Pediatric emergency care最新文献

Objectives: To describe the characteristics and selected quality improvement (QI) measures of pediatric emergency department (ED) encounters within Epic Cosmos.

Methods: We performed a retrospective study within Cosmos of all pediatric (<18 years) US-based ED encounters between January 1, 2020, and June 30, 2025. We summarized demographics, visit characteristics, and diagnoses. We evaluated QI metrics for key conditions.

Results: We included 41,735,030 ED encounters from 18,757,872 distinct patients. The median encounter age was 6 years (IQR 2 to 12) and 52.0% were male. Most patients were White (58.7%), non-Hispanic (67.4%), publicly insured (58.5%), urban-dwelling (85.7%), and nearly half resided in the South (47.6%). The most common chief complaints were fever (16.6%), cough (11.7%), vomiting (8.2%), and abdominal pain (7.4%). Most patients were triaged as Emergency Severity Index (ESI) 4 (45.4%) or ESI 3 (35.7%), and 88.3% were discharged from the ED. QI metric analysis demonstrated corticosteroid use for asthma in 86.3% of encounters, chest radiography among children with asthma in 42.8%, brain CT for head injury in 18.6%, antibiotic use for viral illness in 4.8%, corticosteroid use for croup in 91.7%, intravenous fluid use for dehydration in 10.7%, and topical anesthesia use for lacerations in 56.4%.

Conclusions: We characterized pediatric ED encounters within the Epic Cosmos platform, which is consistent with national patterns of pediatric ED care. These findings highlight the utility of Cosmos for assessing care quality and variability in pediatric emergency medicine, although findings should be interpreted cautiously given variability in coding, data mapping, and institutional representation.

Background: Transient synovitis (TS) is a benign condition characterized by acute hip pain and is a common cause of limping in children. Ultrasonography (US) examination frequently reveals hip joint effusion. However, accurate documentation of its prevalence among children with a diagnosis of TS is scarcely documented in the literature.

Objectives: The main objective of our study was to evaluate the prevalence of hip joint effusion among children diagnosed with TS in the pediatric emergency department (PED).

Methods: A Retrospective chart review of children diagnosed with TS in the PED between 2017 and 2021 who underwent an US examination as part of their evaluation.

Results: Overall, 392 children with a mean age of 5 years were included in the study group, of whom hip effusion was demonstrated in 302 (77%) patients. Most participants underwent point-of-care ultrasound (POCUS) performed by the PED physician as part of their evaluation (328, 83%). Children with hip joint effusion had higher pain levels, hip joint tenderness, and higher CRP values compared with children without an effusion.

Conclusions: In our study, the prevalence of hip joint effusion among children presenting to the PED with a final clinical diagnosis of TS was 77%. Higher pain levels and hip joint tenderness were associated with the presence of hip effusion in TS.

Purpose: The anatomic position of the appendix may influence both the clinical presentation and diagnostic imaging accuracy in pediatric appendicitis, but its impact remains uncertain. This study aimed to determine the prevalence of retrocecal appendicitis in children and to evaluate whether appendix positioning affects ultrasound diagnostic performance or clinical outcomes.

Methods: This was a retrospective cohort study including all children 0 to 18 years of age who presented to the Mayo Clinic Rochester Emergency Department between 2018 and 2023 and were diagnosed with appendicitis during their evaluation or subsequent hospitalization. Appendix location was determined by imaging or surgical documentation. Demographics, symptoms, signs, and complication rates were collected for patients with retrocecal appendicitis (RCA) and non-retrocecal appendicitis (NRCA).

Results: Four hundred seven patients were included with 12.5% having RCA. Ultrasound was obtained in 92% of patients with RCA versus 82% of NRCA (rate difference: 10%, 95% CI: 2%-19%, P=0.018). In patients who received ultrasound imaging, findings were equivocal or falsely negative in 53% of RCA patients versus 30% of NRCA patients (RD = 24%, 9%-39%; P=0.003). Computed tomography (CT) was obtained in 51% of RCA patients versus 29% of NRCA (RD = 22%, 8%-37%; P=0.003) and was equivocal or falsely negative at similar rates in RCA (12%) and NRCA (13%; P=0.88). Clinically, there were no differences in diarrhea, emesis, location of abdominal pain, or white blood cell counts between RCA and NRCA. Rates of perforation, abscess formation, hospitalization longer than 7 days, and repeat hospitalizations were also similar.

Conclusions: Retrocecal appendicitis is a common anatomic variant in children that presents with similar clinical features and outcomes compared with non-retrocecal appendicitis. However, its retrocecal position reduces the diagnostic sensitivity of limited abdominal ultrasound, often necessitating additional imaging with computed tomography. Despite these diagnostic challenges, retrocecal positioning is not associated with a worsened clinical course.

Objectives: Lumbar puncture (LP) is an essential skill in which pediatric and emergency medicine trainees should be proficient. Despite its importance, research indicates that LP success rate in new graduates trained using traditional methods is only around 24% to 54%. Simulation provides the ideal grounds for practicing and refining this skill safely. This systematic review aimed to examine the use of simulation in teaching pediatric lumbar puncture to medical students and pediatric and emergency medicine trainees.

Methods: Five electronic databases (EMBASE, Medline, CINAHL, Web of Science, and PsycINFO) were searched, alongside grey literature and reference list screening. Studies that used simulation-based educational methods to teach pediatric LP in undergraduate and postgraduate pediatric and emergency medicine education were included. Methodological rigor was evaluated using the QuADS tool.

Results: Of the 17 included studies, most used partial/task trainers (eg, frequency building trials on task trainers; 82.4%) or mixed simulation methods (eg, video-recorded 'informed consent' OSCE followed by simulated LP on an infant simulator; 17.6%). Most simulation sessions were time-based (focused on the amount of time spent practicing clinical skills; n=10, 58.8%), whereas outcome-based learning (focused on the achievement of specific learning objectives) was used by 8 studies (47.1%). Training was frequently assessed in terms of knowledge and skills (70.6% of studies), behavior (52.9%), reactions to the training (17.6%), and attitudes (5.9%). Outcomes were mostly positive (64%) or had no clear effect (36%), with most positive outcomes related to knowledge and skills (75%), reactions (66.7%), and behavior (55.6%).

Conclusions: Research is needed to determine which modalities suit differing learning outcomes and stages of LP skill development. Studies favored time-based learning, highlighting the need for outcome-based, learner-centric LP programs. Simulation programs positively impacted knowledge and skills; however, behavioral, organizational, and patient impact warrants further research.

Objectives: Prehospital emergency anesthesia (PHEA) is a critical intervention in pediatric prehospital emergency medicine but presents risks and unique challenges. Consequently, some services limit the provision of this practice. This study aimed to determine first-pass success (FPS) rates for pediatric PHEA delivered by the North West Air Ambulance (NWAA) service in the United Kingdom.

Methods: A 7-year retrospective analysis (April 3, 2018 to April 10, 2025) of pediatric PHEA cases managed by NWAA was conducted using a standardized quality database. All patients aged 0 to 15 years who underwent drug-assisted intubation were included. The primary outcome was FPS, defined as successful tracheal intubation on the first attempt.

Results: During the study period, 1742 patients attended by NWAA underwent PHEA in the prehospital setting, of whom 161 were pediatric patients aged 0 to 15 years. In all, 96 pediatric patients underwent RSI. FPS was achieved in 96% of these patients, with all patients successfully intubated within a maximum of 3 attempts. Patients between 0 and 5 years had 95% FPS. For context, 1441 adults underwent prehospital RSI in the same period, with an FPS rate of 88%.

Conclusions: This study demonstrates that FPS rates for children undergoing PHEA in a well-trained, consultant-led prehospital service can be high, exceeding those reported in adults. Our findings provide reassurance that pediatric PHEA can be delivered safely and effectively when supported by senior clinicians, robust training, and rigorous governance. Concerns regarding FPS in children should focus on continued investment in training, service design, and audit, rather than limiting PHEA as a life-saving intervention. Further research is needed to assess whether these results are reproducible in other services, non-PHEA intubations, and across wider clinical outcomes.

Objectives: Diagnostic uncertainty is an important, yet understudied, driver of patient safety within pediatric emergency medicine. Understanding how uncertainty is experienced and communicated may reveal opportunities to optimize patient safety. This study aims to determine the frequency of physician-reported uncertainty at emergency department (ED) discharge for pediatric acute respiratory illness and to describe strategies and challenges in communicating uncertainty to caregivers.

Methods: This was a cross-sectional study of children (<18 y) discharged with acute respiratory illness from a tertiary care pediatric ED (April to May 2025). For each patient, the discharging attending physician completed a survey assessing diagnostic uncertainty (6-point Likert scale, dichotomized for analysis), and whether and how this was communicated to caregivers. Physicians indicated their general overall comfort communicating uncertainty. Wilson CIs were calculated around the prevalence of visits with uncertainty.

Results: Among 220 patients with acute respiratory illness, 68 (31%, 95% 25 to 37%) were discharged with diagnostic uncertainty. Uncertainty was communicated to 61 caregivers (90%) in the following ways: using terms such as "maybe," "probably," or "likely" (74%), provision of return precautions (59%), discussion of the differential diagnosis (56%), and discussion of diagnoses excluded (27%). Many (45% of 60 physicians surveyed) reported communication challenges, citing perceived caregiver expectations, anxiety, and risk communication concerns.

Conclusions: Diagnostic uncertainty occurred in nearly one-third of ED discharges for pediatric acute respiratory illness. Communication approaches varied, and several challenges were noted. Future research engaging clinicians and families is needed to address these challenges and develop optimal methods of family-centered communication of uncertainty.

Objective: The purpose of this study was to describe the prehospital care for neonatal resuscitations (age <6 h) encountered by emergency medical services (EMS) in the United States.

Methods: We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 data sets. We included EMS activations related to a 9-1-1 scene response for patients <6 hours old with evidence of resuscitative efforts or an out-of-hospital cardiac arrest. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics.

Results: A total of 580 EMS encounters were included, of which 184 (31.7%) involved out-of-hospital cardiac arrest. Median patient age was 30 minutes (IQR: 5 to 60). Most responses were by advanced life support (93.1%), and median total prehospital time was 32.8 minutes (IQR: 24.0 to 45.9). The majority of encounters took place in a private residence (73.3%) in an urban setting (83.2%). The patient was left on scene in 3.1% of encounters, and all others were transported to the hospital. Basic airway management was most often required (74.3%), oxygen was delivered in 43.5% of cases, and advanced airway management was performed in 5.7% of encounters. Field delivery was performed in 20.5% of encounters, and compressions/defibrillation were performed in 21.2% of cases.

Conclusion: Prehospital neonatal resuscitation by EMS is uncommon but often requires advanced interventions rarely performed by EMS on newborn patients. These findings have important implications for EMS training and education, including the development of protocols, training programs, and other preparedness innovations for neonatal resuscitation specific to the prehospital setting.

Objectives: Acute agitation is a behavioral health emergency necessitating timely, effective intervention. Consensus guidelines recommend de-escalation techniques before restraint use. We examined the impact of de-escalation training on attitudes, knowledge, and behaviors of interdisciplinary staff caring for agitated patients in the pediatric emergency department (PED).

Methods: Asynchronous, multi-faceted de-escalation training interventions were delivered biweekly in an urban tertiary care PED as one facet of a quality improvement initiative to reduce disparities in physical restraint use. An electronic survey including the Management of Aggression and Violence Attitude Scale (MAVAS) plus questions on knowledge of and behaviors with pediatric agitation was distributed before and after the training interventions. Baseline and post-intervention survey results were compared, measuring changes in attitudes, knowledge, and self-reported behaviors.

Results: Sixty-one of 148 (41%) eligible participants completed the baseline survey and 44 (30%) completed the post-intervention survey. Post-intervention, participants were less likely to agree that it is difficult to prevent patients from becoming violent or aggressive (OR=0.31, 95% CI: 0.14-0.70) or that internal causative factors contribute to patient aggression (OR=0.50, 95% CI: 0.26-0.97). Post-intervention, respondents were more likely to recognize existing racial disparities in pediatric restraint use (OR=3.41, 95% CI: 1.64-7.09) and to believe that agitated patients were verbally de-escalated without restraint use often (OR= 2.11, 95% CI: 1.02-4.37).

Conclusions: After implementing asynchronous, multi-faceted de-escalation training, PED staff positively shifted their attitudes of children with acute agitation, improved knowledge about disparities in their care, and were more likely to believe that verbal de-escalation of agitated patients without restraint use was used often. De-escalation training can be easily implemented and impactful, and these data warrant further investigation into best de-escalation practices.

Objectives: Unintentional injury is a leading cause of morbidity and mortality in children. The Accreditation Council for Graduate Medical Education (ACGME) requires competency in medical and trauma resuscitation in patients from newborn through adulthood. Yet there is a paucity of data regarding best practices for pediatric trauma training. The goal of this study was to evaluate knowledge gaps in pediatric trauma training, implement a trauma simulation curriculum, and evaluate changes in fellows comfort level with trauma skills preimplementation and postimplementation.

Methods: We utilized Kern's 6-step approach to design an innovative longitudinal trauma curriculum for Pediatric Emergency Medicine (PEM) fellows. A needs assessment was sent to PEM faculty, PEM fellows, pediatric surgery faculty, pediatric surgery fellows, and pediatric ED nursing. Learning objectives were derived and categorized as technical skills, nontechnical skills, and case-based medical knowledge. This guided a year-long curriculum including 11 simulation cases and 3 didactic sessions. The curriculum was assessed at Kirkpatrick levels 1 and 2 through preimplementation and postimplementation surveys. We assessed fellows' self-reported comfort and faculty perception of the supervision required.

Results: Fellows began with higher overall comfort with nontechnical skills compared with technical skills. Following implementation, there was a statistically significant improvement in fellow comfort in overall technical skills ( P < 0.05), traction splint application ( P < 0.05), and initiating massive transfusion protocol ( P < 0.05). There were positive trends in obtaining access, placing pelvic binders, managing increased intracranial pressure, and leadership skills. There were no statistically significant findings noted in the surveys completed by the faculty.

Conclusions: This study presents a promising foundation for a comprehensive longitudinal pediatric trauma curriculum. Our study, while small, showed overall improvement in fellow comfort with trauma resuscitation at Kirkpatrick level 1, most notably with technical skills. Future areas of research include increased sample size, enhanced skills assessment methods, and expansion to other trauma team stakeholders.

Objective: The objective of this study is to investigate differences in pain outcomes for pediatric trauma patients who receive Child Life Services versus pediatric trauma patients who do not.

Methods: Retrospective chart reviews were completed on patients birth to 21 years of age who were seen by trauma services in the Emergency Department and various inpatient units. These individuals were characterized into 2 groups: those seen by child life specialists and those who were not. Pain scores were recorded by using the following scales: face, legs, activity, cry, consolability (FLACC), The Wong-Baker FACES, the Verbal Numeric Rating Score, and Critical Care Pain Observation Tool (CPOT). Baseline data included age, sex, race, injury type, Injury Severity Score (ISS), pain score, and length of stay. Patients were matched using the initial pain score and ISS score. An ordinal logistic model was built regressing pain at discharge on group (CLS visit or no CLS visit). Significance was set at P ≤0.05.

Results: One hundred ninety-six patients' data were used; 107 (54%) of them had been seen by child life specialists. The study groups had similar baseline demographics and injury severity scores. The pain score at discharge was significantly lower in children with child life services' visits (median=0, min=0, max=10) compared with those without [median=2, min=0, max=10; OR=0.48, 95% CI (0.28, 0.83), P =0.009].

Conclusions: Certified child life specialist involvement in pediatric trauma patients' care correlates to a lower pain score upon discharge.