Pediatric emergency care最新文献

Introduction: Needle-free procedural sedation (PS) is an attractive option for children presenting to the emergency department (ED) who require a painful procedure, as it avoids inflicting additional pain either with intravenous line placement or intramuscular injection. While use of oral (PO) ketamine has been reported in the literature, limited information is available to guide ED-based use in children.

Methods: This is a descriptive study of the patient experience receiving PS with the following regimen: PO ketamine 6 mg/kg (max of 200 mg) with or without PO midazolam 0.5 mg/kg (max 15 mg) approximately 30 minutes before a procedure. We performed a retrospective chart review of children younger than 18 years receiving this PS regimen at a tertiary care children's hospital ED and an affiliated community hospital ED from January 1 through September 30, 2023.

Results: Fifty-eight children were sedated with PO ketamine during the study period. The most common procedure performed was laceration repair (46.5%), followed by incision and drainage (17.3%). All but 2 children received PO midazolam along with PO ketamine. Eight patients received additional medications due to inadequate sedation. Sedation depth was clinician-reported as moderate in 74.1% (43), mild in 15.5% (9), and deep in 10.3% (6). Procedures were completed in 98.3% (57) cases. 93.1% (54) of patients had no adverse event (AE) of any kind and no patient had a significant adverse event (SAE).

Discussion: PO ketamine with or without midazolam resulted in procedure completion of a variety of procedures in the pediatric ED with minimal AE, no SAE, and without need for additional sedative medications in 86.2% (50). This regimen is an option for needle-free moderate PS in this setting. Further study is needed to clarify the benefit of the addition of midazolam to PO ketamine, rates of AE and SAE, sedation duration, and recovery times.

Objective: Dengue has emerged as the most widely spread mosquito-borne disease, hyperendemic in India. Although severe dengue occurs only in a small proportion of cases, delays in the recognition and management can result in significant morbidity and mortality. Risk stratification of children in the emergency care and identifying those at risk for worsening during hospital stay facilitates optimum utilization of health care resources. The objective of our study was to develop and validate a scoring model to predict the development of severe dengue in hospitalized children by identifying risk factors present in them at the time of admission in emergency department.

Methods: A retrospective study of consecutive children aged 1 month to 18 years admitted with serologically confirmed dengue from January 2019 through December 2021 was conducted. Analysis of clinical and laboratory parameters of children resulted in the development of a comprehensive predictive scoring model. This model was internally validated prospectively on 107 children presenting with nonsevere dengue in the emergency care.

Results: A total of 743 children with confirmed dengue were studied out of which 216 (29.1%) had severe dengue. Presence of third spacing (odds ratio [OR] 3.74, 95% confidence interval [CI] 1.088-7.42, P < 0.001), tender hepatomegaly (OR 1.62, 95% CI 1.04-2.52, P < 0.032), respiratory distress (OR 3.50, 95% CI 1.89-6.51, P < 0.001), and moderate (OR 3.51, 95% CI 1.82-6.74, P < 0.001) to severe (OR 4.76, 95% CI 2.59-8.76, P < 0.001) elevation of aspartate aminotransferase were independent risk factors found to be associated with development of severe dengue. A score ≥7 had a specificity of 87%, negative predictive value of 86%, and overall diagnostic accuracy of 78.5% for predicting severe dengue.

Conclusions: The dengue severity scoring model was found to have reasonable diagnostic accuracy in predicting severe disease prior to hospitalization. However, more studies are required to validate the score in different emergency care settings with varied pediatric populations.

Objective: The aim of the study is to determine if there is a correlation between perceived staff workload, measured by the NASA Task Load Index (TLX), and the National Emergency Department Overcrowding Scale (NEDOCS) in a pediatric ED.

Methods: We collected staff questionnaires in a large, urban pediatric ED to assess perceived workload on each of six different TLX subscales, which we weighted evenly to create an overall estimate of workload. We evaluated the correlation between individual TLX responses and NEDOCS overall and by staff subgroup. Additionally, we analyzed: (1) the correlation between mean TLX responses and NEDOCS within a given hour and (2) the performance of a logistic regression model, using TLX as a predictor for "severely overcrowded," as measured by NEDOCS.

Results: Four hundred one questionnaires between 6/2018 and 1/2019 demonstrated significant variation between concurrently collected TLX responses and an overall poor correlation between perceived workload and NEDOCS (R2 0.096 [95% confidence interval, 0.048-0.16]). TLX responses by subgroups of fellows (n = 4, R2 0.96) and patient financial advisors (n = 15, R2 0.58) demonstrated the highest correlation with NEDOCS. Taking mean TLX responses within a given hour, during periods with NEDOCS >60 (extremely busy or overcrowded), a polynomial trend line matched the data best (R2 0.638). On logistic regression, the TLX predicts "severely overcrowded" with an area under the curve of the receiver operating characteristic of 0.731.

Conclusions: NEDOCS does not have a strong correlation with individual responses on questionnaires of perceived workload for staff in a pediatric ED. NEDOCS, as a measure of overcrowding, may be better correlated with perceived workload during periods with elevated crowding or when interpreted categorically as yes/no "severely overcrowded".

Objectives: Major studies have defined clinical rules to regulate the use of computed tomography in children after head trauma. Infants younger than 3 months are considered at higher risk of brain injuries than older children and at the same time at higher risk of radiation-induced damage. Hence, it would be desirable to have clinical decision rules more adapted to this subset of patients. The objectives of this study are to compare the rate of brain injuries in children younger than 3 months or 3 to 24 months and to assess predictors of clinically important traumatic brain injuries (ciTBIs) (the ones causing death, neurosurgical intervention, long intubation, or hospitalization for 2 days or more) in the former group.

Methods: Records of children younger than 24 months evaluated in a single emergency department for minor head trauma during a 3 years period were retrospectively reviewed. The rates of brain injuries were compared in children younger or older than 3 months. Variables associated with severe lesions were assessed in younger children.

Results: The study included 744 patients, 86 (11.6%) aged 0 to 90 days and 658 (88.4%) aged 91 to 730 days. Within the young group, we found higher rates of traumatic brain injuries (14.0% vs 4.1%, P = 0.0008) and ciTBI (8.1% vs 1.5%, P = 0.002) compared with the old group. A significant correlation with ciTBI in the young group was observed for heart rate (odds ratio [OR], 12.3; 95% confidence interval [CI], 2.4-62.4), nonfrontal scalp hematoma (OR, 9.2; 95% CI, 1.8-46.1), severe mechanism (OR, 5.6; 95% CI, 1.1-27.6), presence of hematoma (OR, 6.1; 95% CI, 1.2-30.0), hematoma size >3 cm (OR, 23.8; 95% CI, 4.2-135.6), and hematoma location (OR, 9.2; 95% CI, 1.8-46.1).

Conclusions: Children younger than 3 months presenting after minor head trauma constitute a relevant population. Available clinical predictors well correlate with ciTBIs in this age group.

Objectives: Clinical event debriefing (CED) improves healthcare team performance and patient outcomes. Most pediatric emergency medicine (PEM) physicians do not receive formal training in leading CED. Our objectives were to develop a CED curriculum and evaluate its effect on performance, knowledge, comfort, and clinical practice.

Methods: This was a single group pre-post-retention study. We developed a hybrid curriculum with simulation, an interactive module, and individual feedback. We invited faculty and fellows from the PEM division of our hospital to participate. During an in-person training day, participants led standardized clinical simulation scenarios followed by simulated CED with immediate feedback on their leadership performance. They watched an interactive module between scenarios. Participants returned for a retention assessment 2-6 months later with a third simulation and debrief. Participants completed surveys measuring attitudes, experiences, and knowledge. Participants also evaluated the curriculum.The primary outcome was CED leadership performance using a novel 21-item tool that we developed, the Debrief Leadership Tool for Assessment (DELTA). A blinded, trained rater measured performance with DELTA. Secondary outcomes included changes in knowledge and comfort and changes in clinical practice.

Results: Twenty-seven participants enrolled and completed all parts of the curriculum and assessments. Debrief leadership performance improved by a mean of 3.7 points on DELTA pre-training to post-training (95% confidence interval = 2.7, 4.6, P < 0.01) and by 1.4 points from pre-training to retention (95% confidence interval = 0.1, 2.8, P = 0.03). Knowledge and comfort also significantly improved from pre-training to post-training and were sustained at retention. Most (67%) participants changed their clinical practice of CED after completing the curriculum. All participants would recommend the training to other PEM physicians.

Conclusions: A hybrid simulation-based curriculum in leading CED for PEM physicians was associated with improvement in CED leadership performance, knowledge, and comfort. PEM physicians incorporated training into their clinical practice.

Purpose: Diagnosis of acute appendicitis is more difficult in children aged 0-4 years due to atypical clinical presentation, leading to delay in diagnosis and higher incidence of complications. Nonvisualization of the appendix on ultrasound increases diagnostic challenge. We examined the utility of standardized reporting of sonographic secondary signs of appendicitis in children younger than 5 years with nonvisualization of the appendix.

Methods: A retrospective cohort study of children younger than 5 years who underwent appendectomy following nonvisualization of the appendix on ultrasound from 2016 to 2022 was performed. Primary outcome was comparison of ultrasound and intraoperative findings. Two-sample t test and Wilcoxon sum-rank test compared continuous variables, and Fisher exact test compared categorical variables. Univariate and multivariate logistic regression analyses were performed to assess risk factors for complicated appendicitis in those with category 3 ultrasounds.

Results: Overall, 92 patients whose appendix was not visualized on ultrasound were included: 26 without secondary signs (category 2) and 66 with secondary signs (category 3). Significant differences in intraoperative findings between category 2 and category 3 patients existed (P < 0.001). On intraoperative assessment of patients with ultrasound category 2, 3.8% had no appendicitis, 46.2% had simple appendicitis, 34.6% had complicated appendicitis, and 15.4% underwent interval appendectomy. Conversely, of category 3 patients, 0% had no appendicitis, 7.6% had simple appendicitis, 48.5% had complicated appendicitis, and 43.9% underwent interval appendectomy. On logistic regression, in children with category 3 ultrasounds, presence of both fluid collection and free fluid as secondary signs was associated with intraoperative findings of complicated appendicitis. However, number of secondary signs was not significantly associated with increased likelihood of complicated appendicitis intraoperatively.

Conclusion: Presence of secondary signs without visualization of the appendix was shown to be indicative of appendicitis, with high suspicion for complicated appendicitis, in patients younger than 5 years. Further validation of the presence of secondary signs on right-lower-quadrant ultrasound may lead to more expedient diagnosis, reduction in cross-sectional imaging, and earlier treatment of complicated appendicitis.

Context: Family-centered care is a critical component of critical care interfacility and medical retrieval transport (MRT) services. These services provide a critical bridge for a physiologically and psychologically unique population often best served in specialized, tertiary centers. Caregivers often wish to accompany patients during MRT. However, there is currently little research on the impact of caregiver accompaniment on MRT.

Objective: The aim of the study is to determine: 1) What are caregiver attitudes to accompanied and unaccompanied MRT? 2) What are healthcare provider attitudes to caregiver presence? 3) What are patient attitudes to caregiver presence? and 4) Are there differences in patient outcome depending on caregiver presence?

Data sources: Data sources are MEDLINE, Embase, and CINAHL.

Study selection: Studies with a focus on patient, caregiver, or family-oriented care practices in MRT. Reviewed articles were not restricted unless they discussed neonatal transport, palliative transport, were non-English, or were conference proceedings.

Data extraction: We screened 1373 articles, with 45 full-text articles reviewed. After removal of duplicates and abstract-only results, 25 articles remained. Three additional articles were found in references of reviewed articles.

Results: Articles generally supported caregiver presence on MRT, with caregivers and providers in agreement. However, for many services, space was a limiting factor controlling when caregivers could travel.

Limitations: There is a paucity of literature on this topic, and studies were entirely from English-speaking countries.

Conclusions: Caregivers and healthcare providers largely prefer caregiver accompaniment on MRT services. There is little data on patient perspectives and transport-related adverse events affecting patient outcomes.

Introduction: Scorpion envenomation is a leading cause of envenomation in our region. Antivenom has been used successfully to treat the systemic manifestations of envenomations inflicted by toxic scorpions. Toxic scorpions common in our area include Leiurus quinquestriatus, Androctonus australis, and Buthus occitanus. This study describes the outcomes of children envenomated by these scorpions, and treated with SCORPIFAV, a polyvalent scorpion antivenom F(ab')2 (equine), used since 2016 at our institution.

Methods: A retrospective chart review of all children admitted with symptoms and signs of scorpion envenomation to Soroka University Medical Center, between September 1, 2019, and December 1, 2020, who received antivenom SCORPIFAV. Our center has a protocol mandating antivenom therapy for all patients manifesting autonomic excitation, agitation, and anxiety, or more pronounced symptoms, following suspected scorpion envenomation.

Results: Three hundred patients were seen in the pediatric emergency department for scorpion envenomation during the study period, and 49 required antivenom (SCORPIFAV) as per departmental policy. Four of 49 developed allergic reactions during antivenom treatment: 2 manifested minor skin rashes treated with antihistamines only, and a further 2 required intramuscular adrenaline. There were no deaths in the study cohort and all patients recovered fully, with complete resolution of symptoms, signs, and laboratory features.

Conclusions: Patients treated with antivenom exhibited rapid resolution of symptoms without severe hypersensitivity. We recommend broadened availability of antivenom at sites where it is needed.

Objectives: Each year, 5.3 million children under 5 years of age die in low-resource settings, often due to delayed recognition of disease severity, inadequate treatment, or a lack of supplies. We describe the use of a comprehensive digital facility-readiness survey tool, recently developed by the Pediatric Sepsis Data CoLaboratory, which aims to identify target areas for quality improvement related to pediatric emergency and critical care.

Methods: Facility-readiness surveys were conducted at six sub-Saharan African hospitals providing pediatric emergency and critical care in Uganda (n = 4) and Cameroon (n = 2). The tool is a 2-phase survey to assess readiness to provide pediatric essential emergency and critical care: (1) an "environmental scan," focusing on infrastructure, availability, and functionality of resources, and (2) an "observational scan" assessing the quality and safety of care through direct observation of patients receiving treatment for common diseases. Data were captured in a mobile application and the findings analyzed descriptively.

Results: Varying levels of facility readiness to provide pediatric emergency care were observed. Only 1 of 6 facilities had a qualified staff member to assess children for danger signs upon arrival, and only 2 of 6 had staff with skills to manage emergency conditions. Only 21% of essential medicines required for pediatric emergency and critical care were available at all six facilities. Most facilities had clean running water and soap or disinfectants, but most also experienced interruptions to their electricity supply. Less than half of patients received an appropriate discharge note and fewer received counseling on postdischarge care; follow-up was arranged in less than a quarter of cases.

Conclusions: These pilot findings indicate that facilities are partially equipped and ready to provide pediatric emergency and critical care. This facility-readiness tool can be utilized in low-resource settings to assist hospital administrators and policymakers to determine priority areas to improve quality of care for the critically ill child.

Objective: The aim of the study is to determine the epidemiology, cost, and factors associated with hospital admission, deterioration if hospitalized, and mortality for children with a history of clinically significant cardiovascular disease (CVD) presenting to pediatric emergency departments (EDs).

Study design: Using the Pediatric Health Information System, we performed a retrospective analysis of ED encounters of children ≤17 years old with clinically significant CVD between 2016 and 2021. Patients were included if they had a cardiovascular complex chronic condition, defined by ICD diagnosis, and procedure codes. We assessed the primary diagnosis, admission rate, ICU transfer rate (as a marker of disease progression), mortality, resource utilization, and costs. We conducted multivariable analyses to identify risk factors for admission, ICU transfer, and mortality.

Results: There were 201,551 ED visits (mean 33,592 ± 3354 per year) among 129,938 children with clinically significant CVD. Most ED encounters had a primary diagnosis of a circulatory (21.1%) or respiratory (19.7%) illness. Seventy-six percent of visits had at least one blood test or imaging study conducted. The overall admission rate was 59.7%, with 28.7% admitted to the ICU, and 6.2% transferred to the ICU after the first 24 hours. The median costs for encounters resulting in admission were $13,605 in US 2023 dollars. In multivariable analyses, younger age, a greater number of noncardiac complex chronic conditions, and CVD type were associated with increased odds of admission, ICU transfer after 24 hours, and mortality (all P < 0.05).

Conclusions: ED visits for children with clinically significant CVD lead to substantial resource utilization, including frequent hospitalization, ICU level of care, and costs. This baseline data aids in the development of prospective studies to inform the appropriate ED management for children with clinically significant CVD.