James A. Meltzer

Is Nonperforated Pediatric Appendicitis Still Considered a Surgical Emergency? A Survey of Pediatric Surgeons

OBJECTIVE To describe the beliefs and preferences of pediatric surgeons regarding the emergent nature of nonperforated appendicitis. METHODS An electronic mailing was sent to all 1052 members of the American Pediatric Surgical Association (APSA) inviting participation in a 26-item survey, which was administered by Survey Monkey (www.surveymonkey.com). Chi-square and Mann-Whitney tests were used for bivariate analysis. Spearmans rho was used for nonparametric correlation. RESULTS Four hundred eighty-four pediatric surgeons (46%) responded to the survey. Few respondents (4%) considered nonperforated appendicitis to be a surgical emergency. A minority (14%) would come in from home to perform an overnight appendectomy. Most (92%) believe that postponing overnight appendectomy until daytime does not result in a clinically significant increase in perforation. Respondents endorsed surgeon fatigue (56%) and limited operating room availability (56%) most often among factors that would make them more likely to postpone surgery. Sixty-eight percent reported no departmental guideline regarding delay of overnight appendectomy. CONCLUSIONS Most pediatric surgeons in our study believe nonperforated appendicitis is not a surgical emergency and prefer to postpone overnight appendectomy.

Identifying children at low risk for bacterial conjunctivitis.

OBJECTIVE To identify a population of children at low risk for bacterial conjunctivitis on the basis of history and physical examination findings. DESIGN Prospective observational cohort study. SETTING Urban pediatric emergency department. PARTICIPANTS Children aged 6 months to 17 years with conjunctival erythema, eye discharge, or both. The exclusion criteria were eye trauma, exposure to a noxious chemical, contact lens use, and antibiotic drug use in the past 5 days. INTERVENTIONS Clinicians completed a checklist of signs and symptoms and collected a conjunctival swab for bacterial culture. MAIN OUTCOME MEASURES The chi(2) test, the Mann-Whitney test, and logistic regression were used to create a prediction model for a negative bacterial culture. RESULTS Of 368 patients enrolled, 194 (52.7%) were males. The median patient age was 3 years (interquartile range, 1-5 years). Conjunctival cultures were negative in 130 patients (35.3%). Age 6 years or older, presentation in April through November, no or watery discharge, and no glued eye in the morning were the clinical factors found to be independently associated with a negative conjunctival culture. If 3 factors were present, 76.4% (95% confidence interval, 63.6%-85.6%) of patients had a negative culture. If all 4 factors were present, 92.3% (95% confidence interval, 66.1%-98.2%) of patients had a negative culture. CONCLUSION The combination of 4 clinical factors may enable clinicians to identify children at low risk for bacterial conjunctivitis and may reduce routine antibiotic drug administration.

A Validation Study of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) Tape–A New Weight Estimation Tool

OBJECTIVE To evaluate the performance of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) tape, a new weight-estimation tool with a modifier for body habitus, in our increasingly obese population. STUDY DESIGN A convenience sample of children presenting to the pediatric emergency department of an urban public hospital was enrolled. A nurse or doctor assigned the patient a body habitus score and used the PAWPER tape to estimate the weight. The true weight was then recorded for comparison.The estimated weight was considered accurate if it was within 10% of the true weight. RESULTS We enrolled 1698 patients; 579 (34%) were overweight or obese. Overall, the estimated weight was accurate for 64% of patients (95% CI 61%-65%). For children with an above-average body habitus, the tape was accurate 50% of the time (95% CI 46%-55%). There was no significant difference in the accuracy of the PAWPER tape for children assessed during medical and trauma resuscitations. CONCLUSION Although the PAWPER tape may ultimately be useful, its initial performance was not replicated in our population. A simple, accurate method of weight estimation remains elusive.

Penetrating neck trauma in children: an uncommon entity described using the National Trauma Data Bank

BACKGROUND Penetrating neck trauma is uncommon in children; consequently, data describing epidemiology, injury pattern, and management are sparse. The aim of this study was to use the National Trauma Data Bank (NTDB) to describe pediatric penetrating neck trauma (PPNT). METHODS The NTDB was queried for children (defined as <15 years old) with PPNT between years 2008 and 2012. Descriptive analysis was used to describe age groups (0–5, 6–10, and 11–14 years) and injury type categorized as aerodigestive, vascular, cervical spine, and nerve. RESULTS A total of 1,238 patients with penetrating neck trauma were identified among 434,788 children in the NTDB (0.28%). Mean age was 7.9 years, and 70.6% of patients were male. The most common mechanisms of injury were stabbing (44%) and gunshot/firearm (24%). Most patients were treated at a pediatric trauma center (65.8%). Computed tomographic scan was the most frequent (42.2%) diagnostic study performed, followed by laryngoscopy (27.0%) and esophagoscopy (27.4%). Almost a quarter of patients (23.7%) went directly to the operating room from the emergency department (ED). Aerodigestive injuries were most common and occurred more frequently in the youngest age group (p < 0.001). Operative procedures for aerodigestive type injuries were most common (82.7%). There were 69 deaths, yielding a mortality rate of 5.6%. When adjusting for age, admission to a pediatric trauma center, and injury type, only vascular injury (odds ratio, 3.92; 95% confidence interval, 2.19–7.24; p < 0.0001) and ED hypotension (odds ratio, 27.12; 95% confidence interval, 15.11–48.67; p < 0.0001) were found to be independently associated with death. CONCLUSION PPNT is extremely rare—0.28% reported NTDB incidence. Age seems to influence injury type but does not affect mortality. Computed tomographic scan is the dominant diagnostic study used for selective management. Vascular injury type and hypotension on presentation to the ED were independently associated with mortality. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Risk factors associated with bladder and urethral injuries in female children with pelvic fractures: An analysis of the National Trauma Data Bank.

BACKGROUND Bladder and/or urethral injuries (BUIs) secondary to pelvic fractures are rare in children and are associated with a high morbidity. These injuries are much less likely to occur in females and are often missed in the emergency department. To help clinicians detect these injuries in female children, larger studies are needed to identify risk factors specific to this patient population. This study aimed to identify risk factors associated with BUI in female children with a pelvic fracture. METHODS We reviewed the National Trauma Data Bank for females younger than 16 years who sustained a pelvic fracture from 2010 to 2012. Patients with penetrating injuries were excluded. Variables including patient characteristics, mechanism of injury, and type of pelvic fracture were selected for bivariate analysis. Variables with an association of p < 0.05 were then tested using binary logistic regression. RESULTS Of the 149,091 females younger than 16 years in the National Trauma Data Bank, 2,639 patients (2%) with pelvic fractures were identified. The median patient age was 12 years (interquartile range [IQR], 7–14 years). BUI was identified in 81 patients (3%). Patients with BUI had a significantly higher median Injury Severity Score (ISS) (25 [IQR, 17–34] vs. 13 [IQR, 6–22], p < 0.001). Four variables were found to be independently associated with BUI in the logistic regression model: vaginal laceration (adjusted odds ratio [OR], 9.1; 95% confidence interval [CI], 4.4–18.7), disruption of the pelvic circle (adjusted OR, 3.0; 95% CI, 1.6–5.6), multiple pelvic fractures (adjusted OR, 2.3; 95% CI, 1.3–3.9), and sacral spine injury (adjusted OR, 1.6; 95% CI, 1.0–2.6). In total, 62 patients (77%; 95% CI, 67–86%) with BUI had at least one of these findings. CONCLUSION Female children who sustained a pelvic fracture and have a vaginal laceration, disruption of the pelvic circle, multiple pelvic fractures, or a sacral spine injury seem to be at highest risk for BUI. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Association of Whole-Body Computed Tomography With Mortality Risk in Children With Blunt Trauma

Importance Although several studies have demonstrated an improvement in mortality for injured adults who receive whole-body computed tomography (WBCT), it is unclear whether children experience the same benefit. Objective To determine whether emergent WBCT is associated with lower mortality among children with blunt trauma compared with a selective CT approach. Design, Setting, and Participants A retrospective, multicenter cohort study was conducted from January 1, 2010, to December 31, 2014, using data from the National Trauma Data Bank on children aged 6 months to 14 years with blunt trauma who received an emergent CT scan in the first 2 hours after emergency department arrival. Data analysis was conducted from February 2 to December 29, 2017. Exposures Patients were classified as having WBCT if they received CT head, CT chest, and CT abdomen/pelvis scans in the first 2 hours and as having a selective CT if they did not receive all 3 scans. Main Outcomes and Measures The primary outcome was in-hospital mortality in the 7 days after ED arrival. To adjust for potential confounding, propensity score weighting was used. Subgroup analyses were performed for those with the highest mortality risk (ie, occupants and pedestrians involved in motor vehicle crashes, children with a Glasgow Coma Scale score lower than 9, children with hypotension, and those admitted to the intensive care unit). Results Of the 42 912 children included in the study (median age [interquartile range], 9 [5-12] years; 27 861 [64.9%] boys), 8757 (20.4%) received a WBCT. Overall, 405 (0.9%) children died within 7 days. After adjusting for the propensity score, children who received WBCT had no significant difference in mortality compared with those who received selective CT (absolute risk difference, −0.2%; 95% CI, −0.6% to 0.1%). All subgroup analyses similarly showed no significant association between WBCT and mortality. Conclusions and Relevance Among children with blunt trauma, WBCT, compared with a selective CT approach, was not associated with lower mortality. These findings do not support the routine use of WBCT for children with blunt trauma.

Association of Delay in Appendectomy With Perforation in Children With Appendicitis.

Objective The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation. Methods We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression. Results Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9–15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8–15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00–1.04). Conclusions Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.

Internal Hernia as a Cause for Intestinal Obstruction in a Newborn

BACKGROUND An internal hernia is a rare cause of intestinal obstruction, which can occur at any age. Children most often develop an internal hernia due to a congenital defect in the mesentery. While some patients are asymptomatic, others present to medical attention with vague abdominal symptoms, an acute abdomen, or in shock. CASE REPORT We report a case of a 5-day-old previously healthy baby who presented to our pediatric emergency department with bilious vomiting, grossly bloody stool, and abdominal distention. During an exploratory laparotomy, the patient was diagnosed with an internal hernia caused by a congenital mesenteric defect. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although internal hernia is an infrequent cause of intestinal obstruction in a newborn and requires emergent operative repair, it may be mistaken for other more common causes, such as necrotizing entercolitis, which are often managed medically. This case report aims to highlight some of the difficulties in diagnosis and key features that may assist the clinician in identifying these patients.

A randomized controlled study in reducing procedural pain and anxiety using high concentration nitrous oxide

Over the past 10 years, pediatric emergency departments (PED) throughout the country have adopted the concept of an “ouchless” PED, using both pharmacologic and non-pharmacologic methods to achieve this goal [1]. Despite our interest in an “ouchless” PED, many routine procedures are performedwithout full attention to patient comfort. Some procedures, such as laceration repair, require local anesthesia, while others, such as intravenous catheter placement, are usually performed without local anesthesia. All of these minor procedures, however, are ones in which the risk of parenteral procedural sedation outweighs the benefit. As the concept of creating a pain-free PED experience has grown, the use of high-concentration nitrous oxide [HC-N2O] (N50%) in the pediatric outpatient setting and PEDs has increased throughout the country. N2O is a colorless, non-narcotic, analgesic gas and its efficacy and safety have been well documented in anesthesia and dental literature [2]. Several studies have been published on the use of HC-N2O in decreasing pain and anxiety in the pediatric emergency setting; however, previous investigations have been either observational, focused on a narrow age range, studied for use with a single procedure type, or included procedures associated with moderate to severe pain such as fracture reduction [1,3-5].

Evaluating the risk of appendiceal perforation when using ultrasound as the initial diagnostic imaging modality in children with suspected appendicitis

Background Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation. Objective To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis. Methods We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy. Results In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and shorter triage-to-incision time (p = 0.003). Conclusion Children with suspected appendicitis receiving ultrasound scan as the initial diagnostic imaging modality do not have increased risk of perforation compared to those receiving computed tomography scan first. We recommend that children <12 years of age receive ultrasound scan first.