Pediatric emergency care最新文献

Objectives: Despite the existence of evidence-based guidelines from the Centers for Disease Control and Prevention, studies have demonstrated the need for improvement in the evaluation and treatment of adolescents and young adults with a possible sexually transmitted infection (STI) presenting for care in pediatric emergency departments (PEDs) and general emergency departments (EDs) in the United States. We created an implementation strategy plan for our PED designed to improve STI care for patients.

Methods: Using the Tailored Implementation in Chronic Diseases (TICD) determinants framework, we identified, prioritized, and investigated determinants of implementation success of our initiative. We then conducted stakeholder interviews to refine and design an implementation strategy plan that addressed identified barriers and facilitators.

Results: The resulting implementation strategy included: (1) a standardized STI care protocol; (2) electronic health record (EHR) enhancements, including smart phrases and tailored order sets; (3) staff training materials and academic detailing sessions for physicians and nurses; (4) an adolescent-friendly discharge instruction handout; (5) an EHR-based referral system to an adolescent health clinic; (6) visual aids to support accurate STI sample collection' and (7) an evaluation plan to assess protocol uptake, documentation quality, treatment accuracy, and follow-up linkage.

Conclusions: This TICD-informed, stakeholder-driven approach may serve as a model for EDs aiming to enhance STI care delivery for adolescent and young adult patients.

Introduction: Acute epididymitis (AE) in children usually responds to conservative therapy. However, in rare cases (1% to 2%), it may progress to severe complications such as testicular infarction or necrosis due to vascular compromise. We report a case of progressive segmental testicular necrosis following presumed post-infectious AE after a recent viral respiratory illness.

Methods: An 8-year-old boy presented with a 2-day history of left testicular pain, swelling, and erythema. Initial Doppler ultrasound revealed epididymal enlargement, hyperemia, and reactive hydrocele without signs of torsion. Urine culture was collected, and empirical ibuprofen and trimethoprim-sulfamethoxazole were prescribed.

Results: Six days later, symptoms worsened with increased swelling and pain. Repeat Doppler ultrasound demonstrated hypoechoic avascular areas and reduced flow, consistent with necrosis. Urine, blood, and smegma cultures were negative. Surgical exploration revealed extensive testicular necrosis without torsion, leading to simple orchiectomy. Histopathology confirmed ischemic necrosis secondary to an inflammatory process. The observed evolution supports the concept of TCS, in which rising intratesticular pressure due to venous congestion and extraluminal compression within the noncompliant tunica albuginea leads to impaired microcirculatory perfusion and ischemic necrosis.

Conclusions: Testicular necrosis is an exceedingly uncommon but serious complication of AOE in children. Persistent pain, increasing testicular size, or poor clinical response should prompt early Doppler reassessment and consideration of surgical exploration. Recognition of TCS as a possible pathophysiological mechanism may help guide timely diagnosis and intervention to prevent irreversible ischemic injury.

Objective: In the United States, firearm-related injuries are the leading cause of death in individuals aged 0 to 24 years and lead to substantial cost burden, mortality, and morbidity. This study identifies trends of pediatric firearm injury at this level I pediatric trauma center, which may inform violence prevention and firearm safety intervention at the local level.

Methods: This study is a retrospective review of the pediatric trauma registry at a level 1 pediatric trauma center of children (0 to 17.9 y) who presented between January 1, 2013 and December 31, 2022. Age, sex, race, ethnicity, number of GSWs, location of injury, disposition, intention, mortality, insurance status, length of stay, zip code of residence, location of shooting, hospital charges, and recidivism for firearm injury, police officer-related interactions, or violence-related events were reviewed and analyzed.

Results: There were 585 patient charts reviewed over the 10-year period. The rate of pediatric firearm injuries increased by almost 5 folds and fatality rates tripled from 2013 to 2022. The victims were predominantly male (82.9%), black (75.3), non-Hispanic (88.5%), and Medicaid holder/uninsured (86.3%). Assault accounted for 67% of all GSWs and 13.5% returned with an assault or violence-related concern; 6.4% returned for a GSW-related injury over the study period. The rate of firearm injuries increased from 9.09 (per 100,000) pre-COVID to 17.93 (per 100,000) post-COVID with a rate of 16.74 (per 100,000) while in the peak of the pandemic.

Conclusions: This level 1 trauma center has seen an overall increase in pediatric GSW injuries and fatalities in 10 years.

Objective: To analyze the reasons for ordering a CT scan and the abnormalities identified in children with mild head trauma classified as intermediate-risk according to the PECARN rule.

Methods: This retrospective observational study included patients aged 3 months to 14 years who presented to the emergency department (ED) of a tertiary hospital between 2021 and 2022 with mild head trauma classified as intermediate-risk. Two multivariable analyses were performed to identify demographic and clinical factors associated with CT scan utilization and CT abnormalities.

Results: We included 555 patients; 40% were girls, and the median age was 4 years (interquartile range: 1 to 8 y). Most patients (98.6%) were managed as outpatients after a median ED stay of 4.5 hours (IQR: 4 to 6.75). CT scans were performed in 78 patients (14.1%), of whom 24 (30.8%) had abnormalities: 13 had traumatic brain injuries and 11 had isolated skull fractures. Six patients (1.1%) had clinically important traumatic brain injuries (ciTBI). Four independent factors were associated with CT scan utilization: number of vomiting episodes (OR: 1.31; 95% CI: 1.16-1.49), headache (OR: 2.1; 95% CI: 1.21-3.6), abnormal behavior reported by parents (OR: 3.45; 95% CI: 1.99-5.95), and time elapsed before being seen by an ED physician (OR: 1.05; 95% CI: 1.01-1.08). Two factors were associated with CT abnormalities: younger age (OR: 0.82; 95% CI: 0.71-0.95) and severe injury mechanism (OR: 5.89; 95% CI: 2.04-18.37).

Conclusions: In children with mild head trauma classified as intermediate-risk, the factors leading to CT scan utilization differ from those associated with CT abnormalities. Further studies are needed to confirm these findings.

Objectives: High-flow nasal cannula (HFNC) use in bronchiolitis has increased substantially with wide variability, likely due to the lack of objective means of predicting clinical outcomes. Our objective was to identify features associated with care escalation for infants started on HFNC in the Emergency Department (ED), thereby assisting in disposition of patients and optimizing the utilization of limited resources.

Methods: This is a retrospective cohort study from 3 free-standing children's hospitals of infants younger than or equal to 12 months with bronchiolitis who were initiated on HFNC in the ED between 2/1/2018 and 3/1/2020. The primary outcome was escalation of care within the first 24 hours after HFNC initiation [transfer to pediatric intensive care unit (PICU) and/or initiation of noninvasive positive pressure ventilation (NIPPV) or mechanical ventilation (MV)]. A clinical prediction model was developed using multivariable logistic regression.

Results: We included 738 infants with a mean age of 5.4 months (SD 3.4), of which 73 (10%) experienced care escalation within the first 24 hours. Fever, tachypnea, tachycardia, and hypoxemia were associated with escalation, whereas historical features, physical examination findings, and response to ED therapies were not. A prediction model consisting of the highest ED respiratory rate and the lowest oxygen saturation yielded an AUC of 0.75, with a sensitivity of 57.9% and specificity of 82.2% (based on an optimal predicted probability threshold of 7.9%).

Conclusions: Hypoxemia and tachypnea predicted early escalation of care in infants with bronchiolitis with moderate performance. This model may have promise to assist with management decisions; however, it requires prospective validation.

Objectives: Implicit bias and structural racism in pediatric health care cause significant inequities and poorer outcomes. To help educate pediatric health-care providers, health equity rounds (HER) engage teams in discussions on the impact of bias and racism on patient care using a case-based curriculum. This mixed-methods study assessed the feasibility and acceptability of incorporating HER in a pediatric emergency medicine (PEM) setting.

Methods: Two HERs, focusing on implicit bias in medicine (June 2021) and linguistic barriers to health care (December 2021), were completed during the institution's multidisciplinary, PEM update rounds. Cases presented were selected if patient care and/or outcomes were negatively affected, were appropriate for educational discussion and relevant to the presentation topic. HER participants were invited to complete an online survey and semi-structured interview post-HER to explore their experiences, including professional and personal impacts.

Results: Both HERs were well-attended and had a moderate survey uptake (20/25 vs. 14/22). Three-quarters of survey participants found HER engaging (80%), and believed the learned objectives would impact their clinical practice (73.7% vs. 78.6%). Responses varied between presentations for educational value (80% vs. 61.6%) and interest in future HERs (94.7% vs. 78.6%). Four themes emerged from 3 qualitative interviews: HER satisfaction and experience, influence on service provision, supports and resources, and ideas for future HERs.

Conclusions: Our findings suggest HER is an acceptable and feasible forum for discussing and reflective practice on relevant topics in PEM educational sessions. Implementing HER in other specialized areas or settings and the impact of different topics should be explored further.

Objectives: Bacterial musculoskeletal infections (MSKIs) can be challenging to diagnose. We compared the accuracy of calcitonin gene-related peptide (CGRP), a neuropeptide which is transcribed from the same gene as procalcitonin, to procalcitonin for the diagnosis of a MSKI in children.

Methods: We conducted a prospective cohort study of patients 21 years old or younger who underwent evaluation for MSKIs at one of 3 emergency departments. Our primary outcome was a MSKI, defined as septic arthritis, osteomyelitis, or pyomyositis. We used a Spearman correlation coefficient to measure the association between serum CGRP and procalcitonin and compared the diagnostic accuracy using area under the receiver operating characteristic curve (AUC) analysis.

Results: Of the 200 enrolled patients, 33 (17%) had a MSKI. Overall, median serum CGRP level did not differ between patients with and without a MSKI (13.5 pg/mL MSKI vs 10.9 pg/mL no MSKI; difference: 2.6, 95% CI: -0.6, 5.8), while PCT was higher in patients with a MSKI (0.12 ng/mL MSKIs vs 0.04 ng/mL no MSKI; difference: 0.08, 95% CI: 0.03 to 0.13). CGRP and PCT levels were not correlated (Spearman rank coefficient: -0.01, 95% CI: -0.15 to 0.13). CGRP had a lower AUC than procalcitonin [0.57, 95% CI: 0.47 to 0.66 CGRP vs 0.78, 95% CI: 0.69 to 0.87 PCT, P < 0.01].

Conclusions: Although biochemically related, CGRP was not correlated with procalcitonin in children undergoing evaluation for a MSKI. Our exploratory pilot highlights the ongoing need for novel biomarkers for the accurate and timely identification of children with a MSKI.

Objectives: Point-of-care ultrasound of the lung is a useful tool in the assessment of pediatric patients with acute respiratory distress or hypoxemia. However, the sonographic features of atelectasis and pneumonia appear similar. Unlike pneumonia, the use of lung ultrasound to diagnose atelectasis and assess its reaeration in children is not well described. We describe the lung ultrasound features of atelectasis correlated with radiographic imaging and clinical context.

Methods: This series describes 5 pediatric ED patients with atelectasis, confirmed by lung ultrasound with radiographic correlation, to illustrate the use of PoCUS in guiding interventions such as chest physiotherapy and assessing reaeration.

Results: In all 5 cases, lung ultrasound identified lung consolidations consistent with atelectasis, which appeared sonographically similar to pneumonia. Static air bronchograms were seen in all cases. In 1 case of asthma exacerbation, repeat ultrasound demonstrated complete resolution of atelectasis following chest physiotherapy, correlating with clinical improvement. In the other 4 cases, including patients with cystic fibrosis and bronchiolitis, the consolidations persisted on repeat ultrasound despite various treatments for atelectasis.

Conclusions: The overlap between the sonographic features of lung consolidation in atelectasis and pneumonia in children makes it difficult to distinguish between the 2 conditions reliably based on lung ultrasound alone. Clinicians will need to interpret PoCUS images within the patient's clinical context, using radiographic correlation when available. Assessment of atelectasis reaeration on lung ultrasound is feasible and easily repeatable at the point of care, allowing for real-time monitoring of lung consolidations in response to therapy.