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Objectives There is debate regarding the timing of procedural sedation and analgesia (PSA) in relation to fasting status. Point-of-care ultrasound (POCUS) provides the ability to measure gastric content and is being used as a surrogate for aspiration risk in anesthesia. We sought to evaluate the gastric content of pediatric emergency department (PED) patients undergoing PSA using POCUS. Methods We performed a prospective observational study using a convenience sample of pediatric patients undergoing PSA between July 1, 2018, and June 30, 2019. Following a brief history, gastric content was measured using POCUS in both supine and right lateral decubitus positions at 2-hour intervals until the time of PSA. Qualitative content and calculated volume were classified based on the Perlas Model of anesthesia "Risk" assessment. Results Ninety-three patients were enrolled with 61.3% male and mean age of 6.5 years. Gastric content was determined in 92 patients. There were 79.3% that had "high risk" content at the time of PSA, with a median fasting time of 6.25 hours and no serious adverse events. Fasting duration had a weak to moderate ability to predict "risk" category (area under the curve = 0.73), with no patient (n = 17) who underwent multiple evaluations awaiting PSA progressing from "high" to "low risk." Conclusions The majority of PED patients undergoing PSA at our institution had "high risk" gastric content with no clinically significant change occurring during serial evaluations. This calls into question the utility of delaying PSA based upon fasting status and lends support to a more comprehensive risk-benefit approach when planning pediatric PSA.

Toxic ingestions are an increasing concern among pediatric patients in the United States. Less common, but troubling, are those patients with persistent toxicity symptoms despite stabilization, resuscitative, and decontamination efforts. We report a case of refractory serotonin toxicity in an adolescent for whom endoscopic removal of medication remnants led to the resolution of his clinical course. A 14-year-old male patient with anxiety and depression, treated with escitalopram and clonidine, presented to an outside hospital (OSH) emergency department (ED) with tonic-clonic seizure activity and altered mental status. Non-contrast head computed tomography (CT), complete blood count, and basic metabolic panel were unrevealing. Repeated seizure activity that occurred in the OSH ED prompted transfer to a tertiary pediatric care facility for ongoing management. Based on the constellation of symptoms (tachycardia, muscle rigidity, and lower extremity clonus) and his medication history, there was concern for serotonin toxicity. His clinical course worsened, despite treatment with midazolam and cyproheptadine, requiring intubation for respiratory failure. Because of his refractory symptoms and concern for ongoing medication side effects, on hospital day 4, he underwent an esophagogastroduodenoscopy (EGD), which revealed 20 partially digested pills firmly adhered to the gastric mucosa. The pill fragments were removed and whole bowel irrigation was started, and the patient improved rapidly, allowing for extubation within 24 hours. An EGD is not routinely used for the management of toxic ingestions. In addition to this case, evidence from prior case reports supports the judicious use of EGD as a diagnostic and therapeutic decontamination modality for severe toxicities.

Background Necrotizing enterocolitis (NEC) is a gastrointestinal emergency characterized by ischemic necrosis of the intestinal mucosa, leading to bacterial translocation and pneumatosis of the bowel wall. Although there are numerous studies on clinical presentations of preterm NEC, approximately 10–15% of cases occur in full-term neonates. Nearly 10% of all infants with NEC will develop a rapidly progressive and fatal form of the disease called NEC totalis. Case Report A 24-day-old term male infant presented to the Emergency Department (ED) with emesis. The infant was ill-appearing with a tense abdomen and had significant tachycardia and hypotension. The patient was immediately volume resuscitated and started on empiric antibiotics. Initial radiographs revealed no evidence of bowel obstruction or pneumatosis. Pediatric Surgery was consulted, and upper gastrointestinal and abdominal computed tomography scans were obtained, which were nondiagnostic. The patient was taken to the operating room for an exploratory laparotomy after continued clinical deterioration and was diagnosed with NEC totalis and passed away within 6 days. Why Should an Emergency Physician Be Aware of This? This case demonstrates an uncommon presentation of NEC in an otherwise healthy term neonate without any known risk factors. The diagnosis of NEC is challenging because imaging studies may be inconclusive, particularly early in the clinical course. Regardless of the etiology, all infants who present to the ED with signs and symptoms of severe gastrointestinal distress should be treated with basic emergency care, including rapid fluid resuscitation, empiric antibiotics, bowel decompression, and early surgical consultation.

Although there are several reports of intracranial hemorrhage associated with vitamin K deficient bleeding, there are few reported cases of extracranial manifestations, specifically involving the thymus. Here, we discuss the unique case of a 4-week-old infant presenting with scrotal discoloration, respiratory distress, and widened mediastinum, found to have thymic hemorrhage related to confirmed coagulopathy secondary to late-onset vitamin K deficiency bleeding of the newborn.

Objectives A pilot study assessing the potential utility of cerebral oximetry (local cerebral oxygen saturation [rcSO 2 ]) in children presenting to the emergency department (ED) with altered mental status (AMS) and no history of trauma. Methods Patients who presented to a tertiary pediatric ED with AMS were monitored with left and right cerebral near-infrared spectroscopy probes and the first 30 minutes of rcSO 2 data was analyzed. Patients with a history of trauma were excluded. Patients with an abnormal head computed tomography (CT) (n = 146) were compared with those with a negative head CT (n = 45). Results Mean rcSO 2 values were consistent during each time period studied (5, 10, 20, and 30 minutes). In this study population, rcSO 2 less than 50% or greater than 80% and increased absolute difference between the left and right rcSO 2 measurements were associated with an abnormal CT scan. A difference of 12.2% between the left and right rcSO 2 values had a 100% positive predictive value for an abnormal head CT among our patients. Cumulative graphical plots of rcSO 2 trends showed that values 80% were associated with epidural hematomas (EDH). Conclusions This study demonstrated that cerebral oximetry can noninvasively detect altered cerebral physiology among a selected patient population. The difference between the left and right rcSO 2 readings most reliably identified those subjects with altered cerebral physiology. In the future, rcSO 2 monitoring has the potential to be used as a screening tool to identify, localize, and characterize intracranial injuries among children with AMS without a history of trauma.

Summary This report documents our experience with intravenous immune globulin (IVIG) (1 g/kg, iv) and high-dose, anti-D immune globulin (anti-D) (75 μg/kg) as initial treatment for childhood immune thrombocytopenic purpura (ITP). The medical records of children diagnosed with ITP at a single institution between January 2003 and May 2008 were retrospectively reviewed. Participants received either IVIG or high-dose anti-D immune globulin as their initial treatment for ITP. For the 53 patients included for analysis, there was no statistical difference in efficacy between each group; however, patients who received anti-D experienced a higher rate of adverse drug reactions (ADRs), particularly chills and rigours, and 2 of 24 patients in the anti-D group developed severe anaemia requiring medical intervention. Patients who presented with mucosal bleeding had higher rates of treatment failure (32%) compared to those who presented with dry purpura (6%), regardless of treatment. Both IVIG and high-dose anti-D are effective first-line therapies for childhood ITP. However, we observed increased ADRs in the high-dose anti-D group in contrast to previously published reports. Further studies are needed to evaluate safety and premedications for high-dose anti-D and to determine the utility of using the presence of mucosal bleeding to predict treatment failure.

The purposes of the current investigation are to evaluate the epidemiology of water sport injuries at a coastal tertiary trauma center and to determine the association of these activities with spinal column injury and to determine whether aquatic trauma injuries differ significantly from those that occur terrestrially. A retrospective review of a consecutive series of 105 patients with aquatic-based mechanisms of injury admitted to a Level II trauma center over a 3-year period, as well as a matched control cohort with terrestrial-based mechanisms of injury, was conducted. Patients were treated at a Level II trauma center from January 1, 2008, to December 31, 2010. All patients received a full trauma work-up on arrival. Patients were identified retrospectively from a prospectively collected database (N=5298). Eligible patients were identified from billing/coding data as having mechanisms of injury related to an aquatic setting. Patients were evaluated using standard trauma protocols. Spinal column and cord injury occurrence and differences between groups were reviewed. Personal watercrafts accounted for the majority of injuries (n=39). Cervical (33.3%), closed-head (25.7%), and thoracolumbar (21.9%) injuries accounted for the majority of injury types. The cervical spinal column and the spinal cord were at an increased risk of injury in the aquatic injury cohort ( P Orthopedics. 2015; 38(9):e813–e818.]

OBJECTIVES: To determine if thromboelastography (TEG) is predictive of patient outcomes following traumatic injury. METHODS: A retrospective review of 131 patients with pelvic trauma admitted to a Level II trauma center was conducted over four years from 1 January 2009 to 31 December 2012. Patients were identified retrospectively from a prospectively collected database of acute pelvic trauma (n = 372). Eligible patients were identified from billing/coding data as having fractures of the acetabulum, iliac wing or sacral alae. Patients with incomplete TEG data were excluded (n = 241), as were patients with pathological fractures. TEG clotting variables and traditional clotting variables were recorded. RESULTS: Evaluation of TEG data revealed 41 patients with abnormal clotting times (TEG R). TEG R > 6 was an independent risk factor for death (OR, 16; 95%CI 5.4–53; P = 0.0001). The death rate was 52% in patients with TEG R values ≥6 (n = 13/25). There was no significant association between traditional clotting markers and death rate. CONCLUSIONS: TEG reaction time value, representing the time of initial clot formation, was the only hematologic marker predictive of mortality in patients with pelvic trauma. Delay in reaction time was associated with a significantly increased death rate, independent of injury severity. The death rate association was not observed with traditional markers of clotting. Future prospective studies may be warranted to determine the presentation and significance of TEG abnormalities when resuscitating patients with orthopaedic trauma.

Background: More than 3 million people in the United States have atrial fibrillation, most of whom are being managed with anticoagulation therapy for life. The goal of the present study was to examine the effect of chronic anticoagulation therapy on patients with atrial fibrillation who undergo total joint arthroplasty. Methods: We retrospectively reviewed all patients undergoing aseptic primary or revision total joint arthroplasty at our facility from March 2007 to August 2011. One hundred and sixty-one patients with atrial fibrillation (Group A) were compared with 161 matched controls (Group B). A total of 112 hips and 210 knees underwent 239 primary arthroplasties and eighty-three revisions. The groups were compared with use of conditional logistic regression (with matching on the basis of the involved joint [hip or knee], type of procedure [revision or primary], age, and sex) with regard to the length of hospital stay, postoperative hemoglobin levels, transfusion requirements, and readmissions. Results: The preoperative length of stay (1.7 versus 0.2 days; p < 0.0001), postoperative length of stay (4.6 versus 3.2 days; p = 0.0002), and total length of stay (6.3 versus 3.4 days; p < 0.0001) were significantly longer for patients with atrial fibrillation (Group A). Hemoglobin levels were lower (but not significantly so) for Group A at baseline (13.1 versus 13.8 mg/dL), on Postoperative Day 2 (10.1 versus 10.6 mg/dL), on Postoperative Day 3 (9.8 versus 10.2 mg/dL), on Postoperative Day 4 (9.6 versus 10.1 mg/dL), on Postoperative Day 5 (9.7 versus 9.9 mg/dL), and at discharge (9.9 versus 10.3 mg/dL). Group A had a significantly higher prevalence of blood transfusion (15.5% versus 3.7%; p = 0.0005) and periprosthetic joint infection (5.6% versus 0.62%; p = 0.0196). A diagnosis of atrial fibrillation (odds ratio, 4.09; 95% confidence interval, 2.05 to 8.18; p < 0.0001) significantly increased the odds of total joint arthroplasty complication and the need for hospital readmission. Conclusions: Patients with preoperative atrial fibrillation undergoing total joint arthroplasty had an increased length of hospital stay, increased transfusion requirements, and an increased risk of periprosthetic joint infection and unplanned hospital readmission. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Patients with sickle cell disease (SCD) receiving chronic blood transfusions are at risk of developing iron overload and organ toxicity. Chelation therapy with either subcutaneous (SQ) desferrioxamine (DFO) or oral deferasirox is effective in preventing and reducing iron overload but poses significant challenges with patient compliance. Intravenous (IV) infusions of high dose DFO have been utilized in non-compliant patients with heavy iron overload in small case series.We review our experience of high dose IV DFO in 27 patients with SCD who had significant iron overload and were noncompliant with subcutaneous (SQ) DFO. All patients were treated in-hospital with DFO 15 mg/kg/hr IV for 48 hr every 2-4 weeks with a mean duration of 19.6 months.We observed a significant decrease in liver iron burden with high dose intermittent IV DFO. Histological examination of liver biopsies revealed a decrease in the grade of liver iron storage. Also there was significant improvement in liver enzymes (ALT, AST) after high dose IV DFO. No audiologic or ophthalmologic toxicity or acute or chronic pulmonary complications were observed.In our cohort of patients with SCD we observed a significant decrease in liver iron burden with high dose IV DFO. Our patients tolerated the therapy well without any major toxicity. This regimen is safe and may be an option for poorly compliant patients with significant iron overload.

Despite advances in immune prophylaxis, sepsis remains the most feared complication following splenectomy for acute splenic sequestration crisis (ASSC) in children with sickle cell anemia (SCA). We seek to investigate the true prevalence of sepsis and other complications of splenectomy in this patient population.We reviewed the records of children with SCA (HbSS) who underwent splenectomy for ASSC between 1993 and 2008 at a single institution.Fifty-eight patients (33 males) at a median age of 2 years at splenectomy were included with an average post-splenectomy follow-up of 6.4 years (range 6 months-14 years). Thirty-seven patients (64%) underwent laparoscopic splenectomy, and acute chest syndrome (ACS) was the most common post-operative complication (6.9%). There was no difference in the incidence of sepsis pre- and post-splenectomy. The occurrence of vaso-occlusive pain crises (VOC) and ACS was significantly higher after splenectomy. In addition, 14 patients (24%) developed stroke (n = 5) or an abnormal transcranial Doppler (TCD) (n = 9) after splenectomy.Our data suggest that splenectomy can be safely performed in children with SCA given a low risk of sepsis. However, the increased incidence of VOC, ACS, and stroke or abnormal TCDs after splenectomy remains a concern.

In pediatric out-of-hospital cardiac arrest (POHCA), cardiovascular monitoring tools have improved resuscitative endeavors and cardiovascular outcomes but with still poor neurologic outcomes. Regarding cardiac arrest in patients with congenital heart disease during surgery, the application of cerebral oximetry with blood volume index (BVI) during the resuscitation has shown significant results and prognostic significance. We present 2 POHCA patients who had cerebral oximetry with BVI monitoring during their arrest and postarrest phase in the emergency department and its potential prognostic aspect.Basic procedures include left and right cerebral oximetry with BVI monitoring at every 5-second interval during cardiac arrest, resuscitation, and postarrest in 2 POHCA patients in the pediatric emergency department.Regional cerebral tissue oxygen saturation (rSo2) with BVI readings in these 2 POHCA survivors demonstrated interesting cerebral physiology, blood flow, and potential prognostic outcome. In 1 patient, the reference range of cerebral rSo2 with positive blood flow during arrest and postarrest phases consistently occurred. This neurologic monitoring had its significance when the resuscitation effectiveness was used and end-tidal CO2 changes were lost. The other patient's cerebral rSo2 with simultaneous BVI readings and trending showed the effectiveness of the emergency medical services (EMS) resuscitation.Cerebral oximetry with cerebral blood flow index monitoring in these POHCA survivors demonstrates compelling periarrest and postarrest cerebral physiology information and prognostication. Cerebral oximetry with cerebral BVI monitoring during these arrest phases has potential as a neurologic monitor for the resuscitative intervention's effectiveness and its possible neurologic prognostic application in the pediatric OCHA patients.