Itai Shavit

A Novel Imaging Technique to Measure Capillary-Refill Time: Improving Diagnostic Accuracy for Dehydration in Young Children With Gastroenteritis

BACKGROUND. Assessment of dehydration in young children currently depends on clinical judgment, which is relatively inaccurate. By using digital videography, we developed a way to assess capillary-refill time more objectively. OBJECTIVE. Our goal was to determine whether digitally measured capillary-refill time assesses the presence of significant dehydration (≥5%) in young children with gastroenteritis more accurately than conventional capillary refill and overall clinical assessment. METHODS. We prospectively enrolled children with gastroenteritis,1 month to 5 years of age, who were evaluated in a tertiary-care pediatric emergency department and judged by a triage nurse to be at least mildly dehydrated. Before any treatment, we measured the weight and digitally measured capillary-refill time of these children. Pediatric emergency physicians determined capillary-refill time by using conventional methods and degree of dehydration by overall clinical assessment by using a 7-point Likert scale. Postillness weight gain was used to estimate fluid deficit; beginning 48 hours after assessment, children were reweighed every 24 hours until 2 sequential weights differed by no more than 2%. We compared the accuracy of digitally measured capillary-refill time with conventional capillary refill and overall clinical assessment by determining sensitivities, specificities, likelihood ratios, and area under the receiver operator characteristic curves. RESULTS. A total of 83 patients were enrolled and had complete follow-up; 13 of these patients had significant dehydration (≥5% of body weight). The area under the receiver operator characteristic curves for digitally measured capillary-refill time and overall clinical assessment relative to fluid deficit (<5% vs ≥5%) were 0.99 and 0.88, respectively. Positive likelihood ratios were 11.7 for digitally measured capillary-refill time, 4.5 for conventional capillary refill, and 4.1 for overall clinical assessment. CONCLUSIONS. Results of this prospective cohort study suggest that digitally measured capillary-refill time more accurately predicts significant dehydration (≥5%) in young children with gastroenteritis than overall clinical assessment.

Observational pain assessment versus self-report in paediatric triage

Objective: To examine if observational pain assessment can be used for purposes of triage in children aged >3 years. Methods: A prospective, single blind, controlled trial was undertaken in children who presented to the emergency department (ED) with pain. Pain was assessed in the waiting room and again at triage before any treatment was administered using the Alder Hey Triage Pain Score (AHTPS), an observational tool designed for triage, and a self-report tool, either the Wong-Baker Faces Pain Rating Scale (WBS) for 3–7-year-old children or a visual analogue scale (VAS) for 8–15-year-old children. Scores were compared by instrument (observational and self-report) and ED location (waiting room and triage room). Results: 75 children (29 aged 3–7 years and 46 aged 8–15 years) were enrolled in the study. The AHTPS scores were significantly lower than the scores measured by the WBS/VAS (p<0.001). The level of pain measured by both methods (self-report, observational) was lower in the triage room. Compared with the AHTPS, the WBS and VAS scored significantly lower in the triage room than in the waiting room (p<0.042 and p<0.006, respectively). Conclusions: Observational pain assessment underestimates children’s perception of pain and should not be recommended in children aged >3 years. Triage has a calming effect on children.

Sonography of the hip-joint by the emergency physician: its role in the evaluation of children presenting with acute limp.

Objective: To describe a new imaging bedside test called Sonography of the Hip-joint by the Emergency Physician (SHEP) and to examine if its use as a triage tool for the presence of fluid in the hip joint can guide the emergency physician to the right diagnosis. Methods: Case series of 5 children presented to the ED with an acute onset of limp. In addition to a careful clinical history and physical examination, each child received SHEP. Results: Follow-up confirmed that the presumptive diagnosis made in the ED was correct. The SHEP tests were found helpful in diagnosing transient synovitis (3 cases), septic arthritis (1 case), and osteomyelitis of the femur (1 case). Conclusions: The SHEP tests provided additional information that narrowed the differential diagnosis, and minimized unnecessary blood tests and diagnostic imaging studies.

Application of Topical Analgesia in Triage: A Potential for Harm

To reduce the overall time spent in the ED, triage nurses are encouraged to treat patients with a topical anesthetic cream, eutectic mixture of local anesthetics (EMLA). We present a case in which a 28-day-old neonate who was treated with EMLA cream in triage developed severe methemoglobinemia 18 hours post admission to the pediatric ward. This case demonstrates that there may be some risks associated with this approach, and that protocols for the use of EMLA at triage should include not only the indications for its use, but also need to ensure that there is a process to have the EMLA removed before patient discharge or transfer.

Sedation provider practice variation: a survey analysis of pediatric emergency subspecialists and fellows.

Objectives: Pediatric emergency physicians use various techniques and medications when performing procedural sedation and analgesia. The goals of our study were to assess US pediatric emergency medicine subspecialists and fellows (PEMSSFs) for individual practice variation and to evaluate (1) the use of supplemental oxygen and capnography monitoring and (2) adverse sedation events (ADSEs). Methods: A Web-based tool was used to survey and analyze data collected from a selected group of PEMSSFs, regarding their responses to 5 common sedation case scenarios, use of supplemental oxygen and capnography monitoring, and ADSEs. Logistic regression analysis was used to examine the association between medication strategy and various levels of professional experience. Results: Two hundred one surveys were received. One hundred ninety-five of these were eligible for the study: 140 from specialists and 55 from fellows. Respondents used multiple combinations of pharmaceutical agents to the scenarios presented. For some scenarios, statistical association was found between medication selection strategy and longer professional experience. Sixty percent of respondents do not routinely provide oxygen supplementation. Despite current guidelines supporting the routine use of capnography monitoring, 45% of respondents never use it. Adverse sedation event was reported in 17 cases; all patients were discharged with no further complications. A statistical association was found between years of practitioner experience and the likelihood of reporting an ADSE (P < 0.018). Conclusions: This group of PEMSSFs reported a wide spectrum of medication sedation strategies, dichotomous approaches to the use of oxygen supplementation and capnography monitoring, and a low rate of ADSEs.

The practice of pediatric procedural sedation and analgesia in the emergency department.

The treatment of acute pain and anxiety in children undergoing therapeutic and diagnostic procedures in the emergency department has improved dramatically over the last few years. The availability of noninvasive monitoring devices and the use of short-acting sedative and analgesic medications enable physicians to conduct safe and effective sedation and analgesia treatment. In todays practice of pediatric emergency medicine, sedation and analgesia has been considered as the standard of care for procedural pain. The following article describes the basic principles of pediatric procedural sedation and analgesia in the emergency department.

Urethral prolapse misdiagnosed as vaginal bleeding in a premenarchal girl.

We report on a 10-year-old girl who was presented to the Emergency Department with a 3-day history of “vaginal bleeding”, the cause of which was determined to be urethral prolapse. Urethral prolapse occurs when the urethra mucosa evaginates beyond the urethral meatus. This uncommon condition in prepubescent girls should not be confused with other causes of peri-vaginal bleeding, the most importantly being sexual abuse.

Delayed hypersensitivity reaction from black henna tattoo manifesting as severe facial swelling

We report on a 14-year-old boy who was presented to the emergency department with an acute swelling of the face and scalp 3 days after using a new hair dye. The patient had applied a black henna tattoo 1 year earlier. Patch testing revealed an allergy to the potent skin sensitizer paraphenylenediamine, a common ingredient of hair dyes and also found in black henna tattoo. It is important for emergency physicians to be aware of the possibility of a delayed type-IV hypersensitivity reaction from black henna tattoos manifesting as an acute contact dermatitis. These patients may have gross facial swelling but should not be treated for angioedema.

A double-blind, randomised, placebo-controlled trial of oral midazolam plus oral ketamine for sedation of children during laceration repair

Objectives To compare the efficacy of oral midazolam alone with a combination of oral midazolam and ketamine in children requiring laceration repair. Design A randomised, double-blind, placebo-controlled study. Setting Paediatric emergency department. Participants Children 1–10 years of age with lacerations requiring sedation. Interventions Using a computer-generated sequence, children were randomly assigned in blocks of four to one of two groups: oral midazolam (0.5 mg/kg) plus oral placebo and oral midazolam (0.5 mg/kg) plus oral ketamine (5 mg/kg). The allocation sequence was kept by the pharmacy staff, and the investigators were blinded to randomisation until statistical analysis of the study was completed. Main outcome measures Visual Analogue Scale (VAS) assessment by a parent and Sedation Score assessment by an investigator. Results 60 children were recruited; 29 were assigned for treatment with midazolam and 31 for the combination of midazolam and ketamine. There were no differences in basic demographics and wound characteristics between the groups. VAS assessment by a parent was 4.5±3.3 mm in the midazolam+ketamine group versus 4.4±2.7 mm in the midazolam alone group (mean difference 0.1, CI −1.9 to 1.71). Sedation Score during procedure was lower in the midazolam+ketamine group (mean difference 1.14, 95% CI 0.67 to 1.6). Intravenous sedation was required in two (6%) of the children in the midazolam+ketamine group, and in eight (27%) in the midazolam alone group. p=0.039. No clinically significant adverse effects were documented in either group. Conclusions No difference was found in pain assessment during local anaesthetic injection between the group treated with midazolam and ketamine, and the group treated with midazolam alone. The combination of oral midazolam and ketamine led to deeper sedation than midazolam alone, with less children requiring intravenous sedation. Clinical trial registration The trial was registered in www.clinicaltrials.gov as NCT01470157.

Age-dependent structural and radiological changes in the larynx

AIM To define radiological physiological changes in the larynx by establishing an age-related scale. MATERIALS AND METHODS The present retrospective study used radiological records of patients that had undergone lateral cervical imaging. Three hundred patients were included. Thyroid cartilage was divided into anatomical regions. The hyoid bone was evaluated as the body and greater horns. Cases were compared by grouping by age and gender. RESULTS Thyroid tissue and cricoid cartilage only became visible after the second decade. Ossification in the thyroid cartilage began in the posterior inferior horn and progressed to the superior horn and central lamina. It also began in the posterior part of the cricoid cartilage and moved forward with age. In the first decade, the body and greater horn parts of the hyoid bone could be seen more distinctly, and after the third decade the hyoid bone appeared as a single bone. The hyoid bone was the only structure ossified in the laryngeal region below the age of 20 and formed an image on direct imaging. CONCLUSIONS Age-related changes to the laryngeal tissues are evident on radiographs. Clinicians should bear this in mind when evaluating neck radiographs.