Jennifer R. Marin

Trends in Visits for Traumatic Brain Injury to Emergency Departments in the United States

In the last decade, traumatic brain injury (TBI) garnered increased attention, including public campaigns and legislation to increase awareness and prevent head injuries.1 The Centers for Disease Control and Prevention (CDC) describes TBI as a serious public health concern.2 We sought to describe national trends in emergency department (ED) visits for TBI.

Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department.

OBJECTIVES The objective was to evaluate the test characteristics of clinical examination (CE) with the addition of bedside emergency ultrasound (CE+EUS) compared to CE alone in determining skin and soft tissue infections (SSTIs) that require drainage in pediatric patients. METHODS This was a prospective study of CE+EUS as a diagnostic test for the evaluation of patients 2 months to 19 years of age evaluated for SSTIs in a pediatric emergency department (ED). Two physicians clinically and independently evaluated each lesion, and the reliability of the CE for diagnosing lesions requiring drainage was calculated. Trained pediatric emergency physicians performed US following their CEs. The authors determined and compared the test characteristics for evaluating a SSTI requiring drainage for CE alone and for CE+EUS for those lesions in which the two physicians agreed and were certain regarding their CE diagnosis (clinically evident). The performance of CE+EUS was evaluated in those lesions in which the two physicians either disagreed or were uncertain of their diagnosis (not clinically evident). The reference standard for determining if a lesion required drainage was defined as pus expressed at the time of the ED visit or within 2 days by follow-up assessment. RESULTS A total of 387 lesions underwent CE+EUS and were analyzed. CE agreement between physicians was fair (κ = 0.38). For the 228 lesions for which physicians agreed and were certain of their diagnoses, sensitivity was 94.7% for CE and 93.1% for CE+EUS (difference = -1.7%; 95% confidence interval [CI] = -3.4% to 0%). The specificity of CE was 84.2% compared to 81.4% for CE+EUS (difference = -2.8%; 95% CI = -9.7% to 4.1%). For lesions not clinically evident based on CE, the sensitivity of CE was 43.7%, compared with 77.6% for CE+EUS (difference = 33.9%; 95% CI = 1.2% to 66.6%). The specificity of CE for this group was 42.0%, compared with 61.3% for CE+EUS (difference = 19.3%; 95% CI = -13.8% to 52.4%). CONCLUSIONS For clinically evident lesions, the addition of ultrasound (US) did not significantly improve the already highly accurate CE for diagnosing lesions requiring drainage in this study population. However, there were many lesions that were not clinically evident, and in these cases, US may improve the accuracy of the CE.

Use of Emergency Ultrasound in United States Pediatric Emergency Medicine Fellowship Programs in 2011

The purpose of this study was to evaluate the use of and training in emergency ultrasound (US) in pediatric emergency departments (EDs) with pediatric emergency medicine (EM) fellowship programs. We hypothesized that emergency US use and pediatric EM fellow training have become widespread and that more structured training is being offered.

Reliability of Clinical Examinations for Pediatric Skin and Soft-Tissue Infections

OBJECTIVE: To determine the interrater reliability of clinical examination by pediatric emergency medicine physicians for the diagnosis of skin and soft-tissue infections (SSTIs). METHODS: A cross-sectional study of patients presenting to a pediatric emergency department with SSTIs was performed. Each lesion was examined by a treating physician and a study physician (from a pool of 62 physicians) at the bedside during the emergency department visit. The primary outcome was reliability, as measured with the weighted κ statistic, for determining whether the lesion was an abscess and whether the lesion required a drainage procedure. RESULTS: A total of 371 lesions were analyzed for interrater reliability. The weighted κ value for diagnosis of the lesion as an abscess was 0.39 (95% confidence interval: 0.32–0.47), and that for assessment of the need for drainage was 0.43 (95% confidence interval: 0.36–0.51). Agreement was statistically more likely for lesions in children ≥4 years of age but was not more likely for lesions in nonblack patients, lesions in patients with a history of or exposure to a close contact with a SSTI, or lesions examined by 2 experienced pediatric emergency medicine physicians. CONCLUSIONS: Among the 62 participating physicians at our site, the reliability of the clinical examination was poor. This may indicate that improved education and/or more-objective means for diagnosing these infections in the acute care setting are warranted. Additional studies are needed to determine whether these results are generalizable to other settings.

Inter-Rater Reliability of Quantifying Pleural B-Lines Using Multiple Counting Methods

Sonographic B‐lines are a sign of increased extravascular lung water. Several techniques for quantifying B‐lines within individual rib spaces have been described, as well as different methods for “scoring” the cumulative B‐line counts over the entire thorax. The interobserver reliability of these methods is unknown. This study examined 3 methods of quantifying B‐lines for inter‐rater reliability.

Assessment of a Training Curriculum for Emergency Ultrasound for Pediatric Soft Tissue Infections

OBJECTIVES The objective was to evaluate a training protocol for pediatric emergency physicians (EPs) learning emergency ultrasound (EUS) for the evaluation of skin and soft tissue infections (SSTIs) by assessing technical ability and interrater reliability. METHODS Pediatric emergency medicine (EM) fellows and attending physicians completed a 1-day training course taught by an expert emergency sonologist. After the course, EPs performed proctored examinations on patients with SSTIs until they reached predefined performance criteria, after which they performed independent EUS examinations. All EUS examinations were recorded using still images and video clips that were reviewed and rated by the expert sonologist on four technical measures and combined into a composite score. The experts opinion regarding the presence or absence of an abscess was also compared to the study sonologists opinion and analyzed for interrater reliability. RESULTS Seven EPs performed 107 EUS examinations. The mean (±SD) composite score for the evaluation of technical ability for the first EUS was 3.3 ± 0.14 (on a 4-point scale), indicating a high level of quality following the training course. There was a small amount of improvement in the quality score (0.015, 95% confidence interval [CI] = 0.0003 to 0.03) with each consecutive EUS examination. The interrater reliability between the sonologist and the expert for the presence of an abscess as measured by the kappa statistic was 0.80 (95% CI = 0.63 to 0.97), indicating substantial agreement. CONCLUSIONS After a brief training program, pediatric EPs can perform technically successful emergency EUS examination of SSTIs, with excellent agreement with an expert sonologist.

Foreign body removal from the external auditory canal in a pediatric emergency department

Objectives: To describe the experience with external auditory canal foreign body removal in a pediatric emergency department. To identify factors associated with procedural complications and/or failed removal. Methods: Retrospective case series of patients treated in the emergency department over a 5-year period. Primary outcomes include success and complication rates. Secondary outcomes include removal rates in the otolaryngology clinic and operating room. Results: Physicians in our pediatric emergency department successfully removed 204 (80%) of 254 foreign bodies. In 30 cases (12%), there was a complication. Multiple attempts at removal were associated with failure (relative risk [RR], 6.0; 95% confidence interval [CI], 3.0-12.0) and complications (RR, 3.1; 95% CI, 1.5-6.3). The use of multiple instruments was also associated with failure (RR, 5.4; 95% CI, 2.7-10.8) and complications (RR, 4.0; 95% CI, 2.0-7.6). Of the 244 patients in whom emergency department attempts at removal were made, 26 were successfully removed in otolaryngology clinic, and 14 were removed in the operating room. Foreign bodies present in the canal for more than 24 hours were not at higher risk of failed removal or complications. Patients younger than 4 years also were not at increased risk of having failed removal or complications. Conclusions: Physicians in a pediatric emergency department remove most foreign bodies from the external auditory canal successfully with minimal complications and need for operative removal. These data suggest that referral to otolaryngology be considered if more than 1 attempt or instrument is needed for removal.

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Abdominal Pain in Children

Abdominal pain is one of the most common reasons pediatric patients seek emergency care. The emergency physician must be able to distinguish diagnoses requiring immediate attention from self-limiting processes. Pediatric patients can be challenging, particularly those who are preverbal, and therefore, the clinician must rely on a detailed history from a parent or caregiver as well as a careful physical examination in order to narrow the differential diagnosis. This article highlights several pediatric diagnoses presenting as abdominal pain, including surgical emergencies, nonsurgical diagnoses, and extraabdominal processes, and reviews the clinical presentation, diagnostic evaluation, and management of each.

Abscess volume and ultrasound characteristics of community-associated methicillin-resistant Staphylococcus aureus infection.

Background Skin abscesses may vary in volume and inflammation based on organism, although this has not been evaluated using emergency ultrasonography (EUS). Objective The objective of this study was to examine the utility of EUS in discerning skin abscess volume and inflammation by infecting organism. Methods This was a secondary analysis of prospectively enrolled subjects 2 months to 19 years presenting for a skin abscess. Subjects with a prior drainage procedure, multiple lesions, incomplete EUS measurements, or lack of an abscess culture were excluded. Abscess cavity dimensions in the x, y, and z planes and signs of local inflammation (cobblestoning, hyperechoic, or thickened dermis) were determined. Abscess volume was calculated using the ellipsoid formula: 4/3 &pgr; · (rx) · (ry) · (rz). Results One hundred eighty-eight subjects met the inclusion criteria. Mean age was 7.7 ± 6.2 years; 39.9% were male. The gluteal region was most commonly involved (33.0%), and lesions were present for a mean 4.2 days (95% confidence interval [CI], 3.8–4.6 days). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from 125 (66.5%); methicillin-sensitive S. aureus (21.8%) was most common among non-MRSA lesions. Abscess volume was smaller in MRSA (1.12 cm3) compared with non-MRSA (2.46 cm3) lesions (mean difference, −1.33 cm3; 95% CI, −2.21 to −0.47 cm3). No differences between MRSA and non-MRSA lesions were present for EUS signs of inflammation. When adjusting for age, duration of lesion, and spontaneous drainage, smaller abscess volumes were associated with MRSA infection (odds ratio, 0.83; 95% CI, 0.71–0.97). Using an optimal threshold value of 1.32 cm3, sensitivity and specificity for non-MRSA lesion were 50.8% and 81.5%, respectively. Conclusions Methicillin-resistant S. aureus infection is statistically negatively associated with abscess volume, although of limited predictive ability. Findings using EUS suggest that MRSA does not differ from other organisms with respect to size and inflammation. Clinicians should not consider unique treatment for the presence of MRSA abscess based on these EUS findings.