Craig J. Huang

Interrater Reliability of Clinical Findings in Children With Possible Appendicitis

OBJECTIVE: Our objective was to determine the interrater reliability of clinical history and physical examination findings in children undergoing evaluation for possible appendicitis in a large, multicenter cohort. METHODS: We conducted a prospective, multicenter, cross-sectional study of children aged 3–18 years with possible appendicitis. Two clinicians independently evaluated patients and completed structured case report forms within 60 minutes of each other and without knowing the results of diagnostic imaging. We calculated raw agreement and assessed reliability by using the unweighted Cohen κ statistic with 2-sided 95% confidence intervals. RESULTS: A total of 811 patients had 2 assessments completed, and 599 (74%) had 2 assessments completed within 60 minutes. Seventy-five percent of paired assessments were completed by pediatric emergency physicians. Raw agreement ranged from 64.9% to 92.3% for history variables and 4 of 6 variables had moderate interrater reliability (κ > .4). The highest κ values were noted for duration of pain (κ = .56 [95% confidence intervals .51–.61]) and history of emesis (.84 [.80–.89]). For physical examination variables, raw agreement ranged from 60.9% to 98.7%, with 4 of 8 variables exhibiting moderate reliability. Among physical examination variables, the highest κ values were noted for abdominal pain with walking, jumping, or coughing (.54 [.45–.63]) and presence of any abdominal tenderness on examination (.49 [.19–.80]). CONCLUSIONS: Interrater reliability of patient history and physical examination variables was generally fair to moderate. Those variables with higher interrater reliability are more appropriate for inclusion in clinical prediction rules in children with possible appendicitis.

Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries

INTRODUCTION Pancreatic injuries occur in up to 10% of paediatric patients who suffer blunt trauma. Initial amylase and lipase measurements have not been helpful as a screening tool to detect pancreatic injuries. However, one primarily adult study suggests that a delayed measurement may be useful. MATERIALS AND METHODS A retrospective chart review was conducted of patients admitted to a Level I paediatric trauma centre from April 1996 to November 2006 with traumatic pancreatic injuries. RESULTS The trauma database identified 51 patients with traumatic pancreatic injuries. Inclusion and exclusion criteria were met by 26 patients. Patients with initial amylase and lipase levels measured greater than 2h post-injury were more consistently elevated compared to those patients who had levels measured at 2h or less post-injury. There was a significant association between time of measurement and an increased amylase level (p=0.012). No significant association was found for lipase measurements (p=0.178). DISCUSSION AND CONCLUSIONS In children with blunt pancreatic injury, elevated serum amylase levels were seen in a significantly higher percentage of patients with initial measurements at greater than 2h post-injury compared to those measured at 2h or less. Lipase measurements demonstrated a similar trend. Delayed amylase and lipase measurements may be helpful to detect pancreatic injuries, but further study is needed.

Cryptorchid Testicular Torsion

Torsion of the testicle is a well-recognized urological emergency. Torsion of the cryptorchid testicle, however, is described in the urology literature, but not well recognized in the emergency department. We discuss a case of a torsed cryptorchid testicle and review the pathophysiology, imaging modalities, and prognosis.

Lateral patellar dislocation with vertical axis rotation of the patella after attempted reduction of typical patellar dislocation.

CASEA 12-year-old boy with no significant medical history was referred to our pediatric emergency department (ED) from a general ED with the diagnosis of an irreducible right patellar dislocation. He presented to the referring ED approximately 40 minutes after sustaining the injury, which occurred w

Prudent Layperson Definition of an Emergent Pediatric Medical Condition

This study was designed to assess how well parents rated pediatric medical conditions based on their perceived degree of urgency so as to determine if the “Prudent Layperson Standard” is reasonable. A self-administered, supervised survey was given to a convenience sample of 340 caregivers in the emergency department of an urban childrens hospital. Respondents were asked to rank the urgency of 15 scenarios. A caregiver response within 1 point of the physician score was considered concordant with medical opinion. A 2-week-old infant with a rectal temperature of 103.7°F was the only emergent scenario underestimated by caregivers. A 11/2-yr-old child with an upper respiratory tract infection, a 7-year-old child with ringworm, an 8-month-old infant with a simple forehead contusion, and a 4-year-old child with conjunctivitis were the non-urgent scenarios overestimated by caregivers. Laypeople are able to identify cases constructed to represent obvious pediatric medical emergencies. Several patient subgroups frequently overestimate medical urgency.

Benzonatate toxicity in a teenager resulting in coma, seizures, and severe metabolic acidosis.

We report a benzonatate overdose in a teenager resulting in life-threatening toxicity to increase awareness of this overdose, and discuss recent pediatric warnings and labeling information provided by the US Food and Drug Administration (FDA). After an overdose of benzonatate, a 13-yr-old female presented to our emergency department with coma, seizures, hypotension, prolonged QT interval on electrocardiogram, and metabolic acidosis. Benzonatate is an antitussive medication with sodium channel-blocking properties and local anesthetic effects on the respiratory stretch receptors due to a tetracaine-like metabolite. Overdose is reported to cause coma, seizures, hypotension, tachycardia, ventricular dysrhythmias, and cardiac arrest. The FDA recently issued a Drug Safety Communication warning that accidental benzonatate ingestion in children younger than 10 years of age have increased risk of death and added the new information to the Warnings and Precautions section of benzonatates label.

Otolaryngologic, Dental, Maxillofacial and Ophthamologic Emergencies

Signs and symptoms involving the eye, ear, nose, mouth, face, and neck are common complaints in children presenting to the emergency department, representing a wide range of possible diagnoses, from the benign to life-threatening. In this issue of Clinical Pediatric Emergency Medicine, the authors discuss a broad range of conditions and identify those particular problems that require subspecialty assistance. Dr. Geetanjali Srivastava provides 2 in-depth and evidence-based reviews of the presentation, evaluation and management of a wide variety of foreign bodies discovered in the aerodigestive tract and ears. Affected children may be asymptomatic or present with seemingly innocuous symptoms, so a high index of suspicion is necessary to avoid missing this diagnosis, especially in the case of esophageal button batteries or multiple magnets in the intestine. Her review of ingested foreign objects offers a useful chart covering the indications, appropriate timing and methods of removal of intestinal foreign bodies based on their type and location. Mohamed Badawy, MD, describes several congenital, infectious, and inflammatory conditions that present with neck swelling or masses. His review delineates appropriate imaging studies needed for the evaluation of these conditions and when surgical intervention may be necessary. Richard Brodsky, MD, and Hans-David Hartwig, MD, discuss the diagnostic possibilities of patients presenting with non-traumatic maxillofacial swelling, reviewing several common infections, in addition to some interesting non-infectious causes.