Kerry Caperell

Race and Acute Abdominal Pain in a Pediatric Emergency Department

OBJECTIVE: To investigate the demographic and clinical factors of children who present to the pediatric emergency department (ED) with abdominal pain and their outcomes. METHODS: A review of the electronic medical record of patients 1 to 18 years old, who presented to the Children’s Hospital of Pittsburgh ED with a complaint of abdominal pain over the course of 2 years, was conducted. Demographic and clinical characteristics, as well as visit outcomes, were reviewed. Subjects were grouped by age, race, and gender. Results of evaluation, treatment, and clinical outcomes were compared between groups by using multivariate analysis and recursive partitioning. RESULTS: There were 9424 patient visits during the study period that met inclusion and exclusion criteria. Female gender comprised 61% of African American children compared with 52% of white children. Insurance was characterized as private for 75% of white and 37% of African American children. A diagnosis of appendicitis was present in 1.9% of African American children and 5.1% of white children. Older children were more likely to be admitted and have an operation associated with their ED visit. Appendicitis was uncommon in younger children. Constipation was commonly diagnosed. Multivariate analysis by diagnosis as well as recursive partitioning analysis did not reflect any racial differences in evaluation, treatment, or outcome. CONCLUSIONS: Constipation is the most common diagnosis in children presenting with abdominal pain. Our data demonstrate that no racial differences exist in the evaluation, treatment, and disposition of children with abdominal pain.

Is higher ASA class associated with an increased incidence of adverse events during procedural sedation in a pediatric emergency department

Objective: To prospectively investigate whether American Society of Anesthesiologists (ASA) class, as assigned by nonanesthesiologists, is associated with adverse events during procedural sedation in a pediatric emergency department. Methods: A prospectively collected database of children aged 0 to 21 years undergoing procedural sedation in the emergency department of an urban, tertiary care, childrens hospital was retrospectively reviewed. This database included clinical and demographic characteristics, including assigned ASA class. It also included information relative to the procedure, the sedation, and any complications related to the sedation. Complications were defined a priori as persistent oxygen desaturation to less than 93% on pulse oximetry requiring supplemental oxygen, bronchospasm, dizziness, apnea, seizure, hiccoughs, laryngospasm, stridor, arrhythmia, hypotension, rash, vomiting, aspiration, or a disinhibition/agitation/dysphoria emergence reaction. Main outcome measure was the incidence of complications relative to ASA class. Results: Procedural sedation was performed in the emergency department 1232 times during the study period; 30 sedations did not have either ASA class or occurrence of a complication recorded. Thus, 1202 sedations were included in the study. Nine hundred eighty-eight patients were classified as ASA class 1, whereas 214 were classified as ASA class 2 or greater. There were a total of 215 adverse events in the study population. Most of these were hypoxia (185 total) and were more likely to occur in patients with an ASA class 2 or greater (P = 0.021). Conclusions: Adverse events during procedural sedation are more common in patients with higher ASA class.

Seasonal variation of presentation for headache in a pediatric emergency department.

Objectives Headache is a common pediatric complaint. Our experience indicated that there was a seasonal variation in children seeking emergency department (ED) care for headache. We hypothesized that visits to the ED would be more common during the school year compared with that during the summer months. Methods Electronic medical record data were reviewed from January 1, 2008 through June 30, 2010. All patients age 4 years and older with a chief complaint of headache were examined. Patients with ventriculoperitoneal shunts, intracranial mass, trauma, or stroke were excluded. The following data were accumulated: date of visit, birth date, sex, race, and diagnosis. Visits were grouped by month of occurrence and school year (September through May) and non–school year (June through August). Cumulative binomial probabilities were used to determine the likelihood of experiencing the observed number of occurrences or fewer in each period. Results A total of 2731 visits met the inclusion and exclusion criteria. Girls were older, more likely to be white, and more likely to be diagnosed with migraine. There is a clear nadir in May and June and a peak in September, October, and November that is statistically significant (P< 0.001) across age groups, sex, race, and headache type. These findings persisted when comparing the groups based on school year versus non–school year. Conclusions Visits to the ED for headache were less common in May and June and more common during the fall. This remained true across headache type, age, sex, and racial groups.

Concussion Management in the Classroom

There is a new emphasis on the team approach to pediatric concussion management, particularly in the classroom. However, it is expected that educators are unfamiliar with the “Returning to Learning” recommendations. The authors’ primary objective was to assess and improve high school educators’ knowledge regarding concussions and management interventions using an online education tool. A total of 247 high school educators completed a 12 question pretest to assess core knowledge of concussions and classroom management followed by a 20-minute online literature-based education module. Participants then completed an identical posttest. The improvement in core knowledge was statistically significant (P < .001). Initial areas of weakness were the description and identification of concussions. Questions regarding concussion classroom management also showed a statistically significant increase in scores (P < .001). This study identifies the deficits in the knowledge of educators regarding concussions and classroom management as well as the significant improvement after an online educational module.

Ropivacaine Intramuscular Paracervical Injections for Pediatric Headache: A Randomized Placebo-Controlled Trial

Study objective: We seek to determine whether ropivacaine cervical paraspinal injections compared with normal saline solution injections provide headache relief to pediatric patients that is sufficient for emergency department (ED) discharge. Methods: We enrolled children aged 7 to 17 years in a double‐blinded, randomized, controlled trial of patients presenting to a pediatric ED with headache. Subjects were randomized into 1 of 3 groups: bilateral cervical paraspinal injections of either (1) 0.5% ropivacaine or (2) normal saline solution, or (3) a natural history group (not blinded) receiving no headache therapy for the first 30 minutes. Pain scores were assessed at enrollment and at 10‐, 20‐, and 30‐minute intervals after the administration of the injections. After the intervention period of 30 minutes, additional therapy was provided as needed. Primary outcome was the proportion of children discharged with adequate pain relief at 30 minutes without additional therapy. Secondary outcomes included reduction in pain scores, reoccurrence of headache, and re‐presentation to health care with headache. Results: One hundred fifty‐three children were enrolled. The proportion discharged with adequate pain relief 30 minutes after the injections did not differ between the 2 intervention groups (32% in the ropivacaine group versus 28% in the saline solution group; effect difference 4%; 95% confidence interval −14% to 21%). In contrast, only 4% percent of patients in the natural history group were discharged without additional therapy after the 30‐minute assessment. Reduction of pain scores (2.0 and 2.2 in ropivacaine versus saline solution), headache reoccurrence, and return to care was similar between the 2 treatment groups. Conclusion: Cervical paraspinal injections of either ropivacaine or saline solution were effective for approximately one third of patients.

Monthly variation in pediatric visits for headache to US emergency departments

Headache is a common pediatric symptom often associated with stress and fatigue which may be more common during the school year. The purpose of this study is to determine if visits for headache are more common during the months of the school year. This study is a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) database from 2001 to 2010. Patient visits in those aged 18 years or younger not associated with injury were examined. Only visits with an International Classification of Diseases, ninth revision (ICD-9) code consistent with headache were included. Data were analyzed using cumulative binomial probabilities. This statistic was used to establish the chance of seeing up to the observed number of visits for headache in a given month assuming that all months have an equal number of visits. A total of 660 unweighted visits representing 3.2 million patient encounters met the inclusion and exclusion criteria. Visits for headache were more common during the months of January, September, and October and less common in March, April, July, and November. Subgroup analysis was performed for children aged 13–18 years. In this subgroup, headaches were more common in January, September, and October. They were less common in July and December. Headache is more common during the first 2 months back to school in the fall as well as after the winter break in January. While we are not able to establish causality, we propose that children with headache require additional attention during the school year, particularly in the months following summer and winter breaks.

The Utility of Head Computed Tomography in the Evaluation of Apparent Life-threatening Event

Objective This study aimed to evaluate the diagnostic utility of empiric head computed tomography (CT) in apparent life threatening event (ALTE). Methods This was a retrospective chart review of children younger than 12 months presenting to an urban pediatric hospital and its suburban satellite for an ALTE from October 2009 to December 2012. The ALTE cases were identified as having had a diagnosis of ALTE (International Classification of Diseases, 9th Revision 799.82) or as having had a constellation of studies performed consistent with our institutional protocol for ALTE evaluation. Exclusion criteria were known trauma and cases lacking an identifiable ALTE feature on review. Results There were 631 cases identified, of which 617 met inclusion and exclusion criteria. Of those, 537 had a head CT performed. Five patients were identified with clinically important head CT findings: a case of congenital toxoplasmosis, a case of intraventricular hemorrhage, and 3 cases of nonaccidental trauma (NAT). One of the NAT patients had a bruise on his forehead; the other patients had no historical, physical examination, and other laboratory or radiologic findings to raise concern for significant finding on head CT. The rate of clinically significant findings and occult clinically significant findings was 5/537 (0.93%) (95% confidence interval, 0.30%–2.16%; number needed to treat = 108) and 4/537 (0.75%) (95% confidence interval, 0.20%–1.90%; number needed to treat = 135), respectively. Conclusions The rate of clinically important head CT findings in ALTE evaluation was relatively rare, at 0.93%. Given the severe consequences of missing these cases, these data establish a role for empiric head CT in the evaluation of ALTE.