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Introduction:Blood cultures are often obtained from healthy paediatric patients with fever on presentation to the emergency department (ED). Although published guidelines and previous research outlined indications for obtaining blood culture and the relatively low risk of bacteraemia in vaccinated children, there may be practice variability among institutions and physicians. Primary objective: To describe the demographic characteristics, diagnosis, disposition and outcome of children who are fully vaccinated, healthy and have fever from whom bacterial blood cultures were obtained. Secondary objective: To determine the rate of blood culture contamination and outcomes.Methods:Retrospective chart review of all blood cultures collected in the ED between January 1, 2015, and December 31, 2015. Patients aged 6 months to 17 years were eligible for enrolment. Children not fully vaccinated, immunocompromised or with chronic, debilitating disease were excluded. Patients were divided into febrile and afebrile cohorts based on the initial temperature at ED presentation. Data were analysed with two-sample t-test and chisquared analysis.Results:Blood cultures were obtained from 7.980 children at the ED, with an overall positivity rate of 5.51%. No significant difference was detected in the number of positive blood cultures between the two cohorts (p=0.85). No significant difference was found between pathogenic cultures between the two cohorts (p=0.35). All patients who were discharged with a positive blood culture were called back for a repeat culture. None grew a pathogenic organism on the repeat culture. The overall positive blood culture rate for true pathogens was 1.3%, and the overall contamination rate was 1.9%.Conclusion:The rates of positive blood culture between febrile and afebrile cohorts presenting to the ED were comparable. While the overall rate of positive culture remains low, consistent with previously reported rates of bacteraemia, an unacceptably high rate of contamination resulting in return visits was observed. Routine blood culture in children who were fully immunised and had a history of febrile illness is not indicated.

Accuracy of pyuria for urinary tract infection (UTI) varies with urine concentration. Our objective of this study was to determine the optimal white blood cell (WBC) cutoff for UTI in young children at different urine concentrations as measured by urine specific gravity.Retrospective cross-sectional study of children24 months of age evaluated in the emergency department for suspected UTI with paired urinalysis and urine culture during a 6-year period. The primary outcome was positive urine culture result as described in the American Academy of Pediatrics clinical practice guideline culture thresholds. Test characteristics for microscopic pyuria cut points and positive leukocyte esterase (LE) were calculated across 3 urine specific gravity groups: low1.011, moderate 1.011 to 1.020, and high1.020.Of the total 24 171 patients analyzed, urine culture result was positive in 2003 (8.3%). Urine was obtained by transurethral in-and-out catheterization in 97.9%. Optimal WBC cutoffs per high-power field (HPF) were 3 (positive likelihood ratio [LR+] 10.5; negative likelihood ratio [LR-] 0.12) at low, 6 (LR+ 12; LR- 0.14) at moderate, and 8 (LR+ 11.1; LR- 0.35) at high urine concentrations. Likelihood ratios for small positive LE from low to high urine concentrations (LR+ 25.2, LR- 0.12; LR+ 33.1, LR- 0.15; LR+ 37.6, LR- 0.41) remained excellent.Optimal pyuria cut point in predicting positive urine culture results changes with urine concentration in young children. Pyuria thresholds of 3 WBCs per HPF at low urine concentrations whereas 8 WBCs per HPF at high urine concentrations have optimal predictive value for UTI. Positive LE is a strong predictor of UTI regardless of urine concentration.

To examine the association between uropathogens and pyuria in children24 months of age.A retrospective study of children24 months of age evaluated in the emergency department for suspected urinary tract infection (UTI) with paired urinalysis and urine culture during a 6-year period. Bagged urine specimens or urine culture growing mixed/multiple urogenital organisms were excluded. Analysis was limited to children with positive urine culture as defined by the American Academy of Pediatrics clinical practice guideline culture thresholds.Of 30 462 children, 1916 had microscopic urinalysis and positive urine culture. Urine was obtained by transurethral in-and-out catheterization in 98.3% of cases. Pyuria (≥5 white blood cells per high-powered field) and positive leukocyte esterase (small or more) on the urine dipstick were present in 1690 (88.2%) and 1692 (88.3%) of the children respectively. Children with non-Escherichia coli species were less likely to exhibit microscopic pyuria than children with E coli (OR 0.24, 95% CI 0.17-0.34) with more pronounced effect on Enterococcus and Klebsiella (OR 0.08, 95% CI 0.03-0.18 and OR 0.18, 95% CI 0.11-0.27 respectively). Similarly, positive leukocyte esterase was less frequently seen in non-E coli uropathogens compared with E coli.Pyuria and leukocyte esterase are not sensitive markers to identify non-E coli UTI in young children. More sensitive screening biomarkers are needed to identify UTI with these uropathogens.

In 2011, revised Field Triage Guidelines were released jointly by the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons - Committee on Trauma (ACS-COT). It is unknown how the modifications will affect the number of injured children identified by EMS providers as needing transport to a trauma center.To determine the change in under- and over-triage rates when the 2011 Field Triage Guidelines are compared to the 2006 and 1999 versions.EMS providers in charge of care for injured children (15 years) transported to pediatric trauma centers in 3 mid-sized cities were interviewed immediately after completing transport. Patients were included regardless of injury severity. The interview included patient demographics and each criterion from the Field Triage Guidelines' physiologic status, anatomic injury, and mechanism of injury steps. Included patients were followed through hospital discharge. The 1999, 2006, and 2011 Guidelines were each retrospectively applied to the collected data. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. Data were analyzed using descriptive statistics.EMS interviews were conducted for 5,610 children and outcome data was available for 5,594 (99.7%). Average age was 7.6 years; 5% of children were identified as needing a trauma center using the study outcome. Applying the 1999, 2006, or 2011 Guidelines to the EMS interview data the over-triage rate was 32.6%, 27.9%, and 28.0%, respectively. The under-triage rate was 26.5%, 35.1%, and 34.8%, respectively. The 2011 Guidelines resulted in an 8.2% (95% CI 0.6-15.9%) absolute increase in under-triage and a 4.6% (95% CI 2.8-6.3%) decrease in over-triage compared to 1999 Guidelines.Use of the Field Triage Guidelines for children resulted in an unacceptably high rate of under-triage regardless of the version used. Use of the 2011 Guidelines increased under-triage compared to the 1999 version. Research is needed to determine how to better assist EMS providers in identifying children who need the resources of a trauma center.

OBJECTIVE: To determine if the Mechanism of Injury Criteria of the Field Triage Decision Scheme (FTDS) are accurate for identifying children who need the resources of a trauma center. METHODS: EMS providers transporting any injured child ≤15 years, regardless of severity, to a pediatric trauma center in 3 midsized communities over 3 years were interviewed. Data collected through the interview included EMS observed physiologic condition, suspected anatomic injuries, and mechanism. Patients were then followed to determine if they needed the resources of a trauma center by reviewing their medical record after hospital discharge. Patients were considered to need a trauma center if they received an intervention included in a previously published consensus definition. Data were analyzed with descriptive statistics including positive likelihood ratios (+LR) and 95% confidence intervals (95%CI). RESULTS: 9,483 provider interviews were conducted and linked to hospital outcome data. Of those, 230 (2.4%) met the consensus definition for needing a trauma center. 1,572 enrolled patients were excluded from further analysis because they met the Physiologic or Anatomic Criteria of the FTDS. Of the remaining 7,911 cases, 62 met the consensus definition for needing a trauma center (TC). Taken as a whole, the Mechanism of Injury Criteria of the FTDS identified 14 of the remaining 62 children who needed the resources of a trauma center for a 77% under-triage rate. The mechanisms sustained were 36% fall (16 needed TC), 28% motor vehicle crash (MVC) (20 needed TC), 7% struck by a vehicle (10 needed TC)

Given the lack of evidence regarding effective pharmacological and non-pharmacological interventions for pediatric mild traumatic brain injury (mTBI) and the resultant lack of treatment recommendations reflected in consensus guidelines, variation in the management of pediatric mTBI is to be expected. We therefore surveyed practitioners across 15 centers in the United States and Canada who care for children with pediatric mTBI to evaluate common-practice variation in the management of pediatric mTBI. The survey, developed by a panel of pediatric mTBI experts, consisted of a 10-item survey instrument regarding providers' perception of common pediatric mTBI symptoms and mTBI interventions. Surveys were distributed electronically to a convenience sample of local experts at each center. Frequencies and percentages (with confidence intervals [CI]) were determined for survey responses. One hundred and seven respondents (71% response rate) included specialists in pediatric Emergency Medicine, Sports Medicine, Neurology, Neurosurgery, Neuropsychology, Neuropsychiatry, Physical and Occupational Therapy, Physiatry/Rehabilitation, and General Pediatrics. Respondents rated headache as the most prevalently reported symptom after pediatric mTBI, followed by cognitive problems, dizziness, and irritability. Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non-steroidal anti-inflammatory medications (55%; [95% CI: 42,68]) and acetaminophen (59%; [95% CI: 46,71]) were most commonly recommended. One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported. For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI: 0,8]). The most common non-pharmacological interventions were rest ("always" or "often" recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI: 33,53]) and cervical spine exercises (29% [95%CI: 21,39]). Self-reported utilization for common pediatric mTBI interventions varied widely across our Canadian and United States consortium. Future effectiveness studies for pediatric mTBI are urgently needed to advance the evidence-based care.

Children with minor head trauma frequently present to emergency departments (EDs). Identifying those with traumatic brain injuries (TBIs) can be difficult, and it is unknown whether clinical prediction rules outperform clinician suspicion. Our primary objective was to compare the test characteristics of the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules to clinician suspicion for identifying children with clinically important TBIs (ciTBIs) after minor blunt head trauma. Our secondary objective was to determine the reasons for obtaining computed tomography (CT) scans when clinical suspicion of ciTBI was low.This was a planned secondary analysis of a previously conducted observational cohort study conducted in PECARN to derive and validate clinical prediction rules for ciTBI among children with minor blunt head trauma in 25 PECARN EDs. Clinicians recorded their suspicion of ciTBI before CT as1, 1-5, 6-10, 11-50, or50%. We defined ciTBI as 1) death from TBI, 2) neurosurgery, 3) intubation for more than 24 hours for TBI, or 4) hospital admission of 2 nights or more associated with TBI on CT. To avoid overfitting of the prediction rules, we performed comparisons of the prediction rules and clinician suspicion on the validation group only. On the validation group, we compared the test accuracies of clinician suspicion 1% versus having at least one predictor in the PECARN TBI age-specific prediction rules for identifying children with ciTBIs (one rule for children2 years [preverbal], the other rule for children2 years [verbal]).In the parent study, we enrolled 8,627 children to validate the prediction rules, after enrolling 33,785 children to derive the prediction rules. In the validation group, clinician suspicion of ciTBI was recorded in 8,496/8,627 (98.5%) patients, and 87 (1.0%) had ciTBIs. CT scans were obtained in 2,857 (33.6%) patients in the validation group for whom clinician suspicion of ciTBI was recorded, including 2,099/7,688 (27.3%) of those with clinician suspicion of ciTBI of1% and 758/808 (93.8%) of those with clinician suspicion1%. The PECARN prediction rules were significantly more sensitive than clinician suspicion1% of ciTBI for preverbal (100% [95% confidence interval {CI} = 86.3% to 100%] vs. 60.0% [95% CI = 38.7% to 78.9%]) and verbal children (96.8% [95% CI = 88.8% to 99.6%] vs. 64.5% [95% CI = 51.3% to 76.3%]). Prediction rule specificity, however, was lower than clinician suspicion1% for preverbal children (53.6% [95% CI = 51.5% to 55.7%] vs. 92.4% [95% CI = 91.2% to 93.5%]) and verbal children (58.2% [95% CI = 56.9% to 59.4%] vs. 90.6% [95% CI = 89.8% to 91.3%]). Of the 7,688 patients in the validation group with clinician suspicion recorded as1%, CTs were nevertheless obtained in 2,099 (27.3%). Three of 16 (18.8%) patients undergoing neurosurgery had clinician suspicion of ciTBI1%.The PECARN TBI prediction rules had substantially greater sensitivity, but lower specificity, than clinician suspicion of ciTBI for children with minor blunt head trauma. Because CT ordering did not follow clinician suspicion of1%, these prediction rules can augment clinician judgment and help obviate CT ordering for children at very low risk of ciTBI.

BACKGROUND: Provider-dependent practice variation in children hospitalized with bronchiolitis is not uncommon. Clinical practice guidelines (CPGs) can streamline practice and reduce utilization however, CPG implementation is complex. METHODS: A multidisciplinary team developed and implemented CPGs for management of bronchiolitis for children RESULTS: The number CPG-eligible patients in the pre- and 2 postimplementation periods were similar (1244, preimplementation; 1159, postimplementation season 1; 1283 postimplementation season 2). CXRs decreased from 59.7% to 45.1% (P < .0001) in season 1 to 39% (P < .0001) in season 2. Bronchodilator use decreased from 27% to 20% (P < .01) in season 1 to 14% (P < .002) in season 2. Steroid use significantly reduced from 19% to 11% (P < .01). Antibiotic use did not change significantly (P = .16). LOS decreased from 2.3 to 1.8 days (P < .0001) in season 1 and 1.9 days (P < .05) in season 2. All-cause 7-day readmission rate did not change (P = .45). CONCLUSIONS: Bronchiolitis CPG implementation resulted in reduced use of CXRs, bronchodilators, steroids, and LOS without affecting 7-day all-cause readmissions.

Objectives Computed tomography (CT) is often used in the emergency department (ED) evaluation of children with posttraumatic seizures (PTS); however, the frequency of traumatic brain injuries (TBIs) and short-term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBIs on CT and short-term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED. Methods This was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 EDs in the Pediatric Emergency Care Applied Research Network. We evaluated children

There is limited research on how well the American College of Surgeons/Center for Disease Control and Prevention Guidelines for Field Triage of Injured Patients assist EMS providers in identifying children who need the resources of a trauma center.To determine the accuracy of the Physiologic Criteria (Step 1) of the Field Triage Guidelines in identifying injured children who need the resources of a trauma center.EMS providers who transported injured children 15 years and younger to pediatric trauma centers in 3 mid-sized cities were interviewed regarding patient demographics and the presence or absence of each of the Field Triage Guidelines criteria. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. This data was obtained through a structured hospital record review. The over- and under-triage rates and positive likelihood ratios (+LR) were calculated for the overall Physiologic Criteria and each individual criterion.Interviews were conducted for 5,610 pediatric patients; outcome data were available for 5,594 (99.7%): 5% of all patients needed the resources of a trauma center and 19% met the physiologic criteria. Using the physiologic criteria alone, 51% of children who needed a trauma center would have been under-triaged and 18% would have been over-triaged (+LR 2.8, 95% CI 2.4-3.2). Glasgow Coma Score (GCS)14 had a +LR of 14.3 (95% CI 11.2-18.3), with EMS not obtaining a GCS in 4% of cases. 54% of those with an EMS GCS14 had an initial ED GCS14. Abnormal respiratory rate (RR) had a +LR of 2.2 (95% CI 1.8-2.6), with EMS not obtaining a RR in 5% of cases. 41% of those with an abnormal EMS RR had an abnormal initial ED RR. Systolic blood pressure (SBP)90 had a +LR of 3.5 (95% CI 2.5-5.1), with EMS not obtaining a SBP in 20% of cases. SBP was not obtained for 79% of children1 year, 46% 1-4 years, 7% 5-9 years, and 2% 10-15 years. A total of 19% of those with an EMS SBP90 had an initial ED SBP90.The Physiologic Criteria are a moderate predictor of trauma center need for children. Missing or inaccurate vital signs may be limiting the predictive value of the Physiologic Criteria.

The development and use of seatbelts has saved numerous lives and prevented serious injuries in the setting of automobile crashes. However, restraints designed for adults are not necessarily effective in preventing injury to small children and may actually be harmful. Here, we present a case of upper cervical spine fracture in a 5-year-old female patient caused by neck flexion over an inappropriately applied adult 3-point seatbelt during a motor vehicle collision. The American Academy of Pediatrics currently advises against the use of vehicle safety belts until the shoulder belt can be positioned across the chest with the lap belt snug across the thighs. As clinicians who care for children, it is imperative that we continue to educate parents about proper use of age-appropriate child safety restraints.

Background Verbal prehospital reports on an injured patient’s condition are typically used by trauma centers to determine if a trauma team should be present in the emergency department prior to patient arrival (i.e., trauma team activation). Efficacy studies of trauma team activation protocols cannot be conducted without a criterion standard definition for which pediatric patients need a trauma team activation. Objective To develop a consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation. Methods Ten local and national experts in emergency medicine, emergency medical services, and trauma were recruited to participate in a Modified Delphi survey process. The initial survey was populated based on outcomes that had been used in previously published literature on trauma team activation. The criterion standard definition for trauma team activation was refined iteratively based on survey responses until at least 80% agreement was achieved for each criterion. Results After five voting rounds a consensus-based definition for pediatric trauma team activation was developed. Twelve criteria were identified along with a corresponding time interval in which each criterion had to occur. The criteria include receiving specific surgery types, interventional radiology, advanced airway management, thoracostomy, blood products, spinal injury, emergency cesarean section, vasopressors, burr hole or other procedure to relieve intracranial pressure, pericardiocentesis, thoracotomy, and death in the emergency department. All expert panel members voted in all 5 voting rounds, except 1 member missed rounds 1 and 2. Each criterion had greater than 80% agreement from the panel. Conclusion A criterion standard definition for the highest-level pediatric trauma team activation was developed. This criterion standard definition will advance trauma research by allowing investigators to determine the accuracy and effectiveness of highest-level pediatric trauma team activation protocols. Level of Evidence/Study type Qualitative

Children evaluated in emergency departments for blunt head trauma (BHT) frequently undergo computed tomography (CT), with some requiring pharmacological sedation. Cranial CT sedation complications are understudied. The objective of this study was to document the frequency, type, and complications of pharmacological sedation for cranial CT in children.We prospectively enrolled children (younger than 18 years) with minor BHT presenting to 25 emergency departments from 2004 to 2006. Data collected included sedation agent and complications. We excluded patients with Glasgow Coma Scale scores of less than 14.Of 57,030 eligible patients, 43,904 (77%) were enrolled in the parent study; 15,176 (35%) had CT scans performed or planned, and 527 (3%) received pharmacological sedation for CT. Sedated patients' characteristics were as follows: median age, 1.7 years (interquartile range, 1.1-2.5 years); male 61%; Glasgow Coma Scale score of 15, 86%; traumatic brain injury on CT, 8%. There were 488 patients (93%) who received 1 sedative. Sedation use (0%-21%) and regimen varied by site. Pentobarbital (n = 164) and chloral hydrate (n = 149) were the most frequently used agents. Sedation complications occurred in 49 patients (9%; 95% confidence interval [CI], 7%-12%): laryngospasm 1 (0.2%; 95% CI, 0%-1.1%), failed sedation 31 (6%; 95% CI, 4%-8%), vomiting 6 (1%; 95% CI, 0.4%-2%), hypotension 13 (4%; 95% CI, 2%-7%), and hypoxia 1 (0.2%; 95% CI, 0%-2%). No cases of apnea, aspiration, or reversal agent use occurred. One patient required intubation. Vomiting and failed sedation were most common with chloral hydrate.Pharmacological sedation is infrequently used for children with minor BHT undergoing CT, and complications are uncommon. The variability in sedation medications and frequency suggests a need for evidence-based guidelines.

To describe the clinical presentations and outcomes of children with intraventricular hemorrhages (IVHs) after blunt head trauma (BHT).Subanalysis of a large, prospective, observational cohort study performed from June 1, 2004, through September 31, 2006.Twenty-five emergency departments participating in the Pediatric Emergency Care Applied Research Network. Patients Children presenting with IVH after BHT. Exposure Blunt head trauma.Clinical presentations and outcomes, including the Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scores at hospital discharge.Of 15 907 patients evaluated with computed tomography, 1156 (7.3%) had intracranial injuries. Forty-three of the 1156 (3.7%; 95% CI, 2.7%-5.0%) had nonisolated IVHs (ie, with intracranial injuries on computed tomography), and 10 of 1156 (0.9%; 95% CI, 0.4%-1.6%) had isolated IVHs. Only 4 of 43 (9.3%) of those with nonisolated IVHs had Glasgow Coma Scale (GCS) scores of 14 to 15, and all 10 (100.0%) with isolated IVHs had GCS scores of 15. No patients with isolated IVHs required neurosurgery or died. One patient had moderate overall disability (by the POPC score), and no patient had moderate or severe disability at discharge (by the PCPC score). Of the 43 patients with nonisolated IVHs, however, 16 (37.2%) died and 18 (41.9%) required neurosurgery. In 27 patients (62.8%), injuries ranged from moderate overall disability to brain death by the POPC score.Children with nonisolated IVHs after BHT typically present with GCS scores of less than 14, frequently require neurosurgery, and have high mortality rates. In contrast, those with isolated IVHs typically present with normal mental status and are at low risk for acute adverse events and poor outcomes.

CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation24 h, or hospital admissionor=2 nights).We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

A 7-month-old male presents to the emergency department with a three-day history of left scrotum swelling. Parents report no fevers and normal urine output. The left testicle is firm and not tender; cremasteric reflex is present. An ultrasound is performed (figures 1⇓ …