Pediatric emergency care最新文献

Objectives: The aims of the study are to characterize children with mental and behavioral health conditions (MBH) transported by emergency medical services (EMS) and examine differences in patient, emergency department (ED), and EMS transport characteristics based on restraint interventions during EMS transport.

Methods: This is a retrospective cohort study of EMS patients with MBH crises, aged 5-18, transported to 2 pediatric EDs over 9 years. Demographic and ED data were collected electronically; EMS data were extracted manually from prehospital care records. Field interventions studied included pharmacologic and mechanical restraints by EMS clinicians. Univariate analysis compared variables between patients who received EMS restraints and those who did not and multivariable logistic regression identified patient factors independently associated with EMS restraint use.

Results: Among 10,264 patients transported by EMS for MBH crises, 1400 encounters were randomly selected, with 768 records available. EMS restraint interventions were used in 73 (9.5%) patients: 5 (0.7%) received only pharmacologic restraints, 58 (7.6%) received only physical restraints, and 10 (1.3%) received both. Those who received EMS restraints were more likely to be younger (35.6% vs 19.6%, P = 0.001), male (71.2% vs 44.6%, P < 0.0001), and had longer scene times (13 vs 9 min). Restraint use was more common when patients were picked up from schools (30.1% vs 14.8%, P = 0.007). EMS-restrained patients were also more likely to receive physical (12.3% vs 2.3%, P < 0.0001), mechanical (15.1% vs 1.0%, P < 0.0001), or pharmacologic (24.7% vs 3.9%, P < 0.0001) restraints in the ED. Predictors of EMS restraint use were male sex (odds ratio, 3.00; 95% confidence interval, 1.74-5.17) and being picked up from schools (odds ratio, 2.08; 95% confidence interval, 1.13-3.81), whereas age group, race, and insurance type were not independent predictors.

Conclusions: Nearly 1 in 10 pediatric patients experiencing mental health crises and transported by EMS required restraint interventions in the field. Male patients, younger aged children, and those picked up from school represent a distinct and vulnerable population that could benefit from specialized prehospital care to manage agitation.

Objective: To examine differences in pediatric fracture prevalence, severity, and mechanisms of injury before and during the COVID-19 pandemic.

Methods: This is a subanalysis of data from a multicenter, cross-sectional study of all injury-related visits to 40 urban pediatric emergency departments (EDs) for children younger than 18 years occurring January 2019-December 2020. ED visits for injuries including fractures were identified by International Classification of Diseases, Tenth Revision codes. Comparative analyses of patient demographics, fracture prevalence, severity, and mechanisms of injury for March 17, 2019, to December 31, 2019 (pre-COVID), versus March 15, 2020, to December 31, 2020 (during COVID), were performed.

Results: Fracture-related visits comprised 21.0% (n = 123,684) of all injury visits (n = 589,083) during the study period. There were 16,190 fewer fracture-related visits (-23.2%) in 2020 than 2019. There were differences in the proportion of fracture-related visits by age (P < 0.0001), with increases in children younger than 5 years and decreases in children 5 to 18 years old. There were higher proportions of visits in 2020 among female patients, White children, non-Hispanic children, and those with private insurance (P < 0.0001, respectively). Patients with fractures in 2020 were more severely injured, with higher proportions of hospitalizations (P < 0.0001), intensive care unit admissions (P < 0.0001), deaths (P = 0.007), and higher injury severity scores (P < 0.0001). Fracture mechanisms shifted to more motor vehicle crashes, bicycles, and firearms in 2020 (P < 0.0001).

Conclusions: Despite a decrease in fracture-related visits to urban pediatric EDs during the early COVID-19 pandemic, there was an increase in the proportion of ED visits for children younger than 5 years and higher severity injuries. These findings highlight injury epidemiology pattern shifts that occurred during the pandemic. Identifying higher-risk populations for fracture may help guide targeted education and prevention efforts.

Purpose/objectives: The U.S. health care system is experiencing a critical workforce shortage of nurse case managers exacerbated by an older workforce and looming retirements and the growth of this specialty. This quality improvement project aimed to develop an online case manager preceptor training program and examine its impact on the nurse case manager preceptors' self-efficacy.

Practice setting: This project was implemented at a 395-bed acute care, community-based hospital in the northeast.

Methodology and sample: The target population for the intervention included a convenience sample of 13 nurse case managers who were assigned a preceptor role. The intervention was an abbreviated version of an online preceptorship program by Lippincott. The Preceptor Self-Efficacy Questionnaire (PSEQ), with a Cronbach's alpha of 0.96, measured nurse preceptors' confidence in various skills including fostering critical thinking and providing feedback. Data from pre- and post-intervention PSEQ surveys were analyzed using a Wilcoxon rank sum test in SPSS version 28.

Results: The Wilcoxon rank sum test revealed a statistically significant improvement in preceptor confidence scores ( p = .043) between pre- and post-intervention PSEQ results.

Implications for case management practice: This project demonstrated feasibility of an online nurse case manager preceptor training program while also identifying improved preceptors' self-efficacy. Future research can include investigating the impact of a preceptor training program on the nurse case manager learners receiving role training from the trained case manager preceptor.

Objective: Our objective was to identify the hospital- and community-related factors associated with the hospital-level rate of potentially unnecessary interfacility transfers (IFTs) for pediatric patients with asthma exacerbations.

Methods: We analyzed California Emergency Department (ED) data from 2016 to 2019 to capture ED visits where a pediatric patient (age, 2-17 years) presented with an asthma exacerbation and was transferred to another ED or acute care hospital. The primary outcome was hospital-level rate of potentially unnecessary IFTs, defined as a visit where length of stay after transfer was <24 hours and no advanced services (eg, critical care) were used. Hospital- and community-related characteristics included urbanicity, teaching hospital status, availability of pediatric resources in the sending facility and patient's community, pediatric patient volume, and Social Vulnerability Index. We described and compared hospitals in the top quartile of potentially unnecessary IFT rate versus all others and used a multivariable modified Poisson model to identify factors associated with potentially unnecessary IFT.

Results: A total of 325 sending hospitals were included, with a median 573 pediatric asthma visits (interquartile range, 183-1309) per hospital annually. Nearly half of the hospitals (145/325, 45%) sent a potentially unnecessary IFT. Most (90%) hospitals were urban, 9% were teaching hospitals, 5% had >500 beds, and 22% had a pediatric ED on-site. Factors associated with higher adjusted prevalence of potentially unnecessary IFT included availability of pediatric telehealth (prevalence ratio [PR], 1.5; 95% confidence interval [CI], 1.2-2.0), increased pediatric volume (eg, <1800 vs ≥10,000 visits: PR, 2.6; 95% CI, 1.4-4.7), and higher community Social Vulnerability Index (PR, 1.5; 95% CI, 1.1-1.9).

Conclusions: Several hospital- and community-related factors were associated with potentially unnecessary IFTs among pediatric patients presenting to the ED with asthma exacerbations. These findings provide insight into disparities in potentially unnecessary IFT across communities and can guide the development of future interventions.

Objectives: The aim was to evaluate the current status of point-of-care ultrasound (POCUS), perceptions, education, training, and barriers to using POCUS in pediatric emergency departments (PEDs) and pediatric intensive care units (PICUs) in Turkey.

Methods: A descriptive, multicenter, cross-sectional study through an online survey was developed using the REDCap online platform. The survey was distributed through the Turkish Society of Pediatric Emergency and Intensive Care e-mail group. Each survey was answered only once by each PED/PICU and by the clinical chief of the department.

Results: A total of 19 PEDs and 26 PICUs responded to the survey. Among them, 84.2% of PEDs and 100% of PICUs reported the clinical use of POCUS. For diagnostic applications, the most common areas for PEDs and PICUs were thoracic (93.7%/100%) and cardiovascular (62.5%/65.4%) assessment, and in the procedural use of POCUS, the most frequent applications were those for vascular access (75.0%/92.3%) and thoracentesis (31.2%/65.4%). The most commonly reported clinical benefits were rapid diagnosis, rapid treatment, and decreased complications during procedural applications for PEDs and PICUs. Evaluating the barriers to POCUS use in PEDs and PICUs, the most common reasons for insufficient use were the lack of ultrasound machines and/or equipment, a shortage of manpower, lack of awareness, and lack of training. For PEDs (68.4%) and for PICUs (84.6%), participants agreed that POCUS training should be mandatory during fellowship programs.

Conclusions: Most participants were aware of the need for POCUS. However, lack of education, equipment, manpower, and infrastructure still emerged as barriers to the use of POCUS. To further promote POCUS use, it would be helpful to improve accessibility by ensuring sufficient numbers of ultrasound devices together with sufficient numbers of appointed physicians and by expanding POCUS education in PEDs and PICUs.

Introduction: Amphetamine poisoning in children is a significant public health concern due to its potential for severe adverse effects on physical and mental health. In this article, we describe a case series of 29 children under the age of 14 presenting with sympathomimetic toxidrome due to confirmed amphetamine poisoning.

Material and method: In this cross-sectional study, children (1 month to 14 years old) who were hospitalized in the emergency and pediatric departments of Imam Reza and Akbar Hospital in Mashhad from the beginning of April 2021 to September 2022 were identified with the diagnosis of amphetamine poisoning. Their demographic, clinical, and paraclinical (laboratory and electrocardiogram) information, which was included in the relevant checklists, were analyzed and reported.

Findings: Out of 29 children included in the study, 18 (62%) were male and the rest were female. The average age of children was 44.75 ±43.9 months; most of them were less than 4 years old. In all patients, glasgow coma scale (GCS) was 15. In 25.92% of cases (8 patients) blood pressure was above the 90% percentile for age and sex, 82.60% (24 cases) were tachycardia, 72.41% crying (21 cases), 86.20% were restless (25 cases), 10.34% tremor (3 cases), 10.34% had body pain (3 cases), and 6.89% (2 cases) had delusions. None of the subjects had a seizure. The serum level of creatine phosphokinase was on average 771.99 ± 966 units/L. All children had an increase in creatine phosphokinase (CPK) and 25.9% of children had an increase in CPK to more than 1000 units/L.

Conclusion: Based on the results, in children with symptoms such as restlessness, crying, and tachycardia, poisoning with amphetamine group substances should be included in the differential diagnosis list, and also measuring CPK and investigating the possible occurrence of rhabdomyolysis in cases of poisoning of children with amphetamine seems necessary.

Objectives: Over the past decade, there has been a significant effort to decrease radiation exposure in pediatric trauma patients. The objective of this study was to determine if trauma centers (TCs) and nontrauma centers (non-TCs) are practicing in line with this effort. We hypothesized that TCs would demonstrate a significant decrease in the use of chest computed tomography (CT) during the study period, whereas non-TC would show no change in chest CT use.

Methods: We queried a state-wide database from 2010 to 2020 for pediatric trauma encounters at TCs and non-TCs within a single large health system. All transfer encounters were excluded. Chest CTs and chest radiographs (CXRs) were performed, and injury diagnosis codes were extracted for each encounter. Chest CT use and incidence of thoracic injuries were compared between TCs and non-TCs.

Results: A total of 13,014 encounters were included, of which 85.8% occurred at TCs and 14.2% occurred at non-TCs. There were significant differences between TC and non-TC encounter demographics. During the study period, the percentage of trauma encounters in which chest CT was obtained increased yearly at both TCs and non-TCs. Among encounters where both modalities were performed in the first 24 hours, chest CT was performed before CXR in 0.4% of TC and 0.1% of non-TC encounters ( P = 0.086). Among encounters without thoracic injury, chest CT was performed in 5.2% of cases at non-TCs and 4.5% of cases at TCs ( P < 0.001).

Conclusions: In the trauma encounters studied, chest CT was performed prior to CXR more frequently at TCs compared to non-TCs. These data may reflect regional trauma triage protocols, availability of chest CT, or differences in education between institutions. Whereas TCs may see more severely injured patients more frequently, education regarding conservative CT imaging principles should be reinforced through multidisciplinary efforts.

Objectives: At our institution, level 2 trauma (L2T) activations are primarily managed by pediatric emergency medicine (PEM) physicians, whereas level 1 activations are co-managed by pediatric surgery and PEM. Starting in September 2019, the response to L2T activations due to all-terrain vehicles or motorized cycles (ATVs/MCs) changed to include surgical assessment upon patient arrival due to increased likelihood of significant injuries and need for higher level of care. The impact of PEM/surgery co-management of ATV/MC L2T patients on time to an admission decision is unknown.

Methods: We retrospectively reviewed patients <18 years of age presenting to our American College of Surgeons-verified level 1 pediatric trauma center as L2T activations with ATV/MC mechanism between 1/2016 and 10/2022. Patient demographics, injury characteristics, details of imaging, interventions, and emergency department (ED) course were recorded. The χ 2 and Fisher exact tests were performed.

Results: One hundred fifty-five patients met the inclusion criteria prior to augmenting our response to include surgical presence at L2T-ATV/MC activations, and 216 patients were treated after our protocol change. There were no statistically significant differences in age, sex, race, transfer status, vehicle subtype, or Injury Severity Scores between groups. Trauma surgery was involved in the care of 74.8% of L2T-ATV/MC patients before protocol augmentation and 87% after ( P = 0.003). Time to an admission decision significantly decreased by 22.5 minutes (117 minutes [interquartile range, 72-178] vs 94.5 minutes [interquartile range, 60-139]; P = 0.023) after protocol augmentation. There was a trend toward increased completion of mandated postsecondary survey communication huddles after protocol change (84.6% to 91.2%, P = 0.089). The median total ED length of stay did not differ between admitted and discharged patients.

Conclusions: Early surgical assessment for pediatric patients with ATV/MC injuries improved time to an admission decision and trauma communication huddle compliance. Next steps include identifying process improvement opportunities to decrease ED total length of stay for patients with ATV/MC injuries.

Abstract: Metformin (MTF) is a widely used oral antidiabetic medication. Regardless the reason, high doses of MTF cause lactic acidosis as a result of its effects on mitochondrial ATP production and no-mediated vascular smooth muscle relaxation. Metformin-associated lactic acidosis can be life-threatening despite all treatments. Methylene blue (MB) has the potential to reverse the toxic effects of MTF through its effects on both the mitochondrial respiratory chain and nitric oxide production. The use of MB in MTF intoxication has only been reported in a limited number of cases. Herein, we present a 16-year-old female patient who attempted suicide by ingesting high doses of MTF. Supportive treatments, such as vasopressor, inotropic treatments, and sodium bicarbonate, were started in the patient who developed fluid-resistant hypotension after pediatric intensive care unit admission. Because of rising lactate levels, Continuous renal replacement therapy (CRRT) was started immediately. Despite all treatments, hypotension and hyperlactatemia persisted; MB was given as a rescue therapy. Noticeable hemodynamic improvement was observed within 30 minutes of initiating MB infusion, allowing a gradual decrease in the doses of inotropic infusions within the first hour of therapy. Patient's cardiovascular support was discontinued on the second day, and she was discharged on the fifth day. We speculate that, considering the mechanisms of MTF toxicity and the mechanisms of action of MB, it is suggested that early administration of MB, not only as a rescue treatment but as the initial approach to MTF poisoning in combination with other treatments, may result in improved outcomes.