Pediatric emergency care最新文献

Objectives: Traumatic cervical spine injuries in pediatric populations are uncommon, accounting for 1% to 10% of spinal trauma cases. Cervical facet dislocations are particularly rare and usually result from high-energy trauma. This study presents a rare instance of a C5/C6 facet dislocation caused by a low-energy mechanism during judo and discusses management strategies based on a literature review.

Methods: This work includes a case report of a 15-year-old male with a C5/C6 facet dislocation sustained during judo practice. Imaging confirmed vertebral malalignment and a herniated disc without spinal cord compression. The patient was treated with closed reduction, followed by anterior cervical discectomy and fusion (ACDF), incorporating a polyetheretherketone cage and titanium plating. In addition, a systematic literature review was conducted to evaluate current evidence and recommendations for the management of similar injuries in pediatric populations.

Results: Postoperative outcomes showed significant pain relief and a full recovery within three months. Radiographs confirmed spinal stability and successful fusion. The literature review highlighted a variety of surgical and non-surgical strategies, emphasizing the need for tailored management approaches. Long-term follow-up considerations included potential growth-related deformities and adjacent segment degeneration.

Conclusions: This case underscores the complexity of diagnosing and treating cervical spine injuries in adolescents, especially following low-energy trauma. Successful outcomes rely on individualized treatment approaches and a multidisciplinary framework. Further research is necessary to refine management strategies for these rare injuries in pediatric populations.

Objective: To compare the use of intensive care for infants with bronchiolitis following a policy change increasing the rate maximums for high-flow oxygen given by nasal cannula [high-flow nasal cannula (HFNC)] allowable in the inpatient (IP) ward setting.

Methods: This was a retrospective pre-post cohort study at an urban, tertiary care children's hospital. Infants without complex chronic conditions presenting to the emergency department with bronchiolitis from December 2018 to March 2019 and December 2019 to March 2020 were included in the study. In December 2019, our institution increased the allowable HFNC flow rate on IP to 2 liters per minute/kilogram. The primary outcome was patient disposition from the emergency department. Secondary outcomes were the need for IP to pediatric intensive care unit (PICU) transfer, the need for care escalation to positive airway pressure or invasive mechanical ventilation, and hospital length of stay.

Results: In total, 1043 and 1104 patients were included in the 2018 to 2019 and 2019 to 2020 cohorts, respectively. Infants in the second cohort were more likely to be admitted, though this association was not significant after adjusting for patient age and triage acuity. Infants in the second cohort had a lower risk of admission to the PICU, before and after adjusting for age and triage acuity. The risk of IP-to-PICU transfer, risk of care escalation, and length of stay did not increase.

Conclusions: Increasing HFNC flow rates up to 2 liters per minute/kilogram on IP wards was associated with a reduction in intensive care admission and appears safe by balancing measures of care escalation.

Objective: Opioids are common substances involved in poisonings with increasing rates in fentanyl-related mortality since 2014. The COVID-19 pandemic compromised school attendance and supervision, which may have increased the risk of opioid ingestions in children. Our objective was to evaluate pediatric opioid poisonings in Connecticut before and during the COVID-19 pandemic.

Methods: This cross-sectional retrospective study used emergency department (ED) discharges involving children aged 0-17 years captured in the Connecticut Injury Surveillance System. International Classification of Diseases, 10th Revision, Clinical Modification codes were used to identify discharges involving opioids (T40.0-T40.4, T40.60, T40.69, F11). The χ 2 test was used to identify differences by pre-COVID (2017-2019) and COVID (2020-2022) periods. Rates were examined by age, sex, race/ethnicity, insurance, and discharge status.

Results: There were 1,386,796 ED discharges during the study period. Less than 1% involved opioid (N = 257) or fentanyl (N = 31) poisonings; no discharges were coded for both. The rate of opioid poisonings decreased 28.6%, from 2.1 to 1.5 per 10,000 ED visits. Subanalysis showed that the rate of fentanyl poisonings remained the same (0.2 per 10,000 ED visits). The rate of opioid poisonings was highest among non-Hispanic White children during both periods. However, there was a 57.7% increase in the rate of opioid poisonings in non-Hispanic Black children. The rate decreased for all other race/ethnic groups.

Conclusions: Results of our study showed a rise in opioid poisonings among non-Hispanic Black and elementary school-aged children during the COVID-19 pandemic. Future prevention efforts may choose to further investigate and understand the trends in the more vulnerable groups.

Objective: The aim of the stud is to determine whether intravenous magnesium sulfate (IVMg) is associated with hospitalization and time to albuterol every 4 hours in a cohort of children who received intensive asthma therapy (IAT) in the emergency department (ED).

Methods: This retrospective cohort study included children 2-18 years who received IAT, defined as 3 bronchodilators and corticosteroids within 60 minutes of ED triage, with or without IVMg in the ED between 2019 and 2021. Primary outcome was hospitalization and among hospitalized children, secondary outcome was time to albuterol every 4 hours. Additional secondary outcomes included adjuvant medications, respiratory support, and length of stay.

Results: Among 851 patient encounters, 61% (n = 516) received IAT with IVMg in the ED and most patients were hospitalized (n = 565, 66%). Patients who received IVMg had increased odds of hospitalization (adjusted odds ratio [aOR] 25.3, 95% confidence interval [CI] 14.49-42.52, P  < 0.001) and a longer time to albuterol every 4 hours (aOR 13.8, 95% CI 9.61-17.75, P  < 0.001), even when controlling for demographic and clinical markers of severe asthma. In the adjusted analysis, patients who received IAT with IVMg had increased odds of adjuvant medications in the ED (aOR 7.3, 95% CI 2.97-17.95, P  < 0.001) and respiratory support in the ED (aOR 3.6, 95% CI 2.22-5.85, P  < 0.001) and the inpatient setting (aOR 3.9, 95% CI 1.87-7.97, P  < 0.001).

Conclusions: Children who received IAT and IVMg in the ED for management of an acute asthma exacerbation had significantly higher odds of hospitalization without any improvement in the time to albuterol every 4 hours for admitted patients. The results of this observational study underscore the need for randomized controlled trials to determine the efficacy of IVMg for acute pediatric asthma.

Objectives: Delayed diagnosis of acute appendicitis in children may result in complex appendicitis with appendiceal perforation. Delayed diagnosis can result from missed opportunity for initial diagnosis (MOID) despite medical attention. Studies report MOID of less than 5% in pediatric emergency departments (EDs), but we hypothesized that many MOID occurs outside tertiary care facilities. Our goals were to determine the MOID rate in all presenting facilities in children with complex appendicitis and to identify associated risk factors.

Methods: Children (age ≤18) undergoing appendectomy for complex appendicitis between 2018 and 2022 at a single free-standing academic children's hospital were reviewed. Missed opportunity for initial diagnosis was defined as evaluation for related symptoms without a diagnosis of appendicitis within 7 days prior to appendectomy. Logistic regression and UpSet plots were used to identify associated risk factors.

Results: Of 856 children, 140 (16.4%) had MOID. Most MOID originated from nontertiary facilities [urgent care (38.6%), local EDs (26.4%), primary care (25.0%)] compared to our pediatric ED (11.4%). Compared to single-encounter diagnosis, MOID was associated with younger age (adjusted odds ratio per year [aOR] 0.93, 95% confidence interval [CI]: 0.88-0.97) and non-English/Spanish primary language (aOR 2.61, 95% CI: 1.18-5.76). Uninsured patients had lower MOID (aOR 0.22, 95% CI: 0.05-0.96). Missed opportunity for initial diagnosis was associated with more complications (33.6% vs 19.1%, P  < 0.0001), prolonged length of stay (6 vs 4 days, P  < 0.0001), and increased readmission (11.4% vs 6.6%, P  = 0.044).

Conclusions: Missed opportunity for initial diagnosis of complex appendicitis occurs in nontertiary care facilities, is more common in younger children and non-English/Spanish speakers, and is associated with worse outcomes, highlighting the need for interpreters and algorithmic evaluation in nontertiary care facilities.

Abstract: We report the use of point-of-care ultrasound to identify a hydropneumothorax in a 6-year-old previously healthy girl arriving at the emergency department in severe respiratory distress. The use of point-of-care ultrasound in this instance allowed for the expedient management and stabilization of the hydropneumothorax with emergent thoracentesis. The patient was ultimately found to have Streptococcus pyogenes bacteremia and necrotizing pneumonia.

Objectives: In the treatment of agitation in a pediatric emergency department (PED), it is common to use once or as needed (PRN) medications when nonpharmacological management options have failed. Currently, there is limited available evidence on the treatment of pediatric agitation. The objective of this analysis was to characterize the prescribing practices of once or PRN medications for the treatment of agitation in a PED at an academic medical center.

Methods: This was a retrospective chart review of all encounters in which a patient was administered once or PRN medications for agitation treatment in the PED from July 1, 2021, to June 30, 2022. Once or PRN medications were defined as any medication in the antipsychotic, benzodiazepine, and barbiturate classes along with diphenhydramine, clonidine, ketamine, and guanfacine. The primary outcome was to describe the prescribing patterns of the most utilized agents for the treatment of agitation in the PED. Secondary outcomes were to assess effectiveness and safety of the agents utilized.

Results: We reviewed 109 patient encounters in which a once or PRN medication was used for agitation treatment. The most common initial regimens were benzodiazepine monotherapy (n = 47; 43%), antipsychotic monotherapy (n = 23; 21%), and concurrent use of an antipsychotic, benzodiazepine, and diphenhydramine (n = 16; 15%). Patients required another administration of a once or PRN medication within 5 to 120 minutes of initial administration 11% (n = 12) of the time. No patients required rapid sequence intubation and one patient (0.9%) needed treatment for extrapyramidal symptoms.

Conclusions: Results indicate that there is not a standard regimen choice in the treatment of agitation in the PED; however, benzodiazepine monotherapy was used most frequently. Few adverse events occurred. Further research is needed to identify the optimal regimen choice for patients presenting with agitation in a PED.

Objectives: Despite being a frequent entry point of care, it remains unknown if families' needs are being met across pediatric emergency departments (PEDs). Study objectives were to describe caregivers' perceived overall PED experience and needs and to what extent these needs were met.

Methods: This descriptive, cross-sectional survey with medical record review was conducted in 10 Canadian PEDs. Caregivers completed electronic surveys in the PED and within 7 days postvisit. The primary outcome was the degree to which caregivers' overall needs were met in the PED.

Results: A total of 2005 caregivers participated; mean age was 37.8 (standard deviation 7.7) years and 74.3% (1462/1969) were mothers. Mean child age was 5.9 (standard deviation 5.1) years; 51.9% (1040/2003) were male. The median [interquartile range (IQR)] length of stay was 3.9 (2.6-6.1) hours. A total of 22.1% (322/1454) of caregivers reported that their overall needs were not adequately met (Likert scale 1-3/5). The top unmet needs during a PED visit were prompt medical care [20.3% (194/955)], access to practical items [16.8% (160/955)], and effective communication surrounding care [8.7% (83/955)]. Caregiver needs being met were associated with their child's needs being met [odds ratio (OR) 21.2 (13.1-34.2)], child's pain being well managed [OR 3.7 (2.4-5.6)], and satisfaction with overall length of stay [OR 2.6 (1.8-3.8)].

Conclusions: Almost one fourth of caregivers report their overall needs were not fully met. Improving the quality of PED experience through better communication (ie, wait time delays, medical updates) and earlier pain care initiation may improve family experiences while policymakers work nationally to address lengthy wait times.

Context: Postintubation sedation is a critical intervention for patients undergoing mechanical ventilation. Research in the intensive care unit (ICU) and adult emergency department (ED) demonstrates that appropriate postintubation sedation has a significant impact on patient outcomes. There are minimal published data regarding postintubation sedation for pediatric ED patients.

Objective: To identify, describe, and critique published literature on postintubation sedation in pediatric ED patients.

Data sources: Embase, Ovid Medline, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.Gov.

Study selection: Studies describing postintubation sedation in the ED for pediatric patients (<18 years of age) intubated in the ED via rapid sequence intubation (RSI) were included. Studies reporting intubation outside the ED, intubation not by RSI, or nonpediatric patients were excluded, as were studies not reporting novel human clinical research.

Data extraction: Data were abstracted by 2 authors using a standardized worksheet. Data included study design & setting, demographics, medications for RSI and postintubation sedation, administration of any or appropriately timed postintubation sedation, and predictive factors for postintubation sedation-related outcomes.

Results: A total of 10 studies were included, all of which were nonrandomized; there was significant heterogeneity and many key variables and outcomes were not consistently reported. Meta-analysis of eligible studies demonstrated pooled estimates of 77.3% (95% confidence interval [CI]: 62.5-92.0) for proportion of patients receiving any postintubation sedation, 43.5% (95% CI: 29.3-57.6) for proportion of patients receiving appropriately timed postintubation sedation, and 18.6 minutes (95% CI: 12.5-24.7) for median time to postintubation sedation, all with significant heterogeneity.

Conclusions: Data on postintubation sedation in pediatric ED patients are limited. Administration of postintubation sedation is inconsistent and may be substantially delayed. Further high-quality research into the use of postintubation sedation in this setting is needed, and appropriate postintubation sedation should be a target for quality improvement.