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Top 5 Risk Management Pitfalls from 2021 & 2022
Each issue of Pediatric Emergency Medicine Practice includes Risk Management Pitfalls which challenge often conventional or well-meaning misconceptions about the topic.
50 Excuses that won't hold up in Court.
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Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department
This issue reviews the ways in which youth are trafficked, the indicators of trafficking, and the evidence-based and best-practice recommendations for addressing suspected or confirmed trafficking in the pediatric and adolescent patient populations.
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1. "She said everything was fine and she was born and raised here, so this couldn't be a human trafficking situation."
Clinicians can only diagnose and treat conditions that are on their radar. If a clinician lacks awareness about indicators of human trafficking, they can easily be missed. Validated screening tools should be used when available, as there are risks to the patient when a situation is not properly evaluated. -
2. "He's here with his stepfather, who is a distinguished-looking gentleman. The ED is busy and it will take a while to do a one-on-one history. It's only really necessary when the situation seems suspect."
Do not assume that a patient presenting in what appears to be a socially acceptable relationship is in a safe or healthy situation. Always speak with a patient privately at some point during their evaluation.
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3. "Kids these days don't even really work. Labor trafficking isn't something I'm going to see here."
Do not assume pediatric patients do not experience labor trafficking. Children and adolescents of all ages may experience labor trafficking. -
4. "The patient's aunt speaks English pretty well. They both seem fine with proceeding without an interpreter."
Allow patients to speak for themselves. If there is a language barrier, always work with a certified medical interpreter. -
5. "Now that I know the indicators of a trafficking situation, I will be able to intervene and keep my patient safe. It feels good to rescue victims from scary situations."
Do not plan to "rescue" patients from a situation. The goal is to empower them to use their own agency to promote their health and wellbeing. If the patient is a minor and a mandated report is indicated, this should be done in a collaborative and trauma-informed manner. -
6. "I told her, He's not good for you. You're going to end up hurt even worse next time if you don't leave him."
Some patients in trafficking situations may not identify as victims; if you identify them that way, it may ruin your rapport with them and put them in danger. -
7. "It's obvious he is being trafficked. I don't know why he's being so secretive about it."
Do not take it personally if a patient does not want to share much about their experience. Disclosure is not the goal; the goal is to offer an open door and a safe place to seek out support during this encounter or a future one. -
8. "I want to avoid conflict, so I'm going to make this report to child welfare and not tell the patient."
Always inform a patient you are a mandated reporter before you gather sensitive information. If you see concerning indicators, make the mandated report in collaboration with the impacted youth, letting the patient know that you are a mandated reporter and that you are hoping to leverage helpful support for them. Do not make clandestine reports. -
9. "She didn't want to get into the other stuff going on, and she implied she had been a victim of violence in the past. I'm not going to chart much about this."
Document clearly and keep in mind that medical records are sometimes used in a court of law. When developmentally appropriate, discuss with the patient the details that can be included in the chart. If a forensic examination is indicated and the patient is willing, have a trained forensic interviewer assist with and document the examination. -
10. "We don't see much human trafficking here. We'll figure it out when the time comes."
All institutions should have protocols in place to serve patients impacted by human trafficking and to keep patients and ED staff safe. This will also make the work more efficient when the situation does arise.
Pediatric Spinal Epidural Abscess: Recognition and Management in the Emergency Department
This issue reviews key findings on the history and physical examination that are associated with SEA, provides guidance for the laboratory tests and imaging studies that are indicated once SEA is suspected, and discusses treatment options based on current evidence.
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1. "My patient had abdominal pain and fever, so I thought it was, for sure, appendicitis."
Diagnosing a SEA requires a high index of suspicion, as it may present with common, nonspecific chief complaints such as back pain, limp or refusal to bear weight, or abdominal pain. Infants have presented with fever and irritability or respiratory distress. -
2. "The x-rays didn't show any signs of infection, so I was reassured."
MRI is the gold-standard imaging modality for diagnosis of SEA. Plain radiography, bone scans, and CT have inferior sensitivity compared to MRI. While it can sometimes be logistically difficult to obtain an MRI, it is important to do so when there is concern for a SEA.
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3. "The child had no neurologic deficits on exam, so I didn't think it could be a spinal infection."
Examination may be nonspecific, especially in the nonverbal child, and neurologic deficits may not be present early in the disease course. The absence of neurologic symptoms or examination findings does not rule out an SEA. -
4. "He was fine when I saw him in the ED 12 hours ago."
SEA has a very rapid progression of disease. Patients can progress from a normal neurologic examination to signs of paralysis within 12 to 48 hours. -
5. "I didn't think she had a serious bacterial illness because her WBC count was normal."
In SEA, the WBC count can be normal. Often, the only abnormal laboratory value is the ESR. -
6. "During the admission, the patient progressed to having paralysis. I can't believe I didn't think of SEA when I saw the patient."
Diagnostic delay of SEA is common, which is problematic, given the rapid progression of disease. Keep a wide differential that includes SEA. -
7. "The patient had fever and irritability, and I thought it might be meningitis, so I did a lumbar puncture."
Lumbar punctures have been performed when initial suspicion was another diagnosis such as meningitis, but this can be dangerous, depending on location of the SEA. Lumbar puncture may show high levels of protein and pleocytosis in SEA, but these findings would not be specific for an SEA. -
8. "This is a normal, healthy child. He can't have SEA. That is a diagnosis for adult patients with diabetes mellitus."
Do not assume a healthy child could not have an SEA. While it is more common for adults to have risk factors, SEA can occur in children without any risk factors. Obtain a detailed history to determine whether the patient has had any recent surgeries, procedures, or infections, as these can sometimes be the source of hematogenous spread. -
9. "I didn't start antibiotics because I wasn't sure SEA was the final diagnosis."
Initiate antibiotics as soon as an SEA diagnosis is suspected, even if not finalized. This is important given the rapid progression of the disease and possible irreversible neurologic damage without prompt treatment. Vancomycin plus ceftriaxone or meropenem are the antibiotics of choice. -
10. "There's no way this kid could have an abscess without fever."
Fever is seen in only 75% of SEA cases. Absence of fever does rule out SEA.
Pediatric Patients With Acute Demyelinating Syndromes
This issue focuses on the most common acute demyelinating disorders in children: Guillain-Barré syndrome and acute transverse myelitis.
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1. "GBS is an autoimmune disease, I thought I should give corticosteroids."
In randomized controlled trials, corticosteroids were not effective in the management of symptoms or in changing the prognosis, and they can delay time to appropriate management (ie, IVIG). -
2. "She couldn't cooperate with the negative inspiratory force, so I monitored her airway with pulse oximetry."
Hypoxia is often a late finding of respiratory distress. If the patient is unable to cooperate with negative inspiratory force measurements, she should be monitored by continuous pulse oximetry and end-tidal capnography.
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3. "He had a chief complaint of weakness, so I thought he probably had a demyelinating disorder."
The differential diagnosis for weakness is broad, and demyelinating conditions are rare. It is important to distinguish true weakness from presentations that may be interpreted as weakness, such as refusal to bear weight or falling, which may lead to alternative considerations in the differential diagnosis and evaluation of patients. It is important to obtain a careful history and physical examination for any patient who presents with weakness. -
4. "Her negative inspiratory force was 20 cm H2O, but she looked well, so there was no need for intubation."
Although a negative inspiratory force of <30 cm H2O is not a strict cutoff for intubation, if the negative inspiratory force is decreasing and has fallen <30 cm H2O, intubation should be strongly considered. A semielective intubation is preferable to an emergent intubation. -
5. "The CSF parameters were abnormal, but I still thought my patient had GBS."
A CSF white blood cell count >10/mcL is suspicious for an acute central nervous system infection and should indicate that the diagnosis is not GBS. -
6. "She still had reflexes, so it couldn't be GBS."
Although loss of deep tendon reflexes is a hallmark of GBS, patients may still have some preservation of reflexes early in the disease course. -
7. "The boy's oxygen saturation was 100%, so I didn't need to worry about respiratory failure."
In patients who may have GBS, respiratory status should be monitored closely by negative inspiratory force measurement. Reduction in oxygen saturation is a late finding of respiratory distress/failure. -
8. "My patient with GBS required intubation. I used my typical medications."
Although succinylcholine is the most frequent paralytic used in rapid sequence intubation, it may have prolonged effects in GBS. -
9. "This patient's symptoms started slowly. I didn't think his disease severity would be that bad."
Young patients, those with gradual onset of symptoms, and patients with comorbid mobility-reducing conditions are more likely to have increased severity of disease course. -
10. "My patient had back pain and weakness, so I figured it was probably transverse myelitis."
When transverse myelitis is suspected, it is important to take a good trauma history and perform neuroimaging to rule out an acute neurosurgical emergency.
Emergency Department Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion
This issue reviews the most recent literature on concussion and mild traumatic brain injury (mTBI) and provides recommendations for the evaluation, diagnosis, and treatment of mTBI and concussion in the acute setting.
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1. "The parents wanted their child with a concussion to play in a hockey tournament tomorrow."
Concussed patients are at increased risk of SIS and a second concussion as well as prolonged recovery with premature return to play. Concussed patients should be instructed to follow up with their primary care provider for evaluation, school adjustments, and sports clearances. -
2. "The parents were worried that their child may have a serious brain injury and were asking if they should wake their child up every hour at night."
There is no need for frequent wakening of patients with concussion if they have been discharged and there is no concern for a major TBI. Concussed patients need rest to recover.
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3. "This is the second ED visit in 1 week for this 12-year-old football player with a closed head injury. He did not have LOC at the first visit and was discharged home. Since then, he has been complaining of headaches. Today he was tackled and lost consciousness for less than 1 minute. He had 1 episode of vomiting. I discharged him with clear instructions not to return to play."
The threshold to obtain imaging and observe a symptomatic patient with repeated head injury should be lower. SIS is an important concern for the reinjured patient with concussion. -
4. "I order a head CT scan for every pediatric patient with closed head injury with a severe injury mechanism who is cared for in the trauma center."
Severe mechanism of injury alone is not an indication for head CT. Studies show that children with isolated severe injury mechanisms are at low risk for ciTBI. ED observation can assist in the management of these children. -
5. "It was not my responsibility to tell the concussed patient when he could go back to playing sports."
Even though it is the primary care provider's responsibility to manage patients with concussion to ensure full recovery, emergency clinicians are responsible for providing clear discharge instructions with subsymptom threshold exercise recommendations, cautions against return to sport without clearance, and a clear appropriate follow-up plan. -
6. "The infant fell out of his stroller, hitting his head on the sidewalk. There was a large frontal hematoma, but I was not concerned about a fracture because of the hematoma location."
Most frontal hematomas are benign and not a risk factor for ciTBI. Nonetheless, expanding hematoma or a large boggy cephalohematoma might interfere with palpating the skull to detect a step-off. The entire clinical picture of the patient needs to be taken into account. -
7. "After falling when his car seat was accidentally knocked out of the car, the 2 month-old infant was crying in the ED. The baby was vomiting his formula and had a small occipital hematoma. I decided to do an oral challenge in the ED and send him home."
This is a difficult age to assess mental status, and persistent crying can be a sign of altered mental status. This child should undergo either a CT scan or a period of observation to assess whether the mental status normalizes. Additionally, this is a minor mechanism for this degree if irritability, and nonaccidental trauma needs to be considered as well. -
8. "I wasn't sure if CT was needed, but I didn't want to miss anything, so I ordered a head CT for my 1-year-old patient with a closed head injury."
The PECARN clinical decision rule helps emergency clinicians in evaluating children aged <2 years with mTBI. The increased radiosensitivity of younger children compared to adults makes it important to minimize radiation exposure; CT imaging should be performed only when necessary. In addition, children have a longer life expectancy than adults, resulting in a larger window of opportunity for expressing radiation damage and malignancy. -
9. "The 3-year-old boy fell from the top of the slide (5 feet high). He had clear discharge from his nose and ears. He was alert but started vomiting during his ED observation. I discharged him home with an mTBI and viral syndrome."
A CSF leak as a manifestation of rhinorrhea or otorrhea suggests basilar skull fracture and, when there is clinical suspicion, can be confirmed with a beta-2-transferrin assay. The 2009 PECARN study as well as the CHALICE rules found that children with signs of skull fracture have a higher risk of ciTBI and should be imaged. -
10. "I thought I could treat headaches associated with mTBI with a negative CT with ibuprofen for as long as the headache persists."
Headache is the most common symptom associated with mTBI. ED discharge instructions should emphasize appropriate dosing intervals and medications to treat headache. Caregivers should be informed about alternating the use of ibuprofen and acetaminophen to treat headaches. Because of the risk of medication overuse headache, instructions should emphasize limiting daily use of these medications to no more than 2 weeks.
Diagnosis and Management of Pediatric Primary Bone Tumors in the Emergency Department
This issue reviews the specific signs, symptoms, and unique presentations the emergency clinician should know when evaluating a pediatric patient with musculoskeletal pain.
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1. "The CBC was normal, so I didn't think it was cancer."
Do not be falsely reassured by a normal CBC in a child with musculoskeletal complaints, as most patients with a malignant bone tumor will have a normal CBC. Additional laboratory testing such as inflammatory markers, alkaline phosphatase, and lactate dehydrogenase (in addition to imaging) will be more useful. -
2. "The patient didn't have systemic symptoms, organomegaly, or lymphadenopathy, so I didn't think it was cancer."
Patients with malignant bone tumors are not likely to have systemic symptoms (ie, fever, weight loss, night sweats), hepatosplenomegaly, or lymphadenopathy
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3. "The patient had a fever and then musculoskeletal pain, so I thought it was postviral arthralgia."
Acute pain must be differentiated from musculoskeletal pain that has lasted for weeks. Focal pain would not be consistent with postviral arthralgia and should lead to additional workup. -
4. "The x-ray looked fine, so I didn't think it was a bone tumor."
Radiographic findings can be subtle and initially missed. Consider malignant bone tumors in children with repeated presentations of musculoskeletal pain. Radiographs may also be normal because inadequate views were obtained; oblique and unconventional views may be necessary to better demonstrate the tumor. -
5. "The child complained of intermittent back pain, and the x-ray looked fine, so I reassured the family that follow-up wasn't needed."
There can be a delay in the diagnosis of tumors of the spine and pelvis, because these tumors must grow large enough to become palpable and/or visible on x-ray. Again, pain, even when intermittent and that does not appear debilitating, should be taken seriously -
6. "The patient had all the clinical signs of an infectious etiology, so I didn't think it was a tumor."
Remember that localized erythema, edema, and tenderness to palpation—all of which can be seen with infection (eg, septic arthritis or osteomyelitis)—can also be features of malignant bone tumors. -
7. "The pain wasn't worse at night and didn't seem that severe, so I didn't think much of it."
Because the symptoms of malignant bone tumors can be relatively nonspecific and intermittent (eg, pain is not consistently worse at night), pain, in general, should be considered a significant finding. Since the history is often nonspecific and pain may be the only significant finding, a thorough examination to evaluate for a palpable mass, as well as radiographs, are very helpful in establishing the diagnosis of a bone tumor, especially a malignant one. -
8. "I didn't think it was a malignant lesion because the mass was on his face, not on his arm or leg."
Remember to consider unusual sites or rare disease as the presentation of an underlying bone malignancy (eg, craniofacial osteosarcoma or LCH). -
9. "I referred the patient to their primary care provider; I thought that would be sufficient."
All patients with bone lesions found in the ED, whether incidental findings or symptomatic, should have follow-up with orthopedic oncology or pediatric orthopedic surgery. -
10. "I saw the fracture on x-ray, so I splinted it and discharged the patient."
Fractures suspected to be pathologic may require advanced imaging (eg, MRI) and admission. Always discuss suspected pathologic fractures with pediatric orthopedics prior to discharge.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
