Nirupama Kannikeswaran

The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED

BACKGROUNDnPresentation of skin and soft tissue infections (SSTIs) to the pediatric emergency department (PED) has increased. Physical examination alone can be inadequate in differentiating cellulitis from an abscess. The purposes of this study were to determine the effect of bedside ultrasound (US) in improving diagnostic accuracy for SSTIs in the PED and to evaluate its effect on the management of patients with SSTIs.nnnMETHODSnWe conducted a prospective study of a convenience sample of children who presented to an inner-city PED with signs and symptoms of SSTI. The treating physicians pretest opinions regarding the need for incision and drainage and procedural sedation were collected. A bedside US was performed by trained PED physicians to evaluate for cellulitis vs abscess. The treating physician was made aware of the US findings, and the effect on management was recorded.nnnRESULTSnSixty-five patients were enrolled, of whom 47 had US-proven abscess and 18 had cellulitis. The sensitivity of US for detection of abscess was 97.5% (95% confidence interval [CI], 90.1%-99.5%), and the specificity was 69.2% (95% CI, 57.8-72.4%). In comparison, the sensitivity for physical examination alone for detection of abscess was 78.7% (95% CI, 71.4%-84.4%), and the specificity was 66.7% (95% CI, 47.6-81.6%). Ultrasound disagreed with clinical examination and changed management in 9 (13.8%) of 65 patients.nnnCONCLUSIONSnEmergency department bedside US improves accuracy in diagnosis of SSTIs. Bedside US changes management in a small but significant number of patients with SSTIs.

Sedation medication received and adverse events related to sedation for brain MRI in children with and without developmental disabilities.

Background:u2002 There are few studies on sedation medication requirements and sedation related adverse events in developmentally disabled children.

Post tonsillectomy hemorrhage: Who needs intervention?

BACKGROUNDnPost-tonsillectomy hemorrhage (PTH) remains a significant complication. There are no guidelines for Pediatric Emergency Department (PED) disposition of children with secondary PTH.nnnOBJECTIVESnTo describe the incidence, clinical characteristics and interventions required by children presenting to a PED with secondary PTH. To identify patient and clinical characteristics associated with need for operative/inpatient intervention.nnnMETHODSnRetrospective chart review of healthy children 1-18 years with secondary PTH from 2005 to 2012. Demographics, clinical and oropharynx findings, laboratory data, intervention type and ED disposition were recorded.nnnRESULTSnWe encountered 181 children with 193 episodes of PTH. One hundred and twenty one patients were included in the final analysis. Secondary PTH rate was 2.3%. Only a minority of patients were hypotensive (3.3%) or had hemoglobin<10g/dl (9.5%) at presentation. 65.3% Children had positive oropharyngeal exam: clot 39 (49.4%) patients; ooze 17 (21.5%) patients; ooze+clot in 5 (6.3%) patients or active bleeder in 18 (22.8%) patients. Eighty seven (71.9%) patients were admitted; 74 (61.1%) patients required active intervention: medical 14.8%, surgical 74.4% or both 10.8%. Thirty seven children needed immediate operative intervention. Only positive oropharyngeal exam and age ≥6 years were significantly associated with need for intervention. None of the patients with a confirmed normal oropharyngeal exam at the initial visit required any intervention either medical or surgical. The rate of return visit for recurrent PTH was found to be similar for both the admitted and the discharged group. No patient returned with a life threatening hemorrhage.nnnCONCLUSIONSnMajority of children with secondary PTH were admitted and nearly 3/5th of them required an intervention. Our data suggests that healthy children <6 years with a confirmed normal oropharyngeal exam are less likely to require an intervention and may be candidates for safe discharge from the ED provided reliability of return for recurrence can be assured.

Utility of endtidal carbon dioxide monitoring in detection of hypoxia during sedation for brain magnetic resonance imaging in children with developmental disabilities

Background:u2002 We have shown previously that children with developmental disabilities have three times higher incidence of sedation‐related hypoxia when compared with normal children.

Safety of procedural sedation and analgesia in children less than 2 years of age in a pediatric emergency department.

BackgroundAlthough young age is considered a risk factor for adverse events related to procedural sedation and analgesia (PSA), data in very young children (<2xa0years of age) are lacking.AimsThe main objective of our study is to describe PSA in children <2xa0years of age in an inner city tertiary care pediatric emergency department (PED).MethodsWe conducted a retrospective chart review from January 2005 to June 2007 of children <2xa0years of age who received PSA in our PED. We collected demographic variables, indication for and medications used for PSA, adverse events (AE) related to PSA, and interventions performed to treat them.ResultsOf the children who received PSA, 14.5% (180/1,235) were <2xa0years of age of whom 173 were included for the analysis; 73% (126/173) of the study subjects were between 1 and 2xa0years of age, 54.3% (94/173) were male, and 96.5% (167/173) belonged to American Society of Anesthesiologists class 1. Incision and drainage (45.0%, 78/173) and laceration repair (32.4%, 56/173) were the two most common indications for PSA. Ketamine and midazolam was the most common combination medication used for PSA (62.4%, 108/173). Sedation was deemed ineffective in 5.8% (10/173) of the children. There were only two failed sedations; 5.8% (10/173) of the children experienced AE with most being minor [oxygen desaturations 1.7% (3/173), emesis 2.3% (4/173), and others 1.2% (2/173)]. One child experienced serious AE in the form of apnea and bradycardia requiring intubation.ConclusionsOur data suggest that children under 2xa0years of age can be sedated effectively without increased risk of AE in a PED.

Optimal dosing of intravenous ketamine for procedural sedation in children in the ED—a randomized controlled trial

OBJECTIVEnThe objective of the study is to compare need for redosing, sedation efficacy, duration, and adverse events between 3 commonly administered doses of parenteral ketamine in the emergency department (ED).nnnMETHODSnWe conducted a prospective, double-blind, randomized controlled trial on a convenience sample of children 3 to 18years who received intravenous ketamine for procedural sedation. Children from each age group (3-6, 7-12, and 13-18years) were assigned in equal numbers to 3 dosing groups (1, 1.5, and 2mg/kg) using random permuted blocks. The primary outcome measure was need for ketamine redosing to ensure adequate sedation. Secondary outcome measures were sedation efficacy, sedation duration, and sedation-related adverse events.nnnRESULTSnA total of 171 children were enrolled of whom 125 (1mg/kg, 50; 1.5mg/kg, 35; 2mg/kg, 40) received the randomized dose and were analyzed. The need for ketamine redosing was higher in the 1mg/kg group (8/50; 16.0% vs 1/35; 2.9% vs 2/40; 5.0%). There was no significant difference in the median Ramsay sedation scores (5.5 [interquartile range {IQR}, 4-6] vs 6 [IQR, 4-6] vs 6 [IQR, 5-6]), FACES-R score (0 [IQR, 0-4] vs 0 [IQR, 0-0] vs 0 [IQR, 0-0]), sedation duration in minutes (23 [IQR, 19-38] vs 24.5 [IQR, 17.5-34.5] vs 23 [IQR, 19-29]), and adverse events (10.0% vs 14.3% vs 10.0%) between the 3 dosing groups. Physician satisfaction was lower in the 1mg/kg group (79.6% vs 94.1% vs 97.3%).nnnCONCLUSIONSnAdequate sedation was achieved with all 3 doses of ketamine. Higher doses did not increase the risk of adverse events or prolong sedation. Ketamine administered at 1.5 or 2.0mg/kg intravenous required less redosing and resulted in greater physician satisfaction.

Effect of a rapid assessment program on total length of stay in a pediatric emergency department

Objectives: Wait times and length of stay (LOS) measure efficiency of care in pediatric emergency departments (PEDs). Our hospital introduced a rapid assessment program (RAP) wherein patients will be seen by a physician within 29 minutes of arrival to the PED. Our primary objective was to evaluate the impact of this RAP on total LOS and compare it with the pre-RAP period. The secondary objective was to compare door-to-physician times and admission frequencies. Methods: We conducted an observational study of randomly selected visits before (in 2004) and after (in 2005) RAP in a PED. Data were acquired retrospectively from charts. We compared total LOS (time from arrival at triage to discharge), boarding time (time from the decision to admit to transfer to inpatient bed), door-to-physician time (arrival at triage to first evaluation by physician), and admission frequencies. Results: Data from 990 visits (in 2004) and 1010 visits (in 2005) indicated similar age, sex, seasonal distribution, and weekday distribution. The total median LOS decreased by 37 minutes with RAP (103 [interquartile range {IQR}, 57-187] minutes in 2005 vs 140 [IQR, 78-234] minutes in 2004, P < 0.001) but only among lower triage categories. Median door-to-physician time decreased by 20 minutes with RAP (15 [IQR, 7-29] minutes in 2005 vs 35 [IQR, 18-72] minutes in 2004, P < 0.001) among lower triage categories. The LOS was reduced both in admitted and discharged patients with no difference in the boarding times or admission frequencies. Conclusions: In our PED, a RAP reduced the total LOS of patients with lower acuity of illness.

Concomitant hypercalcemia and hyperammonemia associated with distal renal tubular acidosis.

We describe an infant with concomitant hypercalcemia and hyperammonemia associated with nonanion gap metabolic acidosis secondary to distal renal tubular acidosis (dRTA). The levels of both serum calcium and ammonia rapidly normalized with the correction of dehydration and metabolic acidosis. To the best of our knowledge, there has been only one previous case report of concomitant hypercalcemia and hyperammonemia associated with dRTA that has been reported in the literature. We describe the causes and emergent management of hypercalcemia and review the possible mechanisms of this rare association with dRTA.

Acute Facial Asymmetry

A7-year-old, previously healthy African American girl was brought to the emergency department by her mother, who noticed asymmetry of her daughter’s face when she woke up in the morning. There is no history of trauma, weakness in any part of the body, fever, ear pain, ear discharge, or loss or change in the level of hearing from either ear. Her past medical history along with developmental history was normal. She had not traveled anywhere recently and her immunizations were up to date. Physical examination revealed an alert, well-appearing child in no apparent distress. Her head, ear, and neck examination revealed bilateral normal translucent ear drums with grossly normal hearing. An obvious asymmetry was noted in her face. She was unable to close her left eye completely (Figure 1), her left nasolabial folds was flattened (Figure 2), liquids drooled from the left side of her mouth when she was asked to drink, and she was unable to raise the eyebrow on left (Figure 3). A detailed neurological examination revealed that her higher functions were intact and so were the rest of the cranial nerves. Her sensations were intact on either side of her face and body and there was no abnormality in her power or range of movements at any joint. Her gait was normal and so were her cerebellar functions. Her skin was warm and well perfused without any rashes. There was no joint swelling. The rest of her physical examination was normal. In view of her clinical examination findings, a diagnosis of Bell palsy was made, an ear, nose, and throat (ENT) consult was obtained and the child was sent home with acyclovir, prednisone in tapering doses, and artificial tears with instructions to follow up with ENT and physical therapy. Discussion

Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department.

OBJECTIVESnPrescription errors occur frequently in pediatric emergency departments (PEDs).The effect of computerized physician order entry (CPOE) with electronic medication alert system (EMAS) on these is unknown. The objective was to compare prescription errors rates before and after introduction of CPOE with EMAS in a PED. The hypothesis was that CPOE with EMAS would significantly reduce the rate and severity of prescription errors in the PED.nnnMETHODSnA prospective comparison of a sample of outpatient, medication prescriptions 5xa0months before and after CPOE with EMAS implementation (7,268 before and 7,292 after) was performed. Error types and rates, alert types and significance, and physician response were noted. Medication errors were deemed significant if there was a potential to cause life-threatening injury, failure of therapy, or an adverse drug effect.nnnRESULTSnThere was a significant reduction in the errors per 100 prescriptions (10.4 before vs. 7.3 after; absolute risk reductionxa0= 3.1, 95% confidence interval [CI]xa0=xa02.2 to 4.0). Drug dosing error rates decreased from 8 to 5.4 per 100 (absolute risk reductionxa0= 2.6, 95% CIxa0=xa01.8 to 3.4). Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. The sensitivity of CPOE with EMAS in identifying errors in prescriptions was 45.1% (95% CIxa0=xa040.8% to 49.6%), and the specificity was 57% (95% CIxa0=xa055.6% to 58.5%). Prescribers modified 20% of the dosing alerts, resulting in the error not reaching the patient. Conversely, 11% of true dosing alerts for medication errors were overridden by the prescribers: 88 (11.3%) resulted in medication errors, and 684 (88.6%) were false-positive alerts.nnnCONCLUSIONSnA CPOE with EMAS was associated with a decrease in overall prescription errors in our PED. Further system refinements are required to reduce the high false-positive alert rates.