Emergency ultrasound diagnosis of deep venous thrombosis in the pediatric emergency department: a case series

The diagnosis of deep venous thrombosis (DVT) in patients presenting to the emergency department (ED) has traditionally been limited to examinations by radiologists and ultrasound technicians. Although contrast venography is considered the criterion standard for diagnosis of DVT, time, personnel, cost, exposure to radiation, and the invasive nature of the study (need for venous access) potentially limit the ability to perform the study in an emergent setting. Ultrasonography is an alternative method for thrombus detection and is widely preferred. However, in many health care settings, consultative ultrasound services may not be available immediately, especially after hours and on weekends. Based on recent studies demonstrating accuracy in adult patients, emergency sonographic evaluation of DVT by emergency physicians is considered a core emergency ultrasound application and is recently recommended as standard training to all emergency medicine residents. The diagnosis of DVT in children by emergency ultrasound in the pediatric ED has not been previously described. We present 3 cases of DVT in adolescents identified by emergency ultrasound evaluation in the pediatric ED.     

Recurrent pleural effusions in a neonate

Difficulty breathing is a common presenting complaint for infants in the emergency department (ED). Periodic breathing, respiratory or systemic infection, and congenital heart disease are common diagnoses in this age group. We report the case of a male neonate presenting to the ED on multiple occasions with respiratory distress and recurrent pleural effusions of unique origin. Unlike adult pleural effusions, pediatric effusions are most commonly exudative and of infectious origin. In neonates, acquired chylothorax secondary to surgery or trauma is the most common cause of symptomatic pleural effusions. Congenital chylothorax is a rare entity that has not been presented in the emergency medicine literature. This case illustrates the extremely rare ED presentation of congenital chylothorax and outlines an approach to pediatric pleural effusions.     

Novel applications of ultrasound in pediatric emergency medicine

A new field, termed emergency ultrasound (EUS), has recently been established. The past decade saw rapid development in the field of EUS in adult patients, especially as performed by emergency medicine physicians. Ultrasound imaging offers several advantages over traditional radiographic techniques, many of which are especially relevant to patients in the pediatric emergency department. Recent literature has documented increased use of EUS for pediatric patients. This review will examine basic principles of ultrasound relevant to pediatric emergency medicine physicians. Emphasis will be placed on understanding the instrument and its limitations. In addition, we will review recent developments in this field. It is our goal that the reader will gain an understanding of the strengths and limitations of this instrument and will therefore be in a position to plan their own program in EUS in pediatrics. Furthermore, it is hoped that this review will serve as an impetus for innovative research, to refine and extend the indications of this modality to benefit patients in the pediatric emergency department.     

Bedside ultrasound in pediatric emergency medicine

Bedside emergency ultrasound has been used by emergency physicians for >20 years for a variety of conditions. In adult centers, emergency ultrasound is routinely used in the management of victims of blunt abdominal trauma, in patients with abdominal aortic aneurysm and biliary disease, and in women with first-trimester pregnancy complications. Although its use has grown dramatically in the last decade in adult emergency departments, only recently has this tool been embraced by pediatric emergency physicians. As the modality advances and becomes more available, it will be important for primary care pediatricians to understand its uses and limitations and to ensure that pediatric emergency physicians have access to the proper training, equipment, and experience. This article is meant to review the current literature relating to emergency ultrasound in pediatric emergency medicine, as well as to describe potential pediatric applications.     

The art of communication: strategies to improve efficiency, quality of care and patient safety in the emergency department

The practice of pediatric emergency medicine (PEM) has been supported by wonderful advancements in diagnostic testing, particularly in medical imaging. One of the most remarkable has been CT, which has arguably become our most valuable diagnostic tool in the emergency department (ED). PEM specialists have grown increasingly aware of quality and safety concerns in the care of children in emergency medical settings, spurred in part by a rapid growth in ED utilization and significant overcrowding. In the midst of this comes the revelation that one of our most valued diagnostic tools might place our youngest patients at a significant risk for the development of fatal cancer. This article reinforces the fundamental importance of communication and teamwork as a means to promote patient care quality and safety in the ED, and it offers partnership strategies for PEM and pediatric radiology specialists to consider as they address these important concerns.     

Patient complaints in a pediatric emergency department: averting lawsuits

All emergency departments (EDs) receive complaints from patients and their families. Consumers of pediatric emergency care are becoming more astute about the care they receive, and the malpractice climate is rapidly changing. In order to improve patient care services and reduce the frequency of lawsuits, it is crucial that pediatric emergency medicine physicians become facile at preventing and managing such complaints. All ED physicians should have a well-defined complaint management process in place. Lessons learned from the complaints should be shared with the ED health care providers. Complaints can illustrate the deficiencies in the provision of care and serve as an opportunity for improvement.     

Effectiveness of a pediatric trauma team protocol

OBJECTIVE: To determine the effectiveness of a pediatric trauma triage system and resource allocation for emergency medicine and trauma services. TRAUMA SYSTEM: Two-tier trauma team activation system that triages patients into Level 1 and Level 2 trauma alert categories based on information provided by pre-hospital providers to pediatric emergency physicians at an American College of Surgeons' Level 1 pediatric trauma center in Columbus, Ohio. METHODS: Using the hospital trauma registry database and patient medical records, a retrospective chart review was conducted on all (n = 542) admitted pediatric trauma patients from January 1995 through December 1996. RESULTS: Level 1 patients had a higher median injury severity score and shorter emergency department (ED) length of stay time than Level 2 patients. Level 1 patients were more likely to be admitted to the pediatric intensive care unit and remain for more than 24 hours when compared to Level 2 patients. In addition, Level 1 patients were more likely to have procedures performed (eg, intubation, tube thoracostomy, thoracotomy, diagnostic peritoneal lavage) than Level 2 patients. The mortality rate was significantly higher for Level 1 patients and all ED deaths had been triaged to the Level 1 category. CONCLUSIONS: This pediatric trauma triage system effectively predicts which patients will be more likely to have serious injury. By using a two-tier system, select patients may be managed by a smaller trauma team, thus improving staff utilization and possibly reducing costs while ensuring favorable outcomes.     

Standards for clinical evaluation and documentation by the emergency medicine provider

Pediatric emergency medicine is full of challenges. When a pediatric patient has a poor outcome after treatment in an emergency department (ED), a malpractice lawsuit is likely to result. Pediatric emergency medicine (PEM) physicians might sometimes alter their medical care and practice "defensive medicine" in hopes of avoiding a malpractice lawsuit. Radiographs and other diagnostic studies might be ordered without true indications to "completely rule out" a diagnosis. This can result in excess radiation for a child. On the other hand, failure to order the appropriate study or misinterpretation of a radiographic study by a radiologist or an emergency physician can result in a malpractice lawsuit. PEM physicians must work cooperatively with radiologists to improve the care for children in the ED. Together these specialists can decide on appropriate studies for children in the ED, keep radiation exposure to a minimum and ensure proper management based on these studies.     

Severe Hypertension in a 4-Year-Old Child

The diagnosis and management of acute pediatric hypertension in the ED aim to minimize end-organ dysfunction. Severe hypertension is often due to a secondary cause for which a systems-based approach can guide the development of a pertinent differential diagnosis. Traditionally, history, physical examination, and laboratory data guide the initial narrowing of the differential. When a vascular cause is suspected, echocardiography and/or CT imaging will often lead to a diagnosis. This case demonstrates that ED ultrasound is both effective and rapid in facilitating the ability to make this diagnosis. It may also assist in quickly ruling out other diagnoses before any other imaging studies are performed or laboratory values seen. The learning curve for emergency ultrasound is relatively low, and its use can lead to improved outcomes with relatively little risk to the patient. Finally, for treatment of a hypertensive emergency or urgency, a handful of medications that decrease peripheral vascular resistance can provide immediate blood pressure control. However, some agents may be more effective for certain causes, furthering the need to establish a timely diagnosis.     

Telehealth as a Tool for Quality Improvement in the Care of Pediatric Patients in Community Emergency Departments

Nearly 90% of pediatric emergency care is provided in a general emergency department (ED) that serve both adults and children. Many children in the United States do not live near an ED with a high level of pediatric readiness and many children are transferred to dedicated pediatric centers. Telemedicine provides an opportunity to impact care delivery systems to allow for children to be treated closer to home while maintaining high quality care. In this article, we will explore opportunities to use telemedicine in the emergency department and discuss incorporating quality improvement methodology to increase utilization of telehealth services.     

Ultrasound equipment for the pediatric emergency department: a review

Ultrasound is gaining momentum for use in the pediatric emergency department. It is important to understand the fundamentals of ultrasound equipment as it relates to pediatric emergency medicine.     

Association of emergency department care factors with admission and discharge decisions for pediatric patients

OBJECTIVE: We evaluated overutilization or underutilization of inpatient resources to measure the emergency department (ED) decision-making process and its association with the following care factors: annual pediatric volume, presence or absence of a pediatric emergency medicine specialist; and presence or absence of ED residents. STUDY DESIGN: Block random selection, using the three care factors, of 16 hospitals with pediatric intensive care units. The Pediatric Risk of Admission (PRISA II) Score was used to measure illness severity. Decision-making was evaluated for admissions (Admission Index: observed minus predicted admissions) and returns (Return Index: observed minus predicted 72-hour returns). The Combined Index was a weighted average of the Admission and Return Indexes. RESULTS: There were 11,664 patients enrolled. Residents but not volume or pediatric emergency medicine specialists were associated with the decision-making performance indexes in multivariable analysis (no residents versus residents: Admission Index: 2.5 of 1000 patients versus 34.8 of 1000, P = .082; Return Index: -3.0 of 1000 versus 33.6 of 1000, P = .039; Combined Index: 1.9 of 1000 versus 35.5 of 1000, P = .024. CONCLUSIONS: There is significant variability in ED decision-making for children. Residents but not volume or presence of a pediatric emergency medicine specialist are associated with increased differences in admission decisions. The process by which these differences occur was not investigated.     

Emergency physician perspectives on child passenger safety: a national survey of attitudes and practices

ObjectiveTo understand attitudes and self-reported practices of pediatric and general emergency physicians regarding child passenger safety.MethodsWe conducted a cross-sectional mailed national survey of 600 pediatric emergency medicine (PEM) physicians and 600 emergency medicine (EM) physicians who provide clinical care in the United States randomly sampled from the American Medical Association Physician Masterfile. Survey questions explored attitudes related to the role of the physician and the emergency department (ED) in child passenger safety and self-reported frequency of performing specific child passenger safety practices.ResultsResponses were received from 638 of 1000 (64%) eligible physicians with a valid mailing address. Surveys were completed by 367 PEM and 271 EM physicians. Regardless of their training background, emergency physicians overwhelmingly agreed that it is their role to educate parents about child passenger safety (95% PEM vs 82% EM) and that they can make a difference in how parents restrain their child (92% PEM vs 93% EM). Physicians were similar in their views that the most appropriate person to provide child passenger safety information in their ED was a nurse/midlevel provider followed by a physician. Self-report of child passenger safety practices in response to 2 hypothetical scenarios showed physicians infrequently provide best-practice safety recommendations to families.ConclusionsEmergency physicians are supportive of the ED as a setting to promote child passenger safety, yet do not consistently promote child passenger safety themselves. Differences between PEM and EM physicians’ attitudes toward child passenger safety may necessitate different approaches on injury prevention in general and pediatric EDs.     

Emergency department presentation of pediatric stroke

Pediatric stroke is not a common occurrence. When compared with adults, the pediatric population has a much more diverse group of risk factors, and while numerous rare congenital disorders are possible, most known etiologies are cardiac, vascular, or hematologic. The emergency department (ED) presentation of pediatric stroke does not differ greatly from that of adults, although posterior circulation ischemia is less common, and neurologic findings may be more difficult to recognize. ED treatment is also largely the same, with an attention to resuscitation and avoidance of hypoxia, hypotension, hyperthermia, and changes in blood sugar. Use of specialized agents such as aspirin and heparin should be considered in certain cases. It is important for the emergency physician to recognize acute neurologic events in pediatric patients to minimize complications.     

Regionalization of pediatric emergency care in Korea

In order to care for an ill or injured child, it is crucial that every emergency department (ED) has a minimum set of personnel and resources because the majority of children are brought to the geographically nearest ED. In addition to adequate preparation for basic pediatric emergency care, a comprehensive, specialized healthcare system should be in place for a critically-ill or injured victim. Regionalization of healthcare means a system providing high-quality and cost-effective care for victims who present with alow frequency, but critical condition, such as multiple trauma or cardiac arrest. Within the pediatric field, neonatal intensive care and pediatric trauma care are good examples of regionalization. For successful regionalized pediatric emergency care, all aspects of a pediatric emergency system, from pre-hospital field to hospital care, should be categorized and coordinated. Efforts to set up the pediatric emergency care regionalization program based on a nationwide healthcare system are urgently needed in Korea.     

Substernal Chest Pain with an Abnormal Electrocardiogram in an Adolescent Male Presenting to a Pediatric Emergency Department

This case illustrates the unique issues facing pediatric emergency medicine physicians when evaluating a patient for a suspected MI. It also highlights the challenges of managing a disease process that is rarely encountered in the pediatric ED but is associated with high risk. Although timely diagnosis is a key to improved outcome, diagnosis can be difficult because of the infrequent occurrence of MI in the pediatric population. Optimal management requires advanced planning as well as collaboration between pediatric and adult subspecialists, with interfacility transfer when appropriate.     

The Pediatric Emergency Care Applied Research Network (PECARN): rationale,development, and first steps

Since its formal recognition as a medical specialty, the field of pediatric emergency medicine has made substantial advances with respect to its scope and sophistication. These advances have occurred in clinical practice as well as in the research base to improve clinical practice. There remain, however, many areas in emergency medical services for children (EMSC) in the out-of-hospital, emergency department (ED), and hospital settings that suffer from a lack of data to guide practice. In an effort to expand the quality and quantity of research in pediatric emergency care, the Pediatric Emergency Care Applied Research Network (PECARN) was created in October of 2001. PECARN is the first federally funded national network for research in EMSC and is the result of cooperative agreement grants funded through the Health Resources and Services Administration with the purpose of developing an infrastructure capable of overcoming inherent barriers to EMSC research. Among these recognized barriers are low incidence rates of serious pediatric emergency events, the need for large numbers of children from varied backgrounds to achieve broadly representative study samples, lack of an infrastructure to test the efficacy of pediatric emergency care, and the need for a mechanism to translate study results into clinical practice. PECARN will serve as a national platform for collaborative research involving the continuum of care within the EMSC system, including out-of-hospital care, patient transport, ED and in-hospital care, and rehabilitation. This article describes the history of EMSC, the need for a national collaborative research network in EMSC, the organization and development of PECARN, and the work plan for the network.     

Most frequently missed fractures in the emergency department

This study quantified the types of extremity fractures most commonly missed on plain radiographs by pediatric emergency medicine specialists after an initial emergency department (ED) encounter. From February 2006 to June 2009, extremity radiographs obtained in a pediatric ED in which a radiologist categorized the ED attendings' read of normal as incorrect were tabulated. The authors also counted the total number of each type of radiograph completed when radiologists were unavailable. The percentage of each type of fracture missed was calculated based on the total number of missed fractures. It was found that a total of 220 fractures were missed during ED encounters in the study period. The most frequently missed fractures were of the hand phalanges (26.4%) followed by metatarsus (9.5%), distal radius (7.7%), tibia (7.3%), and phalanges of the foot (5.5%). Emergency physicians should be aware that the most commonly missed fractures were phalanges of the hand and metatarsal fractures.