OBJECTIVE: To examine 14-year temporal patterns and demographic differences in analgesic prescribing and imaging use among children with appendicitis in a tertiary pediatric emergency department (ED). METHODS: We conduct...OBJECTIVE: To examine 14-year temporal patterns and demographic differences in analgesic prescribing and imaging use among children with appendicitis in a tertiary pediatric emergency department (ED). METHODS: We conducted a retrospective cross-sectional study of children <18 years presenting with acute appendicitis (ICD-9/10 codes) to a large urban pediatric ED from 2010 to 2023. Analgesic categories included ketorolac, ibuprofen, acetaminophen, opioids, combination therapy, or no analgesia. Imaging modalities included ultrasound (US), computed tomography (CT), both, or none. Primary outcomes were calendar-year trends in analgesic prescribing and imaging modality use. Secondary analyses evaluated demographic/clinical factors associated with analgesic and imaging patterns using multivariable logistics regression. RESULTS: Among 2275 children (mean [SD] age, 11.0 [3.6] years; 59.7% male; 70.4% White). Overall, 62.9% received analgesics; 43.6% single agents, 19.3% combinations. Opioid-only prescribing declined (32.3% in 2010 to 8.4% in 2023), while combination analgesics (9.2% to 24.2%), acetaminophen only (6.9% to 21.4%), and ketorolac (0% to 9.8%) increased. CT-only imaging decreased sharply (53.1% to 5.1%), while US-only imaging increased (5.4% to 41.9%). In regression analyses, older age was associated with greater odds of ketorolac (AOR 1.17; 95% CI: 1.08-1.26) and opioid use (AOR 1.15; 95% CI: 1.09-1.21). Male sex was associated with higher odds of no analgesia (AOR 1.33; 95% CI: 1.10-1.62). Black children had greater odds of combination analgesics versus White peers (AOR 1.54; 95% CI: 1.06-2.26). Perforation was strongly associated with combination analgesics (AOR 1.84; 95% CI: 1.27-2.65). CONCLUSIONS: In a single-center study, pediatric appendicitis care shifted toward reduced opioid and CT use and increased nonopioid multimodal analgesia and US-based imaging over 14 years.
About one-fifth of adults and children over the age of 5 living in the United States report speaking a language other than English (LOE) at home, with a significant portion of this population also self-reporting limited...About one-fifth of adults and children over the age of 5 living in the United States report speaking a language other than English (LOE) at home, with a significant portion of this population also self-reporting limited English proficiency. Pediatric emergency medicine providers are seeing increasing numbers of patients and caregivers in this demographic. Care for these patients can be complicated by miscommunication. Research has consistently shown that patients with LOE experience numerous disparities in emergency department (ED) care, including under-triage, longer lengths of stay, increased revisit rates, increased rates of adverse events, and worse analgesia for pain. Overcoming linguistic barriers is important to provide excellent and equitable care for this population, and studies show that the use of professional interpretation can mitigate these disparities. Although general guidelines for the use of medical interpreters exist, there are special challenges involved in caring for patients in the emergency setting while also communicating with adult caregivers. This article aims to familiarize the emergency medicine provider with issues they will likely encounter in their practice setting, suggestions to mitigate these difficulties, and best practices for collaborating with interpreters in a fast-paced medical setting.
Kallies KJ, Beyer KM, Koehne WJ
… +4 more, Tomas CW, Tarima S, Beckman MA, Cassidy LD
Pediatr Emerg Care
· 2026 Mar · PMID 41891312
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OBJECTIVES: Unintentional injury is the leading cause of death in American youth. Fewer children live in rural versus urban areas, yet rural children comprise nearly one-quarter of injury mortalities. We sought to descri...OBJECTIVES: Unintentional injury is the leading cause of death in American youth. Fewer children live in rural versus urban areas, yet rural children comprise nearly one-quarter of injury mortalities. We sought to describe differences in pediatric mechanism of injury (MOI), injury severity. and mortality in rural and urban areas and explore geospatial patterns of injury. METHODS: Wisconsin trauma registry data were analyzed for injured pediatric patients from 2021 to 2022. Wisconsin Collaborative for Healthcare Quality and Wisconsin Health Innovation Program's (WI-HIP) rural/urban classification assigned ZIP codes to urban-advantaged, urban, urban-underserved, rural-advantaged, rural, or rural-underserved areas. Geospatial analyses identified high-injury burden areas based on crude and indirectly age and sex-adjusted injury rates. RESULTS: Two thousand four hundred seven children were included; mean age was 6.9±4.4 years; 738 (30.7%) lived in urban, 467 (19.4%) in urban-underserved, 452 (18.8%) in urban-advantaged, 379 (15.8%) in rural, 231 (9.6%) in rural-advantaged, and 140 (5.8%) children in rural-underserved areas. Falls were the most common among urban-advantaged and urban groups, where motor vehicle/transportation injuries were most common among the 3 rural groups; firearm injuries were highest in the urban-underserved group. In-hospital mortality was highest in the urban-underserved group (3.2%), followed by rural (1.3%), rural-advantaged (1.3%), urban (1.1%), urban-advantaged (0.9%), and rural-underserved (0.7%) groups. Crude and adjusted injury rates were highest in the rural-underserved group. CONCLUSIONS: Rural and urban MOI, injury locations, levels of trauma center differed. Tailored prevention strategies for rural and urban communities are needed, particularly in areas with higher injury rates. A community-engaged approach to prevention could reduce pediatric injuries.
OBJECTIVES: To describe the characteristics and selected quality improvement (QI) measures of pediatric emergency department (ED) encounters within Epic Cosmos. METHODS: We performed a retrospective study within Cosmos o...OBJECTIVES: To describe the characteristics and selected quality improvement (QI) measures of pediatric emergency department (ED) encounters within Epic Cosmos. METHODS: We performed a retrospective study within Cosmos of all pediatric (<18 years) US-based ED encounters between January 1, 2020, and June 30, 2025. We summarized demographics, visit characteristics, and diagnoses. We evaluated QI metrics for key conditions. RESULTS: We included 41,735,030 ED encounters from 18,757,872 distinct patients. The median encounter age was 6 years (IQR 2 to 12) and 52.0% were male. Most patients were White (58.7%), non-Hispanic (67.4%), publicly insured (58.5%), urban-dwelling (85.7%), and nearly half resided in the South (47.6%). The most common chief complaints were fever (16.6%), cough (11.7%), vomiting (8.2%), and abdominal pain (7.4%). Most patients were triaged as Emergency Severity Index (ESI) 4 (45.4%) or ESI 3 (35.7%), and 88.3% were discharged from the ED. QI metric analysis demonstrated corticosteroid use for asthma in 86.3% of encounters, chest radiography among children with asthma in 42.8%, brain CT for head injury in 18.6%, antibiotic use for viral illness in 4.8%, corticosteroid use for croup in 91.7%, intravenous fluid use for dehydration in 10.7%, and topical anesthesia use for lacerations in 56.4%. CONCLUSIONS: We characterized pediatric ED encounters within the Epic Cosmos platform, which is consistent with national patterns of pediatric ED care. These findings highlight the utility of Cosmos for assessing care quality and variability in pediatric emergency medicine, although findings should be interpreted cautiously given variability in coding, data mapping, and institutional representation.
BACKGROUND: Transient synovitis (TS) is a benign condition characterized by acute hip pain and is a common cause of limping in children. Ultrasonography (US) examination frequently reveals hip joint effusion. However, ac...BACKGROUND: Transient synovitis (TS) is a benign condition characterized by acute hip pain and is a common cause of limping in children. Ultrasonography (US) examination frequently reveals hip joint effusion. However, accurate documentation of its prevalence among children with a diagnosis of TS is scarcely documented in the literature. OBJECTIVES: The main objective of our study was to evaluate the prevalence of hip joint effusion among children diagnosed with TS in the pediatric emergency department (PED). METHODS: A Retrospective chart review of children diagnosed with TS in the PED between 2017 and 2021 who underwent an US examination as part of their evaluation. RESULTS: Overall, 392 children with a mean age of 5 years were included in the study group, of whom hip effusion was demonstrated in 302 (77%) patients. Most participants underwent point-of-care ultrasound (POCUS) performed by the PED physician as part of their evaluation (328, 83%). Children with hip joint effusion had higher pain levels, hip joint tenderness, and higher CRP values compared with children without an effusion. CONCLUSIONS: In our study, the prevalence of hip joint effusion among children presenting to the PED with a final clinical diagnosis of TS was 77%. Higher pain levels and hip joint tenderness were associated with the presence of hip effusion in TS.
Ashby B, Bellolio F, Klinkner D
… +4 more, Mullan A, Jeffery MM, Penfold M, Anderson J
Pediatr Emerg Care
· 2026 Jul · PMID 41854115
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PURPOSE: The anatomic position of the appendix may influence both the clinical presentation and diagnostic imaging accuracy in pediatric appendicitis, but its impact remains uncertain. This study aimed to determine the p...PURPOSE: The anatomic position of the appendix may influence both the clinical presentation and diagnostic imaging accuracy in pediatric appendicitis, but its impact remains uncertain. This study aimed to determine the prevalence of retrocecal appendicitis in children and to evaluate whether appendix positioning affects ultrasound diagnostic performance or clinical outcomes. METHODS: This was a retrospective cohort study including all children 0 to 18 years of age who presented to the Mayo Clinic Rochester Emergency Department between 2018 and 2023 and were diagnosed with appendicitis during their evaluation or subsequent hospitalization. Appendix location was determined by imaging or surgical documentation. Demographics, symptoms, signs, and complication rates were collected for patients with retrocecal appendicitis (RCA) and non-retrocecal appendicitis (NRCA). RESULTS: Four hundred seven patients were included with 12.5% having RCA. Ultrasound was obtained in 92% of patients with RCA versus 82% of NRCA (rate difference: 10%, 95% CI: 2%-19%, P =0.018). In patients who received ultrasound imaging, findings were equivocal or falsely negative in 53% of RCA patients versus 30% of NRCA patients (RD = 24%, 9%-39%; P =0.003). Computed tomography (CT) was obtained in 51% of RCA patients versus 29% of NRCA (RD = 22%, 8%-37%; P =0.003) and was equivocal or falsely negative at similar rates in RCA (12%) and NRCA (13%; P =0.88). Clinically, there were no differences in diarrhea, emesis, location of abdominal pain, or white blood cell counts between RCA and NRCA. Rates of perforation, abscess formation, hospitalization longer than 7 days, and repeat hospitalizations were also similar. CONCLUSIONS: Retrocecal appendicitis is a common anatomic variant in children that presents with similar clinical features and outcomes compared with non-retrocecal appendicitis. However, its retrocecal position reduces the diagnostic sensitivity of limited abdominal ultrasound, often necessitating additional imaging with computed tomography. Despite these diagnostic challenges, retrocecal positioning is not associated with a worsened clinical course.
Pediatr Emerg Care
· 2026 Jun · PMID 41797583
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OBJECTIVES: Lumbar puncture (LP) is an essential skill in which pediatric and emergency medicine trainees should be proficient. Despite its importance, research indicates that LP success rate in new graduates trained usi...OBJECTIVES: Lumbar puncture (LP) is an essential skill in which pediatric and emergency medicine trainees should be proficient. Despite its importance, research indicates that LP success rate in new graduates trained using traditional methods is only around 24% to 54%. Simulation provides the ideal grounds for practicing and refining this skill safely. This systematic review aimed to examine the use of simulation in teaching pediatric lumbar puncture to medical students and pediatric and emergency medicine trainees. METHODS: Five electronic databases (EMBASE, Medline, CINAHL, Web of Science, and PsycINFO) were searched, alongside grey literature and reference list screening. Studies that used simulation-based educational methods to teach pediatric LP in undergraduate and postgraduate pediatric and emergency medicine education were included. Methodological rigor was evaluated using the QuADS tool. RESULTS: Of the 17 included studies, most used partial/task trainers (eg, frequency building trials on task trainers; 82.4%) or mixed simulation methods (eg, video-recorded 'informed consent' OSCE followed by simulated LP on an infant simulator; 17.6%). Most simulation sessions were time-based (focused on the amount of time spent practicing clinical skills; n=10, 58.8%), whereas outcome-based learning (focused on the achievement of specific learning objectives) was used by 8 studies (47.1%). Training was frequently assessed in terms of knowledge and skills (70.6% of studies), behavior (52.9%), reactions to the training (17.6%), and attitudes (5.9%). Outcomes were mostly positive (64%) or had no clear effect (36%), with most positive outcomes related to knowledge and skills (75%), reactions (66.7%), and behavior (55.6%). CONCLUSIONS: Research is needed to determine which modalities suit differing learning outcomes and stages of LP skill development. Studies favored time-based learning, highlighting the need for outcome-based, learner-centric LP programs. Simulation programs positively impacted knowledge and skills; however, behavioral, organizational, and patient impact warrants further research.
OBJECTIVES: Prehospital emergency anesthesia (PHEA) is a critical intervention in pediatric prehospital emergency medicine but presents risks and unique challenges. Consequently, some services limit the provision of this...OBJECTIVES: Prehospital emergency anesthesia (PHEA) is a critical intervention in pediatric prehospital emergency medicine but presents risks and unique challenges. Consequently, some services limit the provision of this practice. This study aimed to determine first-pass success (FPS) rates for pediatric PHEA delivered by the North West Air Ambulance (NWAA) service in the United Kingdom. METHODS: A 7-year retrospective analysis (April 3, 2018 to April 10, 2025) of pediatric PHEA cases managed by NWAA was conducted using a standardized quality database. All patients aged 0 to 15 years who underwent drug-assisted intubation were included. The primary outcome was FPS, defined as successful tracheal intubation on the first attempt. RESULTS: During the study period, 1742 patients attended by NWAA underwent PHEA in the prehospital setting, of whom 161 were pediatric patients aged 0 to 15 years. In all, 96 pediatric patients underwent RSI. FPS was achieved in 96% of these patients, with all patients successfully intubated within a maximum of 3 attempts. Patients between 0 and 5 years had 95% FPS. For context, 1441 adults underwent prehospital RSI in the same period, with an FPS rate of 88%. CONCLUSIONS: This study demonstrates that FPS rates for children undergoing PHEA in a well-trained, consultant-led prehospital service can be high, exceeding those reported in adults. Our findings provide reassurance that pediatric PHEA can be delivered safely and effectively when supported by senior clinicians, robust training, and rigorous governance. Concerns regarding FPS in children should focus on continued investment in training, service design, and audit, rather than limiting PHEA as a life-saving intervention. Further research is needed to assess whether these results are reproducible in other services, non-PHEA intubations, and across wider clinical outcomes.
OBJECTIVES: Diagnostic uncertainty is an important, yet understudied, driver of patient safety within pediatric emergency medicine. Understanding how uncertainty is experienced and communicated may reveal opportunities t...OBJECTIVES: Diagnostic uncertainty is an important, yet understudied, driver of patient safety within pediatric emergency medicine. Understanding how uncertainty is experienced and communicated may reveal opportunities to optimize patient safety. This study aims to determine the frequency of physician-reported uncertainty at emergency department (ED) discharge for pediatric acute respiratory illness and to describe strategies and challenges in communicating uncertainty to caregivers. METHODS: This was a cross-sectional study of children (<18 y) discharged with acute respiratory illness from a tertiary care pediatric ED (April to May 2025). For each patient, the discharging attending physician completed a survey assessing diagnostic uncertainty (6-point Likert scale, dichotomized for analysis), and whether and how this was communicated to caregivers. Physicians indicated their general overall comfort communicating uncertainty. Wilson CIs were calculated around the prevalence of visits with uncertainty. RESULTS: Among 220 patients with acute respiratory illness, 68 (31%, 95% 25 to 37%) were discharged with diagnostic uncertainty. Uncertainty was communicated to 61 caregivers (90%) in the following ways: using terms such as "maybe," "probably," or "likely" (74%), provision of return precautions (59%), discussion of the differential diagnosis (56%), and discussion of diagnoses excluded (27%). Many (45% of 60 physicians surveyed) reported communication challenges, citing perceived caregiver expectations, anxiety, and risk communication concerns. CONCLUSIONS: Diagnostic uncertainty occurred in nearly one-third of ED discharges for pediatric acute respiratory illness. Communication approaches varied, and several challenges were noted. Future research engaging clinicians and families is needed to address these challenges and develop optimal methods of family-centered communication of uncertainty.
Pediatr Emerg Care
· 2026 Mar · PMID 41749508
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Tranexamic acid (TXA) is an antifibrinolytic medication that helps stabilize clots and reduce bleeding. Although FDA approval is limited, it has become widely used off-label in pediatric and emergency medicine. Evidence...Tranexamic acid (TXA) is an antifibrinolytic medication that helps stabilize clots and reduce bleeding. Although FDA approval is limited, it has become widely used off-label in pediatric and emergency medicine. Evidence shows that TXA decreases blood loss, reduces transfusion requirements, and may improve survival in trauma. It has also been beneficial in pulmonary hemorrhage, post-tonsillectomy bleeding, epistaxis, abnormal uterine bleeding, and secondary postpartum hemorrhage. TXA is generally safe and well tolerated; common side effects include headache and abdominal discomfort, while serious events such as seizures or allergic reactions are rare. Its favorable safety profile and broad applicability make TXA a valuable tool for frontline clinicians managing pediatric bleeding emergencies. More pediatric-specific trials are needed, but current evidence supports TXA as both effective and practical in a variety of emergency settings.
Ortiz-Santiago I, Ibarzabal-Segui N, López-Gutiérrez E
… +3 more, Santos-Zorrozua B, Benito J, Mintegi S
Pediatr Emerg Care
· 2026 Mar · PMID 41749507
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OBJECTIVE: To analyze the reasons for ordering a CT scan and the abnormalities identified in children with mild head trauma classified as intermediate-risk according to the PECARN rule. METHODS: This retrospective observ...OBJECTIVE: To analyze the reasons for ordering a CT scan and the abnormalities identified in children with mild head trauma classified as intermediate-risk according to the PECARN rule. METHODS: This retrospective observational study included patients aged 3 months to 14 years who presented to the emergency department (ED) of a tertiary hospital between 2021 and 2022 with mild head trauma classified as intermediate-risk. Two multivariable analyses were performed to identify demographic and clinical factors associated with CT scan utilization and CT abnormalities. RESULTS: We included 555 patients; 40% were girls, and the median age was 4 years (interquartile range: 1 to 8 y). Most patients (98.6%) were managed as outpatients after a median ED stay of 4.5 hours (IQR: 4 to 6.75). CT scans were performed in 78 patients (14.1%), of whom 24 (30.8%) had abnormalities: 13 had traumatic brain injuries and 11 had isolated skull fractures. Six patients (1.1%) had clinically important traumatic brain injuries (ciTBI). Four independent factors were associated with CT scan utilization: number of vomiting episodes (OR: 1.31; 95% CI: 1.16-1.49), headache (OR: 2.1; 95% CI: 1.21-3.6), abnormal behavior reported by parents (OR: 3.45; 95% CI: 1.99-5.95), and time elapsed before being seen by an ED physician (OR: 1.05; 95% CI: 1.01-1.08). Two factors were associated with CT abnormalities: younger age (OR: 0.82; 95% CI: 0.71-0.95) and severe injury mechanism (OR: 5.89; 95% CI: 2.04-18.37). CONCLUSIONS: In children with mild head trauma classified as intermediate-risk, the factors leading to CT scan utilization differ from those associated with CT abnormalities. Further studies are needed to confirm these findings.
OBJECTIVE: To develop and evaluate an internally validated natural language processing (NLP) model to determine guideline adherence of antibiotic decisions in the emergency department (ED) for skin and soft tissue infect...OBJECTIVE: To develop and evaluate an internally validated natural language processing (NLP) model to determine guideline adherence of antibiotic decisions in the emergency department (ED) for skin and soft tissue infections (SSTIs). METHODS: This cross-sectional pilot study developed and applied a random forest (RF)/NLP model to classify clinical narratives of patients with skin infections as requiring either methicillin-resistant Staphylococcus aureus (MRSA) or non-MRSA antibiotic coverage. Conducted at a quaternary care children's hospital with an annual volume of 50,000 ED visits, our study included patients aged 1 to 18 years presenting for SSTIs to the ED from July 1, 2018, through June 30, 2023. Main outcomes included the NLP model's sensitivity, specificity, and receiver operator characteristic (ROC) curve compared to gold standard manual physician review of the medical records. RESULTS: A total of 1588 patients were part of the training data set, with an additional 423 patients utilized for validation. The RF model achieved an area under the curve (AUC) of 0.99, 97.0% sensitivity, and 94.9% specificity. In the validation data set, the model achieved 96.6% sensitivity and 90.1% specificity. Performance remained strong despite absent/missing patient history in certain narratives. CONCLUSIONS: The NLP model demonstrated that automated analysis of clinical narratives for determining guideline adherence is feasible. Despite missing data in narratives, the model's high performance suggests potential for broader application. Given the rise in antibiotic-resistant infections and the role of judicious antibiotic use, developing automated systems through NLP can significantly contribute to health care delivery and patient safety. The methodology of this study provides a feasible, sustainable path for similar applications in the emergency setting.
Pediatr Emerg Care
· 2026 May · PMID 41749064
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OBJECTIVE: Assess the clinical value of routine laboratory testing in the emergency department (ED) during behavioral disturbance evaluations in children with autism spectrum disorder (ASD). METHODS: A retrospective char...OBJECTIVE: Assess the clinical value of routine laboratory testing in the emergency department (ED) during behavioral disturbance evaluations in children with autism spectrum disorder (ASD). METHODS: A retrospective chart review of patients ages 3 to 21 years with ASD presenting to 3 pediatric EDs with behavioral disturbance from January 2019 to January 2020. Local laboratory standards were used to determine abnormal ranges in ED screening labs. Patients with abnormal findings were reviewed for medical significance, defined as the need for a medical intervention, inpatient observation, or the inclusion of a nonbehavioral diagnostic code due to an abnormal laboratory test result. RESULTS: A total of 209 eligible ED encounters were reviewed. Mean age was 14.5±3.1 years, and 84% were male. Of those, 84% (176/209) received venipuncture for screening labs per protocol, of which 97% (170/176) featured abnormal test results. Only 2 abnormal labs (1%) revealed clinically significant findings. Compared with whites, more patients of non-White race received venipuncture (90% vs. 73%, P =0.001) but less non-whites receiving venipuncture were admitted to psychiatric facilities (44% vs. 62%, P =0.01). CONCLUSION: This study demonstrates that routine screening labs in asymptomatic children with ASD presenting to the ED with behavioral disturbances are often outside the range of normal, but without clinical relevance. This practice may lead to unnecessary and painful venipuncture. Children with ASD are a uniquely vulnerable population for whom we should choose wisely.
Pediatr Emerg Care
· 2026 Jun · PMID 41747083
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OBJECTIVE: To examine Hispanic parental attitudes towards influenza vaccination, identify dimensions of vaccine hesitancy using the 4C framework (Calculation, Complacency, Confidence, Convenience), and assess parental wi...OBJECTIVE: To examine Hispanic parental attitudes towards influenza vaccination, identify dimensions of vaccine hesitancy using the 4C framework (Calculation, Complacency, Confidence, Convenience), and assess parental willingness to have their child receive an influenza vaccine in the emergency department (ED). METHODS: In our multi-methods study, Hispanic Spanish-speaking (HS), Hispanic English-speaking (HE), and non-Hispanic White English-speaking (WE) parents answered a semi-structured interview and the Parent Attitudes about Childhood Vaccines (PACV) survey. We extracted themes from interviews using directed content analysis. We summarized PACVs using descriptive statistics (higher scores indicated higher vaccine hesitancy). RESULTS: From 58 sets of interviews and PACVs, we mapped parents' perceived benefits and barriers of child influenza vaccination to the 4Cs. When compared with WE parents (n=12), HS (n=26) and HE (n=20) parents had less knowledge about influenza and the vaccine, believed more vaccine myths, and were less likely to view influenza as a severe disease. HS and HE parents more often than WE parents expressed community health promotion as a vaccination benefit and poor health care access as a vaccination barrier. PACV scores showed that WE parents were least vaccine-hesitant (M=15.1, SD=15.1), followed by HE (M=22.8, SD=22.1) and HS (M=24.6, SD=14.8) parents. Most parents in all 3 groups expressed willingness to have their child receive the influenza vaccine in the ED. CONCLUSIONS: Influenza vaccine hesitancy is greater among HS and HE parents compared with WE parents. Tailored education to different populations is warranted to increase influenza vaccination within the ED.