The correct initial diagnostic imaging test to evaluate pediatric abdominal pain for appendicitis is an ultrasound. It carries none of the risks associated with CT imaging – except for the increased risk of a non-diagnostic evaluation. It is also highly operator dependent and suffers in centers without sufficient volume of abdominal ultrasonography.
This study evaluates the subset of ultrasonography reports with the dreaded result “Appendix not visualized.” Overall, 37.7% of 662 consecutive ultrasonographic studies at the authors’ institution failed to visualize the appendix. Of interest to these authors were the “secondary signs” of appendicitis – free fluid, pericecal inflammatory changes, prominent lymph nodes, and phlegmon.
Their results are quite complicated – and, woefully, not terribly helpful. Free fluid in females – useless. Free fluid in males – more helpful if there’s a lot, but still only 2 cases of appendicitis out of the 5 males with a moderate/large amount of free fluid. Lymph nodes – useless. Pericecal fat changes – 1 out of 4. Phlegmon – 2 out of 2.
So, there’s some information here. Secondary signs with “Appendix not visualized” are typically not diagnostic alone – but, depending on the summation of other clinical findings, may yet be enough to obviate supplemental CT.
“Appendix Not Seen: The Predictive Value of Secondary Inflammatory Sonographic Signs”
www.ncbi.nlm.nih.gov/pubmed/23528502
Category: Pediatrics
Critical Deficiencies in Pediatric EM Training
This article is an overview of the critical procedures performed over a one-year period at Cincinnati Children’s, a large, well-respected, level 1 trauma center with a pediatric emergency medicine fellowship program. In theory, this facility ought to provide trainees with top-flight training, including adequate exposure to critical life-saving procedures.
Not exactly.
In that one year period, the PEM fellows performed 32 intubations, 7 intraosseus line placements, 3 tube thoracostomies, and zero central line placements. This accounted for approximately 25% of all available procedures – attending physicians and residents poached the remainder of procedures during the year. Therefore, based on this observational data, these authors conclude the training in PEM might not be sufficient to provide adequate procedural expertise. Then, the authors note pediatric emergency departments have such routinely low acuity – 2.5 out of every 1,000 patients requiring critical resuscitation – that it is inevitable these skills will deteriorate.
Essentially, this means the general level of emergency physician preparedness for a critically ill child is very low. PEM folks might have more pediatric-specific experience – but very limited procedural exposure – while general emergency physicians perform procedures far more frequently – but on adults. The authors even specifically note 63% of PEM faculty did not perform a single successful intubation throughout the entire year.
Their solution – which I tend to agree with – is the development of high-quality simulation tools to be used for training and maintenance of skills. Otherwise, we won’t be providing optimal care to the few critically ill children who do arrive.
“The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View”
www.ncbi.nlm.nih.gov/pubmed/22841174
New Pediatrics Otitis Media Recommendations
The content of these recommendations is what made the rounds in various news outlets – the first begrudging revelations that antibiotics are possibly unnecessary for many of acute otitis media. This isn’t news to us, of course, but it’s entertaining to see the precise moment the Rock of Gibraltar starts to make its slow course corrections.
As far as clinical policy statements go, however, this is beautifully constructed. For every actionable statement, these authors offer a concise summary of the benefits, harms, value judgements, intentional vagueness, patient preferences, and exclusions. Whether I agree with the hairs they split on each recommendation is almost overwhelmed by how pleasant it is to understand the basis of their reasoning.
My big irritation: their implication that symptom severity or temperatures greater than 102.2F are somehow specific for bacterial disease more likely to benefit from antibiotics. Odd – or am I missing a notable piece of literature? Please point it out if so!
The other new item of interest is the “Strong Recommendation” for analgesic treatment in cases of AOM. Thank goodness!
“The Diagnosis and Management of Acute Otitis Media”
www.ncbi.nlm.nih.gov/pubmed/23439909
The NICE Traffic Light Fails
Teasing out serious infection in children – while minimizing testing and unnecessary interventions – remains a challenge. To this end, the National Institute for Health and Clinical Excellence in the United Kingdom created a “Traffic Light” clinical assessment tool. This tool, which uses colour, activity, respiratory, hydration, and other features to give a low-, intermediate-, or high-risk assessment.
These authors attempted to validate the tool by retrospectively applying it to a prospective registry of over 15,000 febrile children aged less than 5 years. The primary outcome was correctly classifying a serious bacterial infection as intermediate- or high-risk. And the answer: 85.8% sensitivity and 28.5% specificity. Meh.
108 of the 157 missed cases of SBI were urinary tract infections – for which the authors suggest perhaps urinalysis could be added to the NICE traffic light. This would increase sensitivity to 92.1%, but drop specificity to 22.3% – if you agree with the blanket categorization of UTI as SBI.
Regardless, the AUC for SBI was 0.64 without the UA and 0.61 with the UA – not good at all.
“Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study”
www.ncbi.nlm.nih.gov/pubmed/23407730
The Grim World of ALTE
“The risk of subsequent mortality in infants admitted from our pediatric ED with an ALTE is substantial.”
Dire conclusions! Doom and gloom associated with apparent life-threatening events!
This is a little bit of an odd article. It’s a chart review of all infants aged 0 to 6 months presenting with an ALTE – including seizure, choking spell, and cyanosis. The authors reviewed 176 charts of admitted patients, follow-up studies, and eventual mortality.
- 111 received blood cultures – all negative.
- 65 received lumbar puncture – all negative.
- 113 received chest x-rays – 12 of which had infiltrates.
- 35 received non-contrast head CT – all negative.
- 62 were tested for RSV – 9 were positive.
So, how many infants died after their ALTE to spawn this conclusion of “substantial” mortality?
Two.
This leads to the authors to conclude this high-risk complaint requires admission. However, each death was a generally previously healthy patient was admitted with ALTE, evaluated extensively as an inpatient, discharged from the inpatient service – and died within two weeks, regardless. The only reasoning I can fathom for this recommendation is as a cover-your-ass strategy to prevent being the physician who “last touched” the patient when someone comes back with a lawyer.
“Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event”
Pediatric Blunt Trauma Remains Confounding
The latest output from the Pediatric Emergency Care Applied Research Network is a clinical decision instrument intended to assist clinicians in managing pediatric blunt abdominal trauma.
Like previous PECARN studies, this is a multi-center, prospective, observational study conducted in tertiary pediatric emergency departments. This study enrolled 12,044 children with blunt trauma and prospectively collected structured data regarding their mechanism, external injuries, and physiologic variables. Using the magic of statistical partitioning, the authors derived a decision instrument for use in risk-stratifying a patient as “very low risk for intra-abdominal injury requiring acute intervention.” If the patient meets all criteria, the prediction rule is 97.0% sensitive, missing 6 out of 203 abdominal injuries.
This is critically valuable data – but, as a decision-instrument in a zero-miss environment, I’m not sure if it helps. The authors note that use of their CT decision-instrument actually increased resource utilization if retrospectively applied to the derivation cohort, if the requirement is held that a patient be negative for every variable. If the threshold is raised to 1 or 2 variables present, then sensitivity drops to 82% and 77%, respectively. Only about half received a CT scan, and a small percentage were lost to follow-up – though, given the outcome of “injuries requiring intervention”, the methodology is reasonable. However, because intervention-requiring injuries only represented 26% of all radiographically-identified intra-abdominal injuries, this study is still going to be ignored out-of-hand by folks who want to identify all injuries, not just intervention-requiring injuries. After all, the grade 1 splenic laceration may be intervention-free, but remains important regarding activity restrictions to prevent future morbidity.
The authors also note these findings require external validation – wherever they’re going to find another pedatric emergency care network to enroll 12,000 patients!
“Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries”
http://www.ncbi.nlm.nih.gov/pubmed/23375510
UTI: Yet Another Windmill?
Medicine is full of windmills re-imagined as dragons – and two of the most prominent voices of reason in Emergency Medicine are David Newman and Jerome Hoffman. This skeptical take on pediatric urinary tract infections is David Newman’s latest, which covers content reflective of his SMART EM podcast on the same topic.
The premise of his argument is rather straightforward:
- There’s substantial overlap between UTI and asymptomatic bacteruria, leading to overdiagnosis.
- Even when the diagnosis is correctly made, prompt treatment does not prevent complications.
The complications in question are urosepsis and renal scarring. Urosepsis, in David’s literature review only results from urinary tract infections from the otherwise immunosuppressed, or in infants with congenital anomalies. Renal scarring, purportedly from pyelonephritis, has little or controversial evidence in supporting antibiotic use from preventing it.
This will be published in an upcoming issue of Annals of Emergency Medicine.
“Pediatric Urinary Tract Infection: Does the Evidence Support Aggressively Pursuing the Diagnosis?”
www.ncbi.nlm.nih.gov/pubmed/23312370
Breast Cancer From Pediatric Trauma Imaging
Evaluations for significant pediatric blunt trauma tend to be rather rare. However, one flip side to improved vehicular safety is that previously fatal accidents turn into diagnostic dilemmas with otherwise well-appearing children after horrific potential injury mechanisms.
This specific article tries to address the risk/benefit ratio for imaging the pediatric thoracic spine after trauma, with a focus on the lifetime excess attributable risk for breast cancer. They used estimates of radiation to breast tissue from plain films and CT, and then applied the predictions from the BEIR VII report to determine EAR. From all these various calculations, their worst-case scenario derived an excess of 79.6 cases of breast cancer per 10,000 CT scans in females aged less than 12 years.
Unfortunately, the proponents of CT imaging cite these studies and say we’ve done nothing but document theoretical risk (based on atomic bomb exposure) – while ignoring that the risk of missed injury is equally theoretical. As usual, the prudent course of action is to perform additional testing only when explicitly indicated – the additional cases of breast cancer are not trivial, but neither are missed injuries. The rate of additional breast cancer cases is certainly not so high that CTs should be skipped when clinically indicated.
“Theoretical Breast Cancer Induction Risk From Thoracic Spine CT in Female Pediatric Trauma Patients”
www.ncbi.nlm.nih.gov/pubmed/23184109
The AAP Policy on Firearm Safety
Might not it be helpful if, coincidentally, the Council on Injury, Violence, and Poison Prevention for the American Academy of Pediatrics had just updated their policy statement regarding firearm-related injuries? Indeed, just two months ago, the AAP published an update, featuring a mere 66 citations worth of evidence, rather than politicized talking points.
A couple interesting statistics from their summary:
– The firearm-associated death rate among youth ages 15 to 19 has fallen from its peak of 27.8 deaths per 100 000 in 1994 to 11.4 per 100 000 in 2009.
– However, of all injury deaths of individuals younger than 20 years, still 1 in 5 were firearm related.
– For youth 15 to 24 years of age, firearm homicide rates were 35.7 times higher than in other high-income countries.
– For children 5 to 14 years of age, firearm suicide rates were 8 times higher, and death rates from unintentional firearm injuries were 10 times higher in the United States than other high-income countries.
– The difference in rates is postulated to the ease of availability of guns in the United States compared with other high-income countries.
Their recommendations section seems quite straightforward:
– The most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.
– Health care professionals should counsel the parents of all adolescents to remove guns from the home or restrict access to them.
– Trigger locks, lock boxes, gun safes, and safe storage legislation are encouraged by the AAP.
– Other measures aimed at regulating access of guns should include legislative actions, such as mandatory waiting periods, closure of the gun show loophole, mental health restrictions for gun purchases, and background checks.
– The AAP recommends restoration of the ban on the sale of assault weapons to the general public.
Any chance policymakers might listen to the society of physicians “Dedicated to the health and well-being of infants, children, adolescents and young adults”?
“Firearm-Related Injuries Affecting the Pediatric Population”
www.ncbi.nlm.nih.gov/pubmed/10742344
Pain Control on the Wrong Track
Codeine, the oral narcotic analgesia that is long past its prime. Approximately 8% of the caucasian population cannot metabolize codeine into morphine – and then a small handful are rapid metabolizers that will overdose on an otherwise therapeutic dose. But, this didn’t stop these folks in Montreal from evaluating its efficacy for pediatric musculoskeletal limb pain.
Pediatric pain is a little odd. Overall, the Emergency Department does a poor job of treating pain. Studies in pediatric EDs show significant percentages of injured patients don’t receive any pain control. But, then, we all have the anecdotal experience in which a child is sitting on a stretcher watching TV with a fractured arm denying he’s in any pain at all – why are you bothering me again? Spongebob is on.
Long story short, this study randomized children to receive either ibuprofen alone or ibuprofen plus codeine. At each time point, the difference in pain scales was no different between groups. Pain scores weren’t that high to begin with, and had moderate improvement after either treatment.
For minor pain, acetaminophen and ibuprofen are adequate options. For more severe pain, intravenous narcotics, intranasal narcotics, or even intramuscular ketamine are probably better options.
“Efficacy of an Ibuprofen/Codeine Combination for Pain Management in Children Presenting to the Emergency Department With a Limb Injury: A Pilot Study”
www.ncbi.nlm.nih.gov/pubmed/23232154