Genevieve Santillanes

Pediatric Airway Management

Pediatric airway problems are seen commonly in pediatric and general emergency departments, management of the pediatric airway is often stressful to providers. This article reviews the pediatric airway, highlighting the anatomic and physiologic differences between infant, pediatric and adult airways, and how these differences impact assessment and management of the pediatric airway.

Prospective Evaluation of a Clinical Practice Guideline for Diagnosis of Appendicitis in Children

OBJECTIVES The objective was to assess the performance of a clinical practice guideline for evaluation of possible appendicitis in children. The guideline incorporated risk stratification, staged imaging, and early surgical involvement in high-risk cases. METHODS The authors prospectively evaluated the clinical guideline in one pediatric emergency department (ED) in a general teaching hospital. Patients were risk-stratified based on history, physical examination findings, and laboratory results. Imaging was ordered selectively based on risk category, with ultrasound (US) as the initial imaging modality. Computed tomography (CT) was ordered if the US was negative or indeterminate. Surgery was consulted before imaging in high-risk patients. RESULTS A total of 475 patients were enrolled. Of those, 193 (41%) had appendicitis. No low-risk patient had appendicitis. Medium-risk patients had a 19% rate of appendicitis, and 83% of high-risk patients had appendicitis. Factors associated with an increased likelihood of appendicitis included decreased bowel sounds; rebound tenderness; and presence of psoas, obturator, or Rovsings signs. Of the 475 patients, 276 (58%) were managed without a CT scan. Seventy-one of the 193 (37%) patients with appendicitis went to the operating room without any imaging. The rate of missed appendicitis was 2%, and the rate of negative appendectomy was 1%. CONCLUSIONS The clinical practice guideline performed well in a general teaching hospital. Rates of negative appendectomy and missed appendicitis were low and 58% of patients were managed without a CT scan.

Preparedness of selected pediatric offices to respond to critical emergencies in children.

Febrile seizures are the most common neurological disorders in children and are among the more common symptoms that lead to an emergency department visit. Although most febrile seizures are simple and benign, these seizures can infrequently create a diagnostic dilemma. The diagnosis of cerebral venous thrombosis is challenging to emergency physicians because it can mimic the presentation of many other disorders, including ischemic and hemorrhagic stroke, tumor, and abscess. In addition, the broad variety of signs and symptoms makes the clinical diagnosis difficult. The patients may be presented with signs of increased intracranial pressure or focal neurological deficits. It is an uncommon but potentially dangerous cause of hemiparesis after seizure. Early recognition of this condition and appropriate management may reduce the mortality rate. We present a young child with dural sinus thrombosis who presented with seizures associated with fever and subsequent hemiparesis, and explained a possible mechanism of focal neurological deficit.

Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital.

STUDY OBJECTIVE We identify factors in emergency department (ED) patients presenting with apparent life-threatening events that distinguish those safe for discharge from those warranting hospitalization. METHODS Data were prospectively collected on all subjects presenting to 4 EDs with apparent life-threatening events. Patients were observed for subsequent events or interventions, defined a priori, which would have mandated hospital admission (eg, hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection). For patients discharged from the ED, telephone follow-up was arranged. Classification and regression tree analysis was performed to delineate admission predictors. RESULTS A total of 832 subjects were enrolled. The overall median age was 31.5 days (interquartile range 10 to 90 days); 427 (51.3%) were male patients, and 513 (61.7%) arrived by emergency medical services. One hundred ninety-one (23.0%) infants had a significant intervention warranting hospitalization. One hundred thirty-seven patients (16.5%) met predetermined criteria that would obviously mandate hospital admission (eg, persistent hypoxia requiring oxygen) by the end of their ED stay. In addition to these patients for whom it was obvious that admission would be necessary in the ED, classification and regression tree analysis (receiver operating curve=0.90) yielded 2 factors predictive of hospitalization: having a significant medical history and having greater than 1 apparent life-threatening event in 24 hours. The sensitivity was 89.0% (95% confidence interval 83.5% to 92.9%); specificity was 61.9% (95% confidence interval 58.0% to 65.7%). CONCLUSION We found 3 variables (obvious need for admission, significant medical history, >1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission. These variables require external validation and reliability assessment before clinical implementation.

Accuracy of Magnetic Resonance Imaging and Ultrasound for Appendicitis in Diagnostic and Nondiagnostic Studies

OBJECTIVES Suggestive radiographic studies with nonvisualization of the appendix can present a challenge to clinicians in the evaluation of pediatric abdominal pain. The primary objective of this study was to quantify the accuracy of magnetic resonance imaging (MRI) and of ultrasound (US) in the setting of nonvisualization of the appendix. Secondary objectives reported include sensitivity of MRI and US overall and correlation between MRI and US for diagnosis of appendicitis. METHODS Records of pediatric emergency department patients aged 3 to 21 years undergoing MRI and/or US for the evaluation of appendicitis were retrospectively reviewed. Radiographs were categorized as a normal appendix, neither demonstrating the appendix nor demonstrating abnormalities consistent with appendicitis; equivocal, not demonstrating the appendix but showing evidence of appendicitis; demonstrating an abnormal appendix consistent with appendicitis; or demonstrating an alternate pathology. The reading was compared with the final diagnosis for accuracy. RESULTS Of the 589 patients included, 146 had appendicitis. Diagnostic accuracy for studies with a nonvisualized appendix without secondary signs of appendicitis was 100% for MRI and 91.4% (95% CI = 87.3% to 94.2%) for US. Diagnostic accuracy for studies with a nonvisualized appendix with secondary signs of appendicitis was 50% (95% CI = 2.5% to 97.5%) for MRI and 38.9% (95% CI = 18.2% to 64.5%) for US. Appendicitis was ultimately diagnosed in 8.6% of patients with an otherwise negative right lower quadrant (RLQ) US that failed to directly identify the appendix. There was a moderate correlation between US and MRI (ρ = 0.573, p = 0.0001) when all studies were considered. CONCLUSIONS Magnetic resonance imaging without secondary signs of appendicitis is effective in excluding appendicitis regardless of whether the appendix is directly visualized, while otherwise negative RLQ US that fail to identify the appendix are less useful. Secondary signs of appendicitis without visualization of the appendix were not helpful regardless of radiographic modality. Results of MRI and US correlated moderately well.

Is medical clearance necessary for pediatric psychiatric patients

BACKGROUND Although most studies have found low rates of organic illness in patients with isolated psychiatric complaints, psychiatric patients are frequently brought to emergency departments (EDs) for medical clearance. STUDY OBJECTIVES To assess the utility of ED medical clearance before transfer of pediatric patients on psychiatric holds to inpatient psychiatric facilities, and to evaluate charges associated with ED medical clearance. METHODS Retrospective study of pediatric psychiatric patients in one urban pediatric ED with 22,000 annual patient visits over an 18-month period. Patients were included if transported to the ED for medical clearance after being placed on an involuntary psychiatric hold in the prehospital setting. Main outcome measures were charges for screening laboratory tests and secondary ambulance transfers and wages for sitters resulting from ED visits for medical screening examinations of patients on psychiatric holds. We also determined what percentage of patients truly warranted a medical screen and the percentage of psychiatric holds overturned, avoiding transfer to a psychiatric hospital. RESULTS There were 789 patients included; 72 (9.1%) were determined to require medical screening. Total charges for laboratory assessments and secondary ambulance transfers and wages for sitters were

Impact of Boarding Pediatric Psychiatric Patients on a Medical Ward

1,241,295, or US

Most Routine Laboratory Testing Of Pediatric Psychiatric Patients In The Emergency Department Is Not Medically Necessary

17,240 per patient requiring a medical screen. Only 35 (4.4%) holds were overturned in the ED. CONCLUSION Few patients brought to the ED on an involuntary hold required a medical screen. Use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, rape) could have led to significant savings.

Comparison of Computerized Patients versus Live Moulaged Actors for a Mass-casualty Drill.

BACKGROUND AND OBJECTIVES Psychiatric disorders account for an increasing number of pediatric hospitalizations. Due to lack of psychiatric beds, patients on involuntary psychiatric holds may be admitted to medical units. Our objectives were to evaluate the rate of admission of psychiatric patients to a medical unit, psychiatric care provided, and estimated cost of care. METHODS The study involved retrospective chart review of all patients on involuntary psychiatric holds presenting to 1 pediatric emergency department from July 2009 to December 2010. We determined the rate of admission to a medical unit, the rate of counseling or psychiatric medication administration, and the estimated cost of nonmedical admissions (boarding) of patients on the medical unit. RESULTS A total of 555 (50.1%) of 1108 patients on involuntary psychiatric holds were admitted to the pediatric medical unit. The majority (523 [94.2%]) were admitted for boarding because no psychiatric bed was available. Thirty-two (6.1%) patients admitted for isolated psychiatric reasons had counseling documented, and 105 (20.1%) received psychiatric medications. Patients admitted to an affiliated psychiatric hospital were significantly more likely to receive counseling and medications. Psychiatric patients were boarded in medical beds for 1169 days at an estimated cost of

Does Right Lower Quadrant Abdominal Ultrasound Accurately Identify Perforation in Pediatric Acute Appendicitis

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