Given that Kawasaki disease (KD) can cause cardiac complications, it is crucial to diagnose and treat the disease in the emergency department. We report a case of a 10-year-old girl who presented to the emergency department with cervical lymphadenopathy and fever. The initial diagnosis was retropharyngeal abscess based on computed tomography findings, but antibiotic therapy failed and she was subsequently diagnosed with KD. After 3 doses of intravenous immunoglobulin along with methylprednisolone and methotrexate, she was discharged on hospital day 21. The cervical lymphadenopathy suggesting retropharyngeal abscess might be an early sign of incomplete or intravenous immunoglobulin-resistant KD.
Child* ; Diagnosis* ; Emergency Service, Hospital ; Female* ; Fever* ; Humans ; Immunoglobulins ; Lymphatic Diseases* ; Methotrexate ; Methylprednisolone ; Mucocutaneous Lymph Node Syndrome* ; Neck Pain ; Retropharyngeal Abscess* ; Vasculitis

PURPOSE: The Korean Triage and Acuity Scale (KTAS) is a triage tool for patients in the emergency department (ED). We aimed to investigate the association between the KTAS level and hospitalization of children with abdominal pain, a common chief complaint in the ED. METHODS: This study retrospectively reviewed medical records of children aged 3 to 14 years who visited the ED with abdominal pain as a chief complaint. KTAS level (1–3 vs. 4–5), age, gender, presence of associated symptoms (vomiting, diarrhea, hematochezia, and fever), and disposition (rapid discharge, discharge after intravenous hydration, and hospitalization) were collected and compared between the children with KTAS 1–3 and 4–5. RESULTS: Of 1,050 children enrolled, 618 (58.9%) were classified as KTAS 1–3, and 36 (3.4%) were hospitalized. Vomiting was the most common associated symptom in both groups (63.6%), and 41.5% underwent discharge after intravenous hydration. The children with KTAS 1–3 were more frequently hospitalized (5.0% vs. 1.2%, P < 0.001). CONCLUSION: The KTAS may be reliable to predict the hospitalization of children with abdominal pain in the ED with additional consideration of the associated symptoms.
Abdominal Pain* ; Child* ; Critical Illness ; Diarrhea ; Emergencies* ; Emergency Medicine ; Emergency Service, Hospital* ; Gastrointestinal Hemorrhage ; Hospitalization* ; Humans ; Medical Records ; Pediatrics ; Retrospective Studies ; Triage* ; Vomiting

PURPOSE: To compare the sedation outcome according to the dose of per os chloral hydrate in children who underwent laceration repair in the emergency department (ED). METHODS: This retrospective study was performed to the children who underwent sedation using chloral hydrate for laceration repair in the ED from January 2015 through November 2015. A total of 370 children aged younger than 6 years underwent the sedation. We compared the induction time, duration of sedation, and ED length of stay (EDLOS) between the single dose (50 mg/kg) and additional dose (plus 25 mg/kg) groups. RESULTS: Of 370 children, 335 (90.5%) were sedated successfully, 284 (76.8%) were sedated with initial dose (the single dose group), and 51 (13.8%) were sedated with additional dose (the additional dose group). The induction time and EDLOS were longer in the additional dose group (induction time: 31.0 ± 17.2 minutes vs. 96.2 ± 25.4 minutes, P < 0.001; EDLOS: 137.2 ± 35.5 minutes vs. 193.0 ± 36.0 minutes, P < 0.001). The duration of sedation showed no difference between the 2 groups (44.4 ± 24.0 minutes vs. 42.0 ± 20.8 minutes; P = 0.500). No one had serious adverse reactions. CONCLUSION: Additional dose of chloral hydrate can increase the induction time and EDLOS without increasing the duration of sedation and causing serious adverse reactions. This information may improve the efficiency of ED workflow when shared with parents of the children.
Child* ; Chloral Hydrate* ; Conscious Sedation ; Emergency Service, Hospital ; Humans ; Lacerations* ; Length of Stay ; Parents ; Retrospective Studies

PURPOSE: We aimed to investigate the appropriateness of transport of children via emergency medical service providers (EMSP) according to the decision-maker on referred hospitals (EMSP [EMSP group] vs. guardians [user group]). METHODS: We analyzed first aid records by EMSP for children aged 15 years or younger in Gyeonggi province, Korea, from January 2012 through December 2013. We obtained the following data: scene, symptom, type (high-level [regional/local emergency medical centers] or not) and location (out-of-province or not) of referred hospitals, injury, level of consciousness (alert or not), and prehospital triage results by EMSP (emergent/less emergent or not). RESULTS: A total of 50,407 children were included, of whom 37,626 (74.6%) belonged to the user group. Overall, the most common scene, symptom, and type and location of referred hospitals were home (57.0%), pain (33.3%), and inside-theprovince and local emergency medical centers (44.2%), respectively. The user group showed less frequent injury (P < 0.001), decreased level of consciousness (P < 0.001), and no significant difference in the triage results (P = 0.074). This group showed more frequent transport to high-level and out-of-province emergency medical centers (P < 0.001), and longer transport (P < 0.001). CONCLUSION: The user group showed more frequent transport to high-level or remote referred hospitals without more critical prehospital triage results. Guardian-directed transport of children might be associated with the inappropriate transport of children via EMSP.
Ambulances ; Child* ; Consciousness ; Emergencies* ; Emergency Medical Services* ; Epidemiology ; First Aid ; Gyeonggi-do ; Humans ; Korea ; Transportation of Patients ; Triage

PURPOSE: Peripheral intravenous cannulation (PIC) for children is technically difficult. We aimed to investigate factors associated with the primary success of PIC for children in the emergency department (ED). METHODS: This prospective observational study was conducted on children younger than 3 years who visited the ED from September 2014 to August 2015. The children undergoing primary success, defined as success at the first attempt, comprised the success group. Using a case report form, information about the children (age, sex, and weight), practitioners' occupation (doctors, nurses, emergency medical technicians [EMTs]), treatment venue, insertion site of PIC, presence of guardians, and use of auxiliary devices were collected and compared between the success and failure groups. Multivariable logistic regression models were constructed to identify factors associated with the primary success. RESULTS: Of 439 children, 271 underwent the primary success (61.7%). The success group showed older age, heavier weight, and higher proportion of EMT. No differences were found in treatment venue, insertion site, and presence of the guardian. We found that patients' age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.003–1.1), and practitioners' occupation (EMT; OR, 3.0; 95% CI, 1.9–4.7, compared with doctors) were the factors associated with the primary success. CONCLUSION: Practitioners' occupation (EMT) and children's age (older) may be associated with the primary success of PIC. It may be helpful to have specialized personnel when performing PIC on children in the ED.
Catheterization ; Catheterization, Peripheral ; Catheters* ; Child ; Emergencies* ; Emergency Medical Technicians ; Emergency Service, Hospital* ; Humans ; Logistic Models ; Observational Study ; Occupations ; Pediatrics ; Prospective Studies ; Veins

PURPOSE: Analgesia is essential for the treatment of children's fracture. We aimed to investigate the factors associated with administration of analgesics in children with forearm fracture. METHODS: We retrospectively reviewed medical records of children (< 20 years) with forearm fracture who visited 2 tertiary hospital emergency departments from 2014 to 2015. We analyzed factors, such as gender, age, whether the mother accompanied the visit, visiting time and route, mechanism of injury, duration of symptoms, complicated fracture, manual reduction, surgery, and type and route of analgesics. We also performed logistic regression analysis to identify the factors associated with administration of analgesics. RESULTS: Of 179 children with forearm fracture, 48 (26.8%) were administered analgesics. These children showed older age, shorter duration of symptoms, and more frequent visit with their mothers, visit during the day, use of emergency medical services, and surgery. After logistic regression analysis, we found use of emergency medical service (adjusted odds ratio [OR], 8.73; 95% confidence interval [CI], 3.16–24.08; P < 0.001), visit with the mother (OR, 6.23; 95% CI, 1.68–23.09; P = 0.006), age (OR, 1.18; 95% CI, 1.05–1.32; P = 0.004), and duration of symptoms (OR, 0.99; 95% CI, 0.986–0.999; P = 0.035) as the factors associated with administration of analgesics. CONCLUSION: The factors associated with administration of analgesics might be communicating skill-related factors, such as older age and shorter duration of symptoms. Children with poor communicating skill may need more aggressive analgesia in the emergency department.
Analgesia ; Analgesics* ; Child* ; Emergencies ; Emergency Medical Services ; Emergency Service, Hospital ; Forearm* ; Fractures, Bone ; Humans ; Logistic Models ; Medical Records ; Mothers ; Odds Ratio ; Pain Management ; Retrospective Studies ; Tertiary Care Centers ; Wounds and Injuries

PURPOSE: To retrospectively validate the Step-by-Step approach, a sequential algorithm for prediction of serious bacterial infections (SBI) using the appearance, age, and inflammatory markers, in febrile infants younger than 90 days. METHODS: The presence of SBI was reviewed in febrile infants younger than 90 days undergoing blood and urine cultures (using perineal adhesive bags), assays for procalcitonin, C-reactive protein and absolute neutrophil count, and urinalysis at the emergency department from September 2015 through August 2017. The low-risk infants were classified according to the Step-by-Step approach. SBI was defined as urinary tract infection (UTI), bacteremia or meningitis. We measured the sensitivity and negative predictive value (NPV) of the approach in predicting SBI, and compared the values to those of the Rochester criteria and the Lab-score. RESULTS: Of 488 febrile infants (44.7% underwent lumbar puncture), 71 (14.5%) had SBI, including 67 UTI, 5 bacteremia, and 3 meningitis (mutually inclusive). Of 208 low-risk infants (42.6%), no SBI was found. The Step-by-Step approach showed a 100% sensitivity (95% confidence interval [CI]: 94.9–100.0) and NPV (95% CI: not applicable). The Rochester criteria showed a 98.6% sensitivity (95% CI: 92.4–100.0) and 99.6% NPV (95% CI: 97.1–99.9), and missed 1 meningitis. The Lab-score showed a 59.2% sensitivity (95% CI: 46.8–70.7) and 93.2% NPV (95% CI: 91.2–94.8), and missed 2 meningitis and 27 UTI. CONCLUSION: The Step-by-Step approach showed a 100% sensitivity and NPV in predicting SBI. This approach may help predict SBI without lumbar puncture in febrile infants younger than 90 days.
Adhesives ; Bacteremia ; Bacterial Infections ; Biomarkers ; C-Reactive Protein ; Emergencies* ; Emergency Service, Hospital* ; Humans ; Infant* ; Meningitis ; Neutrophils ; Retrospective Studies* ; Risk Assessment ; Spinal Puncture ; Urinalysis ; Urinary Tract Infections

PURPOSE: The dose of drug and the size of instrument are determined based on children's weight. We aimed to validate the finger counting method (FCM) for weight estimation in Korean children using the Monte Carlo simulation. METHODS: We estimated the weight of Korean children aged 1 to 9 years by the FCM. These measurements were compared with the weight extracted by the Monte Carlo simulation applied to the “2007 Korean Children and Adolescents Growth Standard”. Pearson correlation coefficients (r) were measured to assess the correlation between the weight extracted by the simulation and that estimated by FCM. Bland-Altman analyses were performed to assess the agreement between the weight extracted by the simulation and that estimated by FCM and 2 other well-known pediatric weight estimation formulas (the Advanced Pediatric Life Support and Luscombe formulas). RESULTS: Data regarding 9,000 children's weight selected by age and gender was randomly extracted using the simulation. We found a positive correlation between the weight estimated by the FCM and the weight extracted (in boys, r = 0.896, P < 0.001; in girls, r = 0.899, P < 0.001). The FCM tended to underestimate weight in the children aged 7 years or old. CONCLUSION: This article suggests the usefulness of FCM in weight estimation, particularly in children younger than 7 years. With appreciation of the limitation in older children, the FCM could be applied to emergency practice.
Adolescent ; Body Weight ; Child ; Emergencies ; Emergency Service, Hospital ; Female ; Fingers* ; Humans ; Methods* ; Monte Carlo Method ; Resuscitation

PURPOSE: To investigate the predictors of perforated appendicitis (PA) in pediatric patients with appendicitis seen in the emergency department. METHODS: We retrospectively reviewed 564 pediatric patients (< 16 years) who visited the emergency department and subsequently had pathologically confirmed appendicitis from 2005 through 2014. Clinical features, inflammatory markers, including the white blood cell (WBC), neutrophil, and lymphocyte counts, neutrophil-to-lymphocyte ratio, C-reactive protein (CRP) concentration, erythrocyte sedimentation rate (ESR), and the Alvarado score were compared between the patients with and without PA regarding their predictability of PA. RESULTS: Of 564 pediatric patients with appendicitis, 204 (36.2%) had PAs. The patients with PA had longer duration of symptoms and median length of hospital stay, more frequent nausea and vomiting, and higher median WBC and neutrophil counts, neutrophil-to-lymphocyte ratio, ESR, and CRP concentration. Overall, WBC count showed the highest sensitivity of 79.9% and negative predictive value of 82.6%, and CRP concentration had the highest area under the receiver operating characteristic curve of 0.72. Multivariable logistic analysis showed that WBC count > 13.5 × 109/L (odds ratio [OR], 3.27; confidence interval [CI], 1.49–7.18; P = 0.003) and ESR > 15 mm/h (OR, 3.18; 95% CI, 2.13–4.74; P < 0.001) are independent predictors of PA. CONCLUSION: WBC count and ESR might be better predictors of PA in pediatric patients with appendicitis in the emergency department than the Alvarado score and CRP concentration.
Appendicitis* ; Blood Sedimentation ; C-Reactive Protein ; Child* ; Emergencies ; Emergency Service, Hospital ; Humans ; Length of Stay ; Leukocyte Count* ; Leukocytes* ; Lymphocyte Count ; Nausea ; Neutrophils ; Pediatrics ; Prognosis ; Retrospective Studies ; ROC Curve ; Vomiting

Pediatric patients (younger than 19 years) account for approximately 25% of all emergency patients. Pediatric patients have large proportions of toddlers (aged 1–5 years), low severity, illness (rather than injury), and after-hours visits. Considering these features, the authors, affiliated with the policy research team in the Korean Society of Pediatric Emergency Medicine, suggest the establishment of the pediatric certified emergency center (PCEC) to stratify Korean pediatric emergency medical system according to the Korean Acuity and Triage Scale (KTAS). The PCEC is a facility dedicated to the emergency care for a large population of KTAS 3–4 patients (i.e., mildly ill). In addition, the PCEC may perform early stabilization and transfer to the pediatric emergency centers for pediatric patients having KTAS 1–2 illnesses and injuries. To facilitate the application of emergency centers for the PCEC, the designation criteria should be flexible in terms of manpower, facility, and equipment. Financial support from the government is essential for sustainable PCEC.
After-Hours Care ; Child ; Emergencies* ; Emergency Medical Services* ; Emergency Medicine ; Emergency Service, Hospital ; Financial Support ; Humans ; Triage