelial growth factor (VEGF) and its receptor, soluble fms-like tyrosine kinase (sFLT), are biomarkers of endothelial activation. Vascular endothelial growth factor and sFLT have been associated with sepsis severity among adults, but pediatric data are lacking. The goal of this study was to assess VEGF and sFLT as predictors of outcome for children with sepsis., Methods: Biomarkers measured for each patient at time of presentation to the emergency department were compared in children with septic shock versus children with sepsis without shock. For children with septic shock, the associations between biomarker levels and clinical outcome measures, including intensive care unit and hospital length of stay, vasoactive inotrope score, and measures of organ dysfunction, were assessed., Results: Soluble fms-like tyrosine kinase and VEGF were elevated in children with septic shock (n = 73) compared with those with sepsis (n = 93). Elevated sFLT but not VEGF was associated with longer intensive care unit length of stay (P = 0.003), longer time requiring vasoactive agents (P < 0.001), higher maximum vasoactive inotrope score (P < 0.001), and higher maximum pediatric logistic organ dysfunction score (P < 0.001)., Conclusions: Vascular endothelial growth factor and sFLT measured in the emergency department are elevated in children with septic shock, and elevated sFLT but not VEGF is associated with worse clinical outcomes.

Objective: The objective of this study was to determine the incidence and recent trends in serious pediatric emergency conditions., Methods: We conducted a cross-sectional study of the Nationwide Emergency Department Sample from 2008 through 2014, and included patients with age below 18 years with a serious condition, defined as each diagnosis group in the diagnosis grouping system with a severity classification system score of 5. We calculated national incidences for each serious condition using annualized weighted condition counts divided by annual United States census child population counts. We determined the highest-incidence serious conditions over the study period and calculated percentage changes between 2008 and 2014 for each serious condition using a Poisson model., Results: The 2008 incidence of serious conditions across the national child population was 1721 visits per million person-years (95% confidence interval, 1485-1957). This incidence increased to 2020 visits per million person-years (95% confidence interval, 1661-2379) in 2014. The most common serious conditions were serious respiratory diseases, septicemia, and serious neurologic diseases. Anaphylaxis was the condition with the largest change, increasing by 147%, from 101 to 249 visits per million person-years., Conclusions: The most common serious condition in children presenting to United States emergency departments is serious respiratory disease. Anaphylaxis is the fastest increasing serious condition. Additional research attention to these diagnoses is warranted.

Objectives: Screening for urinary tract infection (UTI) includes urinary nitrite testing by dipstick urinalysis. Gram-negative enteric organisms produce urinary nitrite and represent the most common uropathogens. Enterococcus, a less common uropathogen, does not produce nitrite and has a unique antibiotic resistance pattern. Whether to adjust empiric antibiotics in the absence of urinary nitrite has not been established. Our primary objective was to determine prevalence of enterococcal UTI among young children with a nitrite negative urinalysis., Methods: A retrospective study of children aged less than 2 years evaluated in the emergency department for possible UTI and had a paired urinalysis and urine culture was performed. Urinary tract infection was defined by catheterized culture yielding greater than or equal to 50,000 colony-forming units per milliliter of a single uropathogen. Prevalence of uropathogens among nitrite negative samples was studied., Results: A total of 7599 children were studied. Median (interquartile range) age was 5.6 (2.3-11.2) months, and 57% were female. Prevalence of UTI was 8.1%. Enterococcus was the uropathogen in 2.1% of UTIs, and all cases had negative dipstick nitrite. Among nitrite negative UTIs, 95.6% of uropathogens were gram-negative and only 3.2% (confidence interval, 1.8%-5.3%) were enterococcus. None of the 200 UTIs with positive nitrite yielded enterococcus (upper confidence interval, 1.4%). Among children with positive leukocyte esterase and negative nitrite, only 0.7% of cases had enterococcal UTI., Conclusions: Only 3% of nitrite negative UTIs were caused by enterococcus. Given the low prevalence of enterococcal UTI, the absence of dipstick nitrite should not affect routine empiric antibiotic choice for presumptive UTI in young children.

Objective: To compare the clinical presentation of intussusception among children younger and older than 24 months of age., Design/methods: We performed a retrospective cross-sectional cohort study of children treated in the emergency department, aged 1 month to 6 years, who had an abdominal ultrasound to evaluate for intussusception over a 5-year period. After stratifying by an age cut-point of 24 months, univariate and multivariate analyses were performed., Results: One thousand two hundred fifty-eight cases of suspected intussusception were studied; median age was 1.7 years (interquartile range, 0.8, 2.9 years), and 37% were female. Intussusception was identified in 176 children (14%); 153 (87%) were ileocolic, and 23 were ileoileal. Abdominal pain (odds ratio, 4.0; 95% confidence interval [CI], 1.5-10.5), emesis (OR, 3.5; 95% CI, 1.8-6.7), bilious emesis (OR, 2.9; 95% CI, 1.5-5.7), lethargy (OR, 2.3; 95% CI, 1.3-5.7), rectal bleeding (OR, 2.8; 95% CI, 1.4-5.7), and irritability (OR, 0.4; 95% CI, 0.2-0.8) were found to be predictors in those younger than 24 months. In children older than 24 months, male sex was the only predictor identified (OR, 2.0; 95% CI, 1.1-3.7). In cases where abdominal radiographs were obtained (n = 1212), any abnormality on abdominal radiograph was found to be predictive in both age groups (OR, 7.8; 95% CI, 3.8-25.7; and OR, 3.1; 95% CI, 1.8-5.2, respectively)., Conclusions: Intussusception presents differently in children younger than 24 months compared with older children. "Traditional" clinical predictors of intussusception should be interpreted with caution when assessing children older than 2 years.

Isolated amnesia is an uncommon presenting complaint in the pediatric age group. We report the case of an 18-year-old woman who presented with the acute onset of memory difficulty and an otherwise normal neurologic examination. Brain magnetic resonance imaging demonstrated inflammation in the bilateral temporal lobes. Serum and cerebrospinal fluid testing ultimately revealed a diagnosis of autoimmune encephalitis. Although rare, the acute onset of isolated amnesia deserves a prompt, comprehensive evaluation.

Objectives: The aims of this study were to (1) assess the reasons for pediatric interfacility transfers as identified by transferring providers and review the emergency medical care delivered at the receiving facilities and (2) investigate the emergency department (ED) care among the subpopulation of patients discharged from the receiving facility., Methods: We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 US tertiary care pediatric hospitals with a subsequent medical record review at the receiving facility. Referring providers completed surveys detailing reasons for transfer., Results: Eight hundred thirty-nine surveys were completed by 641 providers for 25 months. The median patient age was 5.7 years. Sixty-two percent of the patients required admission. The most common reasons for transfer as cited by referring providers were subspecialist consultation (62%) and admission to a pediatric inpatient (17%) or intensive care (6%) unit. For discharged patients, plain radiography (26%) and ultrasonography (12%) were the most common radiologic studies. Procedural sedation (16%) was the most common ED procedure for discharged patients, and 55% had a subspecialist consult at the receiving facility. Ten percent of interfacility transfers did not require subspecialty consult, ED procedure, radiologic study, or admission., Conclusions: Approximately 4 of 10 interfacility transfers are discharged by the receiving facility, suggesting an opportunity to provide more comprehensive care at referring facilities. On the basis of the care provided at the receiving facility, potential interventions might include increased subspecialty access and developing both ultrasound and sedation capabilities.

Objectives: The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers., Methods: We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training., Results: The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest., Conclusions: Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

Objectives: The aim of this study was to describe the resource utilization for children with common pediatric conditions treated in academic and nonacademic emergency departments (EDs)., Methods: We performed a retrospective, cross-sectional descriptive study using the National Hospital Ambulatory Medical Care Survey Data from 1995 to 2010 including children less than 18 years old with a diagnosis of asthma, bronchiolitis, croup, gastroenteritis, fever, febrile seizure, or afebrile seizure. Academic EDs (A-ED) were those with greater than 25% of patients seen by a trainee. For each condition, we reported the proportion of testing, medications, and disposition between A-ED and nonacademic EDs (NA-ED)., Results: From 1995 to 2010, approximately 450,000,000 estimated pediatric visits are represented by the survey based on 122,811 actual visits. For most common conditions, testing and disposition were comparable; however, some variation was noted. Among patients with bronchiolitis, a higher proportion of patients was admitted and had radiographs in NA-EDs (18% vs 10% and 56% vs 45%, respectively). For children with croup, radiographs were performed more often at NA-EDs (27% vs 6%). Among those with febrile seizures, more lumbar punctures were performed in NA-EDs (14% vs 0%). In children with afebrile seizures, more head computed tomography scans were obtained at NA-EDs (34% vs 21%)., Conclusion: Among pediatric patients with croup, bronchiolitis, and febrile and afebrile seizure, higher resource utilization and admissions were observed in NA-EDs. These preliminary findings from a national survey require a more detailed investigation into the variation in care between A-ED and NA-ED settings.

Objectives: Opportunities to learn advanced airway management skills on pediatric patients in the emergency department are limited. Current strategies have focused largely on traditional didactics coupled with procedural skills training using simulation. However, these approaches are limited in their exposure to anatomic variation and realism. Here, we describe the development and assessment of an advanced airway curriculum that integrates videolaryngoscopic recordings obtained during actual patient intubations into a series of interactive educational sessions., Methods: Trainees and attending physicians were surveyed anonymously to assess the impact of participation in the curriculum. A mixed methods approach to statistical analysis was used. Rating questions were used to evaluate the relative impact of this approach over other traditional strategies and recurrent themes within open-ended questions were identified., Results: Participants reported this to be a highly effective means of learning about pediatric laryngoscopy and endotracheal intubation and regarded it more highly than other traditional educational approaches. Identified benefits included repetitive exposure, approaches to laryngoscopy, the realism of teaching using real and varied anatomy, and the opportunities to identify and troubleshoot difficulty in a learning environment., Conclusions: An advanced pediatric airway curriculum that integrates intubation videos obtained during videolaryngoscopy was highly regarded by pediatric emergency medicine providers. Content emphasis can be shifted to meet the needs of pediatric emergency medicine providers with all levels of skill and experience.

Concerns about radiation exposure have led to a decrease in the use of computed tomography in suspected appendicitis, with increased reliance on ultrasound. Children with suspected appendicitis should be risk stratified using a combination of clinical signs and symptoms, white blood cell count, and ultrasound in order to guide further evaluation and management. Magnetic resonance imaging is a promising imaging modality but remains costly. Ongoing research is evaluating the role of nonoperative management in children with confirmed appendicitis.

Background: The optimal staffing model for emergency departments (EDs) is not known. Improving staffing could lead to more timely, efficient, and effective care. We created a model of staffing to identify times of staffing limitation by provider type., Methods: We analyzed data from an academic pediatric ED with 60,000 visits per year. Each 10-minute interval from January 1, 2011, through December 31, 2012, was categorized as nonlimited (no staffing limitation), space limited (≥2 patients in the waiting room with wait times > 30 minutes and ≥ 80% ED bed occupancy), nurse limited (≥2 patients in the waiting room with wait times > 30 min and < 80% ED bed occupancy), or physician limited (≥2 patients in examination rooms who have waited > 30 minutes for a physician) using computer modeling. We calculated the percentage of time each type of limitation was in effect and the median lengths of stay for patients presenting during times of each category of limitation., Results: The ED was space limited 5.0% of the time, nurse limited 16.1% of the time, and physician limited 0.1% of the time. In nonlimited times, length of stay was 201 minutes (interquartile range, 128-301), whereas patients presenting during space-limited, nurse-limited, and physician-limited times had statistically significantly higher LOS of 265 (187-360), 244 (169-337), and 247 (174-334) minutes, respectively., Conclusions: Times identified as space and staffing limited were associated with longer LOS. This computer model could be used to rapidly identify targeted staffing needs and then measure the effect of modifying staffing.

Objective: National guidelines discourage routine chest radiographs (CXRs) to confirm suspected pneumonia in children managed as outpatients. However, limiting CXRs may lead to antibiotic overuse. We examined the impact of CXRs and clinical suspicion on antibiotic treatment for children with suspected pneumonia., Methods: Children aged 3 months to 18 years undergoing CXR for suspected pneumonia in a pediatric emergency department were prospectively enrolled. Before CXR, physicians indicated their initial plan for antibiotics (yes or no) and clinical suspicion for radiographic pneumonia (<5%, 5-10%, 11-20%, 21-50%, 51-75%, >75%). Subjects had radiographic pneumonia if their CXRs demonstrated definite or possible findings of pneumonia. We compared antibiotic treatment according to pre-CXR antibiotic plan and suspicion for pneumonia and CXR results., Results: Among the 107 children with a plan for antibiotics before CXR, 72% ultimately received antibiotics compared with 19% of the 1503 children without a pre-CXR plan for antibiotics (P < 0.001). Among those patients with a pre-CXR plan for antibiotics, 96% of children with radiographic pneumonia were ultimately treated compared with 54% without radiographic pneumonia (P < 0.001). If antibiotics were not initially planned, 37% with radiographic pneumonia were treated compared with 8% without radiographic pneumonia (P < 0.001). The use of CXR was more likely to influence antibiotic prescribing patterns when the clinical suspicion of pneumonia was low (<20%)., Conclusions: Among children with high suspicion for pneumonia, CXRs infrequently altered the initial plan for antibiotics. However, when clinical suspicion for pneumonia was low, the use of CXR may reduce unnecessary antibiotic use.

Objective: Providing meaningful evaluation to trainees rotating through the pediatric emergency medicine is important yet challenging. Information systems can be used to autopopulate an electronic case log, which can be leveraged to assist in the evaluation process. The objective of this study was to determine if a novel educational initiative using an automated case log improved faculty evaluation of trainees., Methods: This retrospective study examined faculty completion rate, as well as the content of medical student evaluations over a 3-academic-year study period. Three phases of evaluation were utilized: written, electronic, and electronic enhanced with individualized case reports created with the automated case log. The primary outcome was faculty response rate. Secondary outcomes included word count and the number of themes identified following qualitative analysis of narrative responses. Logistic regression was performed., Results: Forty-one faculty members completed evaluations of 43 students. The rates of completion for the written, electronic, and automated case log phases were 18%, 16%, and 62%, respectively. Faculty in the automated case log phase were significantly more likely to complete evaluations compared with those in the written evaluation phase (odds ratio, 7.6; 95% confidence interval, 4.5-13.0). The median word counts across the 3 phases were 19, 36, and 43, respectively. The median numbers of themes identified during the 3 phases were 3, 4, and 5, respectively. The differences in the word count and median number of themes between the written and automated case log phases were significantly different (P < 0.001)., Conclusions: The process of trainee evaluation can be improved by utilizing an automated case log to provide faculty members with individualized reports of shared patient encounters.

The Accreditation Council for Graduate Medical Education has mandated the assessment of medical training across 6 core competencies. The patient care competency is at the core of medical training. With the introduction of patient tracking systems used in emergency departments, patient-physician encounters can be systematically studied. The combination of tracking data with other clinical information systems can be used to create an electronic case log to quantify the experience of fellows, thereby offering a summative measure of the patient care competency. We used an automated case log to assess clinical exposure in our pediatric emergency medicine fellowship.

Objective: To compare bag-mask ventilation performed by emergency department (ED) personnel using anesthesia bags (AB) and self-inflating bags (SIB)., Setting: ED in a teaching children's hospital where the AB is the device used during resuscitations., Design: Experimental study. Bag-mask ventilation was evaluated with an infant resuscitation mannequin equipped to measure airway volumes and pressures. Pediatric residents, ED nurses, and pediatric emergency medicine fellows performed bag-mask ventilation with AB and SIB and rated their confidence using each device., Main Outcome Measure: Ventilation failure rates., Results: Seventy subjects participated (17 interns, 16 junior residents, 13 senior residents, 10 fellows, and 14 nurses). There were 13 failures with the AB (18.6%) versus 1 (1.4%) with the SIB (P < 0.01) [95% confidence interval: 5-29%], with a significant difference even after excluding the least experienced subjects. There was no difference in high pressure breaths delivered (SIB 19% vs AB 15%, P = 0.4) and a higher incidence of hyperventilation with the SIB (67 vs 25%, P < 0.01). While using the SIB, 19 (27%) of the subjects did not turn on the O2 flow. There was no difference in pretest confidence rating, but the posttest confidence rating was higher for the SIB (P < 0.05)., Conclusions: Compared to SIB use for bag-mask ventilation in an ED, AB use resulted in more ventilation failures, no advantage in preventing excessive airway pressures, and less confidence among operators. The SIB should be the first choice for bag-mask ventilation in the ED, with attention to maximize oxygen delivery.