Publications by authors named "Vigil James"

29 Publications

  • Page 1 of 1

Point of Care Ultrasound Identification of Multiple Rib Fractures in a Pediatric Patient with Osteogenesis Imperfecta Type 3.

Children (Basel) 2022 Jun 10;9(6). Epub 2022 Jun 10.

Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore.

Patients with osteogenesis imperfecta (OI) are at an increased risk of pathological rib fractures even if there is no history of trauma. Early and accurate identification of such fractures are crucial for appropriate management. We present a case of a child with OI type 3 with multiple rib fractures who presented with transient cyanosis and increased work of breathing without a history of significant trauma. The patient's chest radiographs were reported to have a single, new right posterior fourth rib fracture and an old, healing anterior fourth rib fracture. A point-of-care ultrasound performed by the attending pediatric emergency physician revealed additional findings of refracture over the old right anterior fourth rib fracture site and a new left posterior third rib fracture. These findings of multiple and bilateral rib fractures better account for the patient's initial presentation. This case highlights the added advantages of ultrasound over conventional chest radiographs in the evaluation and diagnosis of a tachypnoeic pediatric patient with underlying metabolic bone disease and a complex skeletal structure with multiple pathological rib fractures but no chest tenderness.
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http://dx.doi.org/10.3390/children9060864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9221744PMC
June 2022

Epidemiology and Outcome of Nailbed Injuries Managed in Children's Emergency Department: A 10-Year Single-Center Experience.

Pediatr Emerg Care 2022 Feb;38(2):e776-e783

From the Children's Emergency, KK Women's and Children's Hospital.

Background: Fingertip injuries are among the most common hand injuries in children and result in significant health, time, and a financial burden. Nailbed injuries constitute a large proportion of fingertip injuries and are frequent in children.

Objectives: This study aimed to examine the epidemiology, injury patterns, and treatment strategies implemented in patients with nailbed injuries between 0 and 18 years of age. We also wanted to identify various acute and chronic complications associated with nailbed injuries in these patients.

Methods: This was a single-center retrospective study carried out on the data collected between October 1, 2009, and October 31, 2019.

Results: We identified 457 patients with upper extremity nailbed injuries during the study period. Most children were male, accounting for 62.8% (287) of the patients. Door crush injuries (59.5%) resulted in the majority of the nailbed injuries. The commonest place of injury occurrence was home (46.4%), followed by playground (28.4%). The next most frequent areas were public areas (17.5%) and school (7.7%). Simple nailbed laceration with partial avulsion of the nail (44.4%) was the most common type of nailbed injury. Most nailbed injury repairs were done by the pediatric emergency doctor (72.2%). The predictors for the occurrence of complications after nailbed injury were the type of injury (stellate laceration and severe crushed nailbed injuries) and fracture of the distal phalanx. The predictors for the use of antibiotics after nailbed injury in our patients were the mechanism of injury (crushed in door, sports injury, and road traffic accident) and fracture of the distal phalanx. Age was found to be associated with subungual hematomas and avulsion, whereas female sex was found to be associated with crush injuries.

Conclusions: In this study, most patients (72.2%) had their nailbed injuries repaired by pediatric emergency doctors. The commonest mechanism of nailbed injury was door crush injuries. Increased awareness and education of the caregivers might help avoid these injuries because the injury mechanism in most of the patients is preventable. Partial nail avulsion with underlying simple laceration of the nailbed was the most frequent type of nailbed injury seen. The complications that were seen after nailbed injuries were fingertip sensitivity (5.3%), split nail deformity (5.3%), infection (3.9%), nonadherence of the nail plate (2%), and hook nail deformity (1%). The predictors for the occurrence of complications after nailbed injury were the type of injury (stellate laceration and severe crushed nailbed injuries) and fracture of the distal phalanx. The predictors for the use of antibiotics after nailbed injury in our patients were the mechanism of injury (crushed in door, sports injury, and road traffic accident) and fracture of the distal phalanx. Age was found to be associated with subungual hematomas and avulsion, whereas female sex was found to be associated with crush injuries. Possessing a robust understanding of the mechanism of injury and the underlying anatomy with a detailed assessment of the nailbed injury is of paramount importance in the management of these patients. An initial thorough assessment and meticulous repair of the nailbed injuries will result in good outcomes with overall few complications.
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http://dx.doi.org/10.1097/PEC.0000000000002400DOI Listing
February 2022

Neonatal presentations to the paediatric emergency department in Singapore.

Singapore Med J 2021 Oct 11. Epub 2021 Oct 11.

Emergency Department, KK Women's and Children's Hospital, Singapore.

Introduction: This study aimed to characterise neonatal paediatric emergency department (PED) visits, analyse the main paediatric illnesses and establish associations of these demographics with the readmission rates and severity of their presentation.

Methods: A retrospective analysis of neonates (aged < 28 days) presenting to the PEDs of our hospital over seven months was performed. Associations between the clinical and demographic data of admissions to the PED and inpatient admissions were analysed.

Results: In total, 1,200 neonates presented during the study period, 79.4% of whom presented at less than 15 days since birth. Length of stay in the PED was less than four hours for 94.0% of the neonates. Predominant triage categories comprised non-P1 cases (97.5%). The main diagnoses at the PED were neonatal jaundice (NNJ; 66.8%) and neonatal pyrexia (NNP; 14.6%), which corresponded to the main diagnoses upon discharge from the hospital: NNJ (68.4%) and NNP (19.6%). 48.2% of neonates were referred from polyclinics or other clinics. 57.7% of the neonates were admitted. Interestingly, 87.0% of the well babies who presented to the emergency department were brought in owing to parental concerns by the parents themselves, without prior consultation with the doctor.

Conclusion: Outpatient management of NNJ can be considered. Caregivers should be provided better education regarding normal physiological characteristics of newborns through standardised educational materials. Other potential avenues for parents to seek medical advice, for example hotlines and ChatBots such as the recently piloted 'Urgent Paediatric Advice Line' online service, should be considered.
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http://dx.doi.org/10.11622/smedj.2021160DOI Listing
October 2021

Point-of-Care Ultrasound Identification of Portal Vein Thrombosis in a Pediatric Patient.

Pediatr Emerg Care 2022 Apr;38(4):183-186

Children's Emergency, KK Women's and Children's Hospital, Singapore.

Abstract: Abdominal pain is one of the most common presenting complaints encountered in the pediatric emergency department. The use of point-of-care ultrasonography by emergency physicians has been shown to expedite the diagnosis of a large variety of conditions and can be used to accurately identify intra-abdominal pathology in children. We describe the case of a pediatric patient who presented to the pediatric emergency department with acute abdominal pain, in whom point-of-care ultrasonography helped expedite the diagnosis of acute portal vein thrombosis and liver abscess.
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http://dx.doi.org/10.1097/PEC.0000000000002555DOI Listing
April 2022

Associations of initial haemodynamic profiles and neurological outcomes in children with traumatic brain injury: a secondary analysis.

Emerg Med J 2022 Jul 3;39(7):527-533. Epub 2021 Aug 3.

Children's Emergency, KK Women's and Children's Hospital, Singapore.

Introduction: Initial low systolic blood pressure (SBP) in paediatric traumatic brain injury (TBI) is associated with mortality. There is limited literature on how other haemodynamic parameters including heart rate (HR); diastolic blood pressure (DBP); mean arterial pressure (MAP); and shock index, paediatric age-adjusted (SIPA) affect not only mortality but also long-term neurological outcomes in paediatric TBI. We aimed to analyse the associations of these haemodynamic variables (HR, SBP, MAP, DBP and SIPA) with mortality and long-term neurological outcomes in isolated moderate-to-severe paediatric TBI.

Methods: This was a secondary analysis of our primary study that analysed the association of TBI-associated coagulopathy with mortality and neurological outcome in isolated, moderate-to-severe paediatric head injury. A trauma registry-based, retrospective study of children <18 years old who presented to the emergency department with isolated, moderate-to-severe TBI from January 2010 to December 2016 was conducted. The association between initial haemodynamic variables and less favourable outcomes using Glasgow Outcome Scale-Extended Paediatric) at 6 months post injury was analysed using logistic regression.

Results: Among 152 children analysed, initial systolic and diastolic hypotension (<5th percentile) (OR) for SBP 11.40, 95% CI 3.60 to 36.05, p<0.001; OR for DBP 15.75, 95% CI 3.09 to 80.21, p<0.001) and Glasgow Coma Scale scores <8 (OR 14.50, 95% CI 3.65 to 57.55, p<0.001) were associated with 'moderate-to-severe neurological disabilities', 'vegetative state' and 'death'. After adjusting for confounders, only SBP was significant (adjusted OR 5.68, 95% CI 1.40 to 23.08, p=0.015).

Conclusions: Initial systolic hypotension was independently associated with mortality and moderate-to-severe neurological deficits at 6 months post injury. Further work is required to understand if early correction of hypotension will improve long-term outcomes.
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http://dx.doi.org/10.1136/emermed-2020-210641DOI Listing
July 2022

A Young Patient With Hives and Chest Pain.

JAMA Cardiol 2021 07;6(7):847-848

Division of Emergency Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1001/jamacardio.2021.0749DOI Listing
July 2021

Pediatric Abdominal Tuberculosis With Calcified Intra-abdominal Lymph Nodes Identified by Point-of-Care Ultrasound.

Pediatr Emerg Care 2021 Apr;37(4):226-229

From the Children's Emergency, KK Women's and Children's Hospital, Singapore.

Background: Tuberculosis of the abdomen is one of the most common extrapulmonary manifestations of tuberculosis. Even in areas where tuberculosis is endemic, intra-abdominal tuberculous can pose a diagnostic and management challenge because of the lack of presence of overt clinical signs and availability of expertise for point of care diagnostics. Point-of-care ultrasound (POCUS) of the abdomen performed by emergency physicians is increasingly being used for a variety of clinical presentations to facilitate accurate diagnoses in the emergency department.

Case Report: We describe the case of a patient presenting to the pediatric emergency department with acute abdominal pain, in whom POCUS helped expedite the diagnosis of abdominal tuberculosis.

Conclusions: In the right clinical setting, the concurrent presence of intra-abdominal lymphadenopathy, ascites, mesenteric thickening, ileocecal thickening, and splenic microabscesses on ultrasound imaging should lead to consideration of the diagnosis of intra-abdominal tuberculosis. Although typically diagnosed on computed tomography or magnetic resonance imaging, in our case, POCUS helped facilitate the bedside diagnosis of abdominal tuberculosis in the emergency department.
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http://dx.doi.org/10.1097/PEC.0000000000002320DOI Listing
April 2021

Young man with a diffuse rash and red eyes after recovery from COVID-2019.

J Am Coll Emerg Physicians Open 2021 Apr 23;2(2):e12404. Epub 2021 Mar 23.

Children's Emergency KK Women's and Children's Hospital Pte. Ltd Singapore Singapore.

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http://dx.doi.org/10.1002/emp2.12404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987235PMC
April 2021

Point-of-care ultrasound for evaluating intra-abdominal calcification in the pediatric emergency department: case series and review of literature.

Ultrasound J 2020 Dec 3;12(1):51. Epub 2020 Dec 3.

Children's Emergency, C/O KK Women's and Children's Hospital PTE. LTD, 100 Bukit Timah Road, Singapore, 229899, Singapore.

Background: The presence of intra-abdominal calcification in the pediatric population can be due to a wide range of conditions. Calcification in the abdomen can be seen in normal or abnormal anatomical structures. In some patients, abnormal calcification points towards the pathology; whereas in others, calcification itself is the pathology. After a thorough history and clinical examination, point-of-care ultrasound (POCUS) would complement the assessment of acute abdominal pain, based on the list of differentials generated as per the abdominal region. The main objective of this article is to review commonly encountered causes of intra-abdominal calcifications in the pediatric population and help in clinical decision-making in a Pediatric Emergency Department.

Case Presentation: We describe a series of pediatric patients who presented to the Pediatric Emergency Department with acute abdominal pain, in whom point-of-care ultrasound helped expedite the diagnosis by identifying varying types of calcification and associated sonological findings. For children who present to the Pediatric Emergency Department with significant abdominal pain, a rapid distinction between emergencies and non-emergencies is vital to decrease morbidity and mortality.

Conclusions: In a child presenting to the Pediatric Emergency Department with abdominal pain, POCUS and the findings of calcifications can narrow or expand the differential diagnosis when integrated with history and physical exam, to a specific anatomic structure. Integrating these findings with additional sonological findings of an underlying pathology might raise sufficient concerns in the emergency physicians to warrant further investigations for the patient in the form of a formal radiological ultrasound and assist in the patient's early disposition. The use of POCUS might also help to categorize the type of calcification to one of the four main categories of intra-abdominal calcifications, namely concretions, conduit wall calcification, cyst wall calcification, and solid mass-type calcification. POCUS used thoughtfully can give a diagnosis and expand differential diagnosis, reduce cognitive bias, and reduce physician mental load. By integrating the use of POCUS with the history and clinical findings, it will be possible to expedite the management in children who present to the Pediatric Emergency Department with acute abdominal pain.
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http://dx.doi.org/10.1186/s13089-020-00199-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714802PMC
December 2020

A young man with palpitations.

Am J Emerg Med 2021 01 3;39:255.e1-255.e3. Epub 2020 Jul 3.

Department of Emergency Medicine, University of Virginia School of Medicine, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2020.06.070DOI Listing
January 2021

A "Saga" of Adenanthera Pavonina Seed Ingestion in a Toddler.

Ann Acad Med Singap 2020 05;49(5):337-339

Children's Emergency, KK Women's and Children's Hospital, Singapore.

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May 2020

Point-of-Care Ultrasound for Evaluating Lymphadenopathy in the Pediatric Emergency Department: Case Series and Review of Literature.

J Emerg Med 2020 Jul 27;59(1):75-83. Epub 2020 Apr 27.

Children's Emergency, KK Women's and Children's Hospital Pte. Ltd., Singapore.

Background: Children present to the pediatric emergency department (ED) with enlarged lymph nodes due to a broad spectrum of conditions ranging from benign causes like reactive lymph nodes to adverse conditions like malignancy. Identifying sonographic features typical of infection, inflammation, and neoplasms will help assist clinicians in deciding the disposition of the patients from the ED. Point-of-care ultrasound has become an essential adjunct for diagnostic assessment in pediatric emergency medicine. The wider accessibility of ultrasound along with greater resolution using high-frequency probes places this noninvasive, nonradiation-based bedside examination, an ideal tool for real-time examination of the lymph nodes in the EDs.

Case Series: We present a series of cases in which the point-of-care ultrasound examination proved valuable in the timely diagnosis and expedited care of lymph node pathologies secondary to reactive, infectious, and malignant processes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Point-of-care ultrasound will facilitate diagnosis in children with lymph node swelling and should be considered in children of all ages. While assessing the lymph node pathology at the bedside, describe the shape, size, internal echotexture, borders, vascularity, and the pattern of the perinodal soft tissue to differentiate between a normal, reactive, infectious, inflammatory, or malignant underlying pathology.
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http://dx.doi.org/10.1016/j.jemermed.2020.03.026DOI Listing
July 2020

A "Saga" of Adenanthera Pavonina Seed Ingestion in a Toddler.

Ann Acad Med Singap 2020 Apr;49(4):1-10

Children's Emergency, KK Women's and Children's Hospital, Singapore.

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April 2020

Early coagulopathy in children with isolated blunt head injury is associated with mortality and poor neurological outcomes.

J Neurosurg Pediatr 2020 Mar 6:1-7. Epub 2020 Mar 6.

Objective: Traumatic brain injury (TBI) is the leading cause of long-term disability and death in children and adolescents globally. Long-term adverse outcomes, including physical, cognitive, and behavioral sequelae, have been reported after TBI in a significant number of pediatric patients. In this study the authors sought to investigate the epidemiology of TBI-associated coagulopathy and its association with mortality and poor neurological outcome in a pediatric population with isolated moderate to severe blunt head injury treated at the authors' institution.

Methods: This retrospective study was conducted in the children's emergency department between January 2010 and December 2016. Children < 18 years old who presented with isolated moderate to severe blunt head injury were included in the study. The authors collected data on patient demographics, clinical presentation, and TBI management. Outcomes studied were death and poor neurological outcome defined by a score of < 7 (death, moderate to severe neurological disability) at 6 months postinjury on the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds).

Results: In 155 pediatric patients who presented with isolated moderate to severe blunt head injury, early coagulopathy was observed in 33 (21.3%) patients during the initial blood investigations done in the emergency department. The mean (SD) age of the study group was 7.03 (5.08) years and the predominant mechanism of injury was fall from height (65.2%). The median Abbreviated Injury Scale of the head (AIS head) score was 4 and the median GCS score was 13 (IQR 12-15). TBI-associated coagulopathy was independently associated with GOS-E Peds score < 7 (p = 0.02, adjusted OR 6.07, 95% CI 1.32-27.83). The overall mortality rate was 5.8%. After adjusting for confounders, only AIS head score and hypotension at triage remained significantly associated with TBI-associated coagulopathy.

Conclusions: TBI-associated coagulopathy was independently associated with GOS-E Peds score < 7 at 6 months postinjury. Larger prospective studies are needed to investigate the use of TBI-associated coagulopathy to prognosticate these critical clinical outcomes.
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http://dx.doi.org/10.3171/2019.12.PEDS19531DOI Listing
March 2020

Lateral Condyle Fracture of the Humerus Among Children Attending a Pediatric Emergency Department: A 10-Year Single-Center Experience.

Pediatr Emerg Care 2021 Dec;37(12):e1339-e1344

From the Children's Emergency, KK Women's and Children's Hospital, Singapore, Singapore.

Background: The lateral humeral condyle fractures in children accounts for one fifth of all elbow fractures. These fractures have a propensity to displace because of the pull of the extensor muscles on the condyle.

Objectives: The aim of this study was to examine the epidemiology, injury patterns, complications, and predictors for conservative/surgical management in patients with lateral condyle humeral fractures between 0 and 18 years of age.

Methods: This was a single-center retrospective study conducted between January 2006 and December 2016.

Results: There were 268 patients identified with lateral condyle elbow fracture. Majority of the patients (81.4%) with lateral condyle humeral fractures presented with either undisplaced or minimally displaced (<2 mm) fractures. The initial management in majority (90.7%) of the patients was conservative. Of the patients, 26.8% had secondary displacement at follow-up. The overall proportion of patients who required surgical intervention was 36.2%. Varus deformity of elbow (2.2%) and malunion (0.4%) were the complications noticed on long-term follow-up. Increased age and undisplaced fracture were statistically significant positive predictors for conservative management. The presence of concurrent elbow injuries and type of fracture (displaced >2 mm) were statistically significant positive predictors for surgical management.

Conclusions: Our study demonstrated that majority of the patients with lateral condyle humeral fractures had presented with either undisplaced or minimally displaced (<2 mm) fractures. The positive predictors for conservative management of fractures were increased age and undisplaced fracture. The positive predictors for surgical management of lateral condyle humerus fractures were concurrent injuries in elbow and type of fracture (displaced >2 mm). Physician vigilance to the possibility of additional migration of lateral condyle fractures initially managed conservatively, and the need for subsequent surgical stabilization plays an important role in the management of these fractures.
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http://dx.doi.org/10.1097/PEC.0000000000002032DOI Listing
December 2021

A retrospective review of trampoline-related injuries presenting to a paediatric emergency department in Singapore.

Singapore Med J 2021 02 10;62(2):82-86. Epub 2019 Dec 10.

Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.

Introduction: Trampolining is a popular activity. However, to our knowledge, no studies on paediatric trampoline-related injuries (TRIs) have been conducted in Asia. We aimed to provide an Asian perspective on paediatric TRIs and evaluate current safety measures.

Methods: Patients aged under 16 years who presented to the emergency department at KK Women's and Children's Hospital, Singapore, from March 2012 to June 2016 with a TRI were identified from the National Trauma Registry. Data was collated retrospectively focusing on age, location of the trampoline, mechanism and location of injury, treatment, disposition, and follow-up treatment.

Results: 137 children were seen for a TRI during this period. There was even representation across age groups (< 6 years, 6-11 years and 11-16 years). 60.6% of these injuries occurred in a public trampoline park, and a smaller proportion involved home and school trampolines. 61.3% of injuries occurred on the trampoline and 25.5% involved a fall off it, while the remaining were incurred by hitting the trampoline frame. The most common injury was soft tissue injury, followed by fractures and dislocations, of which 16.7% required surgical intervention. Most patients were discharged to an outpatient clinic. 14.6% of all patients required admission and 9.5% eventually required surgical intervention. There were three stable head injuries and no cervical spine injuries or deaths.

Conclusion: The existence of trampoline parks has contributed to a rise in TRIs. We recommend measures such as general education, changes in the setup around the trampoline, increasing the age limit for trampolining, adult supervision and discouraging double bouncing.
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http://dx.doi.org/10.11622/smedj.2019168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027143PMC
February 2021

Foreign body ingestion may be increasing in the US.

Authors:
Vigil James

J Pediatr 2019 11;214:238-241

K K Women's and Children's Hospital, Singapore.

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http://dx.doi.org/10.1016/j.jpeds.2019.09.058DOI Listing
November 2019

Bicycle injuries among the paediatric population at an emergency department in Singapore.

Singapore Med J 2019 Jul 15;60(7):343-346. Epub 2019 Jan 15.

Children's Emergency, KK Women's and Children's Hospital, Singapore.

Introduction: Bicycles injuries are the leading cause of emergency department visits among all recreational activities and have been established as a significant worldwide public health burden. The purpose of this retrospective study was to describe the epidemiology and patterns of paediatric bicycle-related injuries in Singapore.

Methods: This was a single-centre retrospective study based on data collected from a trauma registry between 2011 and 2016.

Results: A total of 760 patients presented to the emergency department during this period, of whom 68.2% were male and 39.7% were aged 10-16 years. 50.1% of the patients were Chinese and 25.9% were Malay. The cyclist was the person most commonly injured (65.7%) during the bicycle accident. From 2011 to 2015, the number of bicycle injuries showed a persistent upward trend. Superficial injuries such as abrasions and bruises were the most common injuries sustained (46.1%), followed by fractures. The majority of the patients were discharged from the emergency department. There were no bicycle accident deaths recorded during the study period.

Conclusion: Our study demonstrated an increasing number of bicycle injuries among paediatric cyclists in the local setting. Parents, teachers, coaches and other caregivers should be educated regarding the need to use protective equipment and to seek medical care promptly in the case of trauma resulting from bicycle injuries.
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http://dx.doi.org/10.11622/smedj.2019009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6658656PMC
July 2019

A Homemade, High-fidelity Ultrasound Model for Simulating Pneumonia with Parapneumonic Effusion and Empyema.

J Emerg Med 2019 Apr 10;56(4):421-425. Epub 2019 Jan 10.

Children's Emergency, KK Women's and Children's Hospital, Singapore, Singapore.

Background: Point-of-care ultrasonography (POCUS) is increasingly used for both diagnostic and guided procedures. Increasingly, POCUS has been used for identification of pneumonia and to assist in the differentiation of pleural effusions, as well as to guide thoracentesis. As such, there is a need for training with ideally high-fidelity lung ultrasound phantoms to ensure ultrasound proficiency and procedural competency. Unfortunately, most commercial ultrasound phantoms remain expensive and may have limited fidelity.

Objective: Our aim was to create and describe a homemade, high-fidelity ultrasound phantom model for demonstrating pneumonia with pleural effusions for teaching purposes.

Discussion: An ultrasound phantom was constructed using a water-filled latex glove with a sliver of meat in it, covered over by a palm-sized piece of meat (skin and ribs are optional to increase ultrasonographic details and realism). This would appear like parapneumonic effusions with organized pneumonia under ultrasound examination. Creamer (or talc) can be added to the water in the glove to simulate empyema. The model can also be used to teach simple effusions and for ultrasound-guided thoracentesis and in clinical decision making.

Conclusions: Easily prepared, homemade high-fidelity ultrasound phantom models for instructions on identification of pleural effusions and ultrasound-guided pleural tap of parapneumonic effusion were made.
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http://dx.doi.org/10.1016/j.jemermed.2018.12.015DOI Listing
April 2019

Periorbital Cellulitis in Paediatric Emergency Medicine Department Patients.

Ann Acad Med Singap 2018 Oct;47(10):420-423

Children's Emergency, KK Women's and Children's Hospital, Singapore.

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October 2018

Handheld Metal Detector Screening for Metallic Foreign Body Ingestion in Children.

J Vis Exp 2018 09 11(139). Epub 2018 Sep 11.

Children's Emergency, KK women's and Children's Hospital.

Coins are the most common ingested metallic foreign bodies among children. The goal of this protocol is to assess the accuracy and feasibility of using a handheld metal detector to detect ingested metallic foreign bodies in children. We propose that by introducing handheld metal detector screening early in the triage process of children with high suspicion of metallic foreign body ingestion, the number of radiographs being ordered to localize the metallic foreign body can be reduced in this radio-sensitive population. The study protocol requires the screening of the participants for history of foreign body ingestion and exclusion of patients with respiratory distress or metallic implants. The patient changes to hospital gown and items that could contain metal like eyeglasses, earrings, pendants, and ornaments are removed. The patient is positioned in the center of the room away from other metallic interferences. The working status of the handheld metal detector is first confirmed by eliciting a positive audio-visual signal. Then the screening is done in an erect position with head in extension to expose the neck, from the level of the chin to the level of the hip joint, to cover the anatomical areas from neck to pelvis in a zig-zag manner both anteriorly and posteriorly. A positive audio-visual signal is carefully noted during the scanning for the presence of metallic foreign body. Relevant radiographs are ordered as per the area detected on the metal detector screening. The handheld metal detector was able to precisely identify all the coins among the ingested metallic foreign bodies in our study. The handheld metal detector could not consistently detect non-coin metallic foreign bodies. This protocol demonstrates the accuracy of handheld metal detector in the identification and localization of coins and coin like metallic foreign bodies.
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http://dx.doi.org/10.3791/58468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235163PMC
September 2018

Elevated Optic Disc Height and Increased Optic Nerve Sheath Diameter on Bedside Ultrasound in a Pediatric Patient With Orbital Cellulitis: More Than Meets the Eye.

J Emerg Med 2018 Dec 22;55(6):813-816. Epub 2018 Sep 22.

Children's Emergency, KK Women's and Children's Hospital, Singapore.

Background: Orbital cellulitis is an uncommon ophthalmological emergency in children, but rapid emergency department (ED) diagnosis is essential.

Case Report: A 13-year-old boy presented to our pediatric ED with left orbital cellulitis secondary to pansinusitis. Emergency bedside ocular ultrasonography was used to evaluate and expedite his management. Besides inflammatory changes observed on ultrasound of his affected orbit, the patient had an elevated optic disc height and increased nerve sheath diameter, which were not commonly reported in published literature on orbital cellulitis. Emergent computed tomography of the orbits and head showed orbital cellulitis without complications of orbital abscess or cavernous sinus thrombosis. Despite initiating early appropriate antibiotics, there was rapid progression of his disease and he developed intraconal abscess and cavernous sinus thrombosis the following day. After emergency surgical drainage of his pansinusitis, antibiotics, and anticoagulation, he was discharged well after a 2-week hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: There are important advantages of using bedside ultrasonography for diagnosis of pediatric orbital cellulitis in the ED setting. Further research should be done to evaluate the clinical significance of an enlarged optic nerve sheath diameter and raised optic disc height in pediatric orbital cellulitis.
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http://dx.doi.org/10.1016/j.jemermed.2018.08.006DOI Listing
December 2018

Urachal Cyst Diagnosed by Point-of-care Ultrasound.

Clin Pract Cases Emerg Med 2017 Nov 18;1(4):374-376. Epub 2017 Oct 18.

University of Toronto, The Hospital for Sick Children, Department of Pediatrics, Division of Emergency Medicine, Toronto, Canada.

Irreducible umbilical swelling in infants is considered a surgical emergency because a delay in surgical intervention for an incarcerated umbilical hernia can lead to bowel ischemia and necrosis. We report two patients who presented to a pediatric emergency department with history and symptoms of irreducible umbilical mass suggestive of umbilical hernia. Point-of-care ultrasound was used at the bedside to demonstrate the presence of urachal cyst remnants and accurately guided the care of these children.
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http://dx.doi.org/10.5811/cpcem.2017.9.34905DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965218PMC
November 2017

Emergency Department Diagnosis of Idiopathic Pneumoparotitis with Cervicofacial Subcutaneous Emphysema in a Pediatric Patient.

Clin Pract Cases Emerg Med 2017 Nov 3;1(4):399-402. Epub 2017 Nov 3.

KK Women's and Children's Hospital, Department of Pediatric Emergency Medicine, Singapore.

Idiopathic pediatric pneumoparotitis, being rare, is often misdiagnosed in acute care settings, resulting in inappropriate initial management and emergency department (ED) disposition. We report the case of a previously well 11-year-old boy who presented to our ED with acute left cheek swelling and pain. He was diagnosed with pneumoparotitis with cervicofacial subcutaneous emphysema with the aid of point-of-care ultrasound (POCUS) and radiographs. Despite appropriate initial ED and inpatient management, he developed bilateral involvement and pneumomediastinum. After 72 hours, his condition improved and he was discharged well after five days of hospitalization. This case report highlights the use of POCUS and radiographs to facilitate an early diagnosis and appropriate ED disposition.
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http://dx.doi.org/10.5811/cpcem.2017.7.34879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965225PMC
November 2017

Handheld Metal Detector for Metallic Foreign Body Ingestion in Pediatric Emergency.

Indian J Pediatr 2018 08 4;85(8):618-624. Epub 2018 Jan 4.

Children's Emergency, K K Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.

Objective: Foreign body ingestion is a common problem for which children present to the emergency department. The most common ingested foreign bodies among children are coins. Metal detector is an equipment, which measures a change in inductance of a coil when an electroconductive material is placed near it and produces an audio-visual signal. The present study was conducted to determine the effectiveness and feasibility of HMD in the local Pediatric population.

Methods: This was a prospective study conducted in the pediatric emergency department among children presenting with history of foreign body ingestion. The outcome measured was presence or absence of metallic foreign body detected on handheld metal detector examination.

Results: During the study period, 36 patients with history of foreign body ingestion presented to the emergency department. Among these, 28 were metallic foreign body ingestions. Coins were the most common type of foreign body ingested. Among the metallic foreign bodies ingested, all the coins were accurately identified by the handheld metal detector. Non-coin metallic foreign bodies like metallic screw, needle and stapler pin were not identified by the handheld metal detector.

Conclusions: The study demonstrates that handheld metal detector can be safely and reliably used as a screening tool in the process of detecting ingested coins. The plain radiograph still appears to be superior as it accurately localizes sharp metallic objects as well as cell batteries (button batteries) which need to be detected early and removed in order to prevent complications. Handheld metal detector is an effective tool that can be used in the follow up of patients to confirm whether the coin like metallic foreign body has been expelled. Handheld metal detector examination is more sensitive than traditional X-ray examination to detect radiolucent metallic foreign bodies like aluminium.
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http://dx.doi.org/10.1007/s12098-017-2552-5DOI Listing
August 2018

Dental injuries in younger emergency department patients.

CJEM 2018 05 13;20(3):425-431. Epub 2017 Jul 13.

*Division of Pediatric Emergency Medicine,Department of Pediatrics,The Hospital for Sick Children,University of Toronto,Toronto,ON.

Background: Dental trauma is a relatively common occurrence in childhood, with an impact exceeding that of periodontal diseases. It places a significant burden on the public health system because of its high frequency, impact on quality of life and consumption of resources.

Objectives: To identify changing trends of dental injury in patients between 0-18 years of age in Canada and provide a detailed assessment of dental injury patterns in patients attending a large pediatric tertiary care hospital.

Methods: This retrospective study was carried out in two parts. Firstly, data from patients who presented to the emergency departments of the 15 Canadian hospitals involved in the Injury Reporting and Prevention Program (CHIRPP) from 1st January 1990 to 31st December 2013 was collected. Secondly, at the Hospital for Sick Children, charts of patients identified from the aforementioned database from the years 2008, 2012 and 2015 were accessed for additional clinical data.

Results: Based on CHIRPP data there appears to be an increasing incidence in dental injuries presenting to emergency departments nationally. Participation in sports and cycling contributed to the majority of dental injuries. The use of safety equipment such as helmets with a face-grill and mouth-guard was low.

Conclusions: Our study demonstrates a rising incidence of dental injuries in young patients. Most dental injuries occurred during sports and playground related activities. The low rate of use of safety equipment and playground safety measures suggests that Canadian Standards Association standards for playgrounds could be more effective if strengthened by mandatory legislation.
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http://dx.doi.org/10.1017/cem.2017.52DOI Listing
May 2018

Point-of-care ultrasound identification of pneumatosis intestinalis in pediatric abdominal pain: a case report.

Crit Ultrasound J 2017 Dec 19;9(1). Epub 2017 Jan 19.

Children's Emergency, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.

We describe a case report of an infant with intussusception who presented to a pediatric emergency department with diarrhea and increased irritability. Pneumatosis intestinalis (intra-mural air) detected on point-of-care ultrasonography (but not apparent on plain abdominal radiographs) alerted the emergency physicians towards the severity of disease process.
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http://dx.doi.org/10.1186/s13089-017-0057-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5247383PMC
December 2017

Point-of-care ultrasound in pediatric small bowel obstruction: an ED case series.

Am J Emerg Med 2016 Dec 6;34(12):2464.e1-2464.e2. Epub 2016 Jun 6.

Paediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2016.06.021DOI Listing
December 2016
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