Objectives To determine the incidence of bacterial meningitis (BM) among all febrile infants 29–56 days old undergoing a lumbar puncture (LP) in the emergency department (ED) of a tertiary care children’s hospital and the number of low-risk FYI with BM, in order to reassess the need for routine LP in these infants. Study design Retrospective cohort study using a quality improvement registry from July 2007-April 2014. Infants included were 29–56 days old with fever and who had an LP in the ED. Low-risk criteria were adapted from the Philadelphia criteria. 4BM was defined as having a bacterial pathogen isolated from the cerebrospinal fluid (CSF). A medical record review of one-third of randomly selected patients in the cohort determined the proportion who met low-risk criteria. Results One of 1188 (0.08%) FYI had BM; this patient did not meet low-risk criteria. An additional 40 (3.4%) had positive CSF cultures; all were contaminants. Sub-analysis of one-third of the study population revealed that 45.6% met low-risk criteria; the most common reasons for failing low-risk classification included abnormal white blood cell count or urinalysis. Conclusions In a cohort of FYI, BM is uncommon and no cases of BM would have been missed had LPs not been performed in those meeting low-risk criteria.

Primary and secondary surveys are frequently performed incompletely and inefficiently regardless of level of training or type of training program. There is no difference in measured performance among different types of residency programs. The impact of trauma resuscitation education on improved survey performance should be studied prospectively.

Objectives The aim of this study is to explore current community emergency department (ED) experiences available to pediatric emergency medicine (PEM) trainees and estimate the proportion of graduates taking positions that involve working in a community ED setting. Methods We conducted an e-mail–based survey among PEM fellowship directors and assistant directors. Results There were 55 program director respondents (74% response rate). Thirty-one percent of the surveyed PEM fellowship programs provide training exposure to a community ED setting. Twenty-nine percent of the surveyed programs reported that 25% to 49% of graduating trainees accepted positions that involve working in a community hospital ED setting, 13% responded 50% to 74%, and 4% report 75% to 100% from 2012 to 2016. Conclusions There is an overall paucity of a dedicated community rotation for PEM trainees, yet many graduates are seeking employment in community-based EDs. Because the need for community-based PEM physicians continues to rise and to adequately prepare the PEM workforce, PEM fellowship training should consider a curriculum that includes community-based ED clinical experiences.

A different approach to the triage and management of pediatric exposures to laundry detergent pod ingestions is required compared with nonpod ingestions. Although the exact cause is not known, practitioners should be vigilant for rapid onset of neurological impairment and inability to protect the airway in addition to its caustic effects.

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Scarfone et al published a retrospective study that identified the incidence of bacterial meningitis in 1188 febrile infants aged 29-56 days of age undergoing sepsis screening. 1 A secondary outcome was to determine whether those infants with bacterial meningitis met "low-risk" criteria. Forty (3.4%) infants had "contaminant" cerebrospinal fluid (CSF) cultures. One infant (0.08%) was diagnosed with bacterial meningitis with positive CSF culture. Analysis of 401 infants showed that 45.6% met low-risk criteria. Of the contaminant CSF culture results, 9 were found in the low-risk group. Based on these results, the authors concluded that no cases of bacterial meningitis would have been missed had a lumbar puncture not been performed in those meeting low-risk criteria. However, important data such as CSF cell counts and whether patients developed other features of bacterial meningitis later in admission were not included. Data regarding when CSF was obtained in relation to antibiotic therapy also was not included. This would have been useful in better validating their conclusion, as diagnoses of bacterial meningitis could have been missed if based primarily on culture results in infants who received antibiotics before lumbar puncture. This may have affected the overall detected incidence of bacterial meningitis. Finally, there was a lack of direct comparison between high-and low-risk groups, which would have been useful to include. The authors have highlighted a common pediatric issue, acknowledging the need for further research into the use of lumbar punctures in this age group. However, without clarification, the paper does not appear to provide sufficiently strong evidence to induce a paradigm shift in current management of this population group.

Background: Bacterial meningitis in low-risk febrile young infants (FYIs) aged >28 days has become increasingly rare. Routine performance of lumbar puncture (LP) in these infants is associated with adverse consequences and may be unnecessary. We modified our clinical practice guideline (CPG) to reduce the number of FYIs 29 to 56 days old who receive LP.Methods: This quality improvement project sought to modify a preexisting CPG to diagnose and manage FYIs 0 to 56 days old that eliminated routine performance of LP in children 29 to 56 days old who were considered low-risk for serious bacterial infection. The change was implemented by making adjustments to the online CPG. A statistical process control chart was used to assess the affect of the initiative on our primary outcome of LP rate in this population of FYIs.Results: Postimplementation of the CPG initiative, 71% of FYIs 29 to 56 days old did not receive LP, compared with 42% preimplementation. This practice change was also associated with fewer hospitalizations, lower median emergency department (ED) length of stay, and fewer 72-hour ED revisits. Over 3 years of sustained practice, 1/713 (0.1%; 95% confidence interval, 0%-0.8%) low-risk FYI returned within 72 hours and was subsequently treated for probable bacterial meningitis, although cerebrospinal fluid culture was negative for bacterial growth.Conclusions: A change in CPG reduced the number of LPs performed in febrile infants 29 to 56 days old. This change resulted in fewer LPs, hospitalizations, ED revisits, and a lower ED length of stay for FYIs 29 to 56 days old.

Facial lacerations from minor trauma are a common presenting complaint to the emergency department. With the increasing availability of topical anesthetics, there is a decrease in the need for injectable local anesthetic and sedation services, facilitating the ease of facial laceration repairs for young children. One such topical anesthetic is a widely used pharmacy preparation of lidocaine 4%-epinephrine 0.1%-tetracaine 0.5% gel (LET). Although the use of LET has decreased the need for injectable lidocaine and sedation for facial lacerations, both of which can be unpleasant for children with potentially life-threatening adverse events, it may still lead to unexpected and untoward adverse events. We explore here a little-known adverse effect of LET in a child who presented to a pediatric emergency department with an eyelid laceration after minor head trauma.