Pediatric emergency care最新文献

Objectives: Pediatric head trauma is a frequent reason for presentation to the emergency department. Despite this, there are few reports on specific characteristics and injury patterns in head injured children. The goal of this study was to evaluate head injury patterns in children with blunt head injury and their prevalence by age group.

Methods: This is a planned secondary analysis of the NEXUS II Head CT validation study. Consecutive patients with blunt head trauma were enrolled between 2006 and 2015. Demographics and criteria from 2 clinical decision instruments (NEXUS and Canadian Head CT rules) were gathered at the time of enrollment. We abstracted and cataloged injuries for pediatric patients based on radiologist report. Frequencies of injuries and severity were analyzed by developmental age group.

Results: A total of 1018 pediatric patients were enrolled, 128 (12.6%) of whom had an injury on computed tomography scan. Median age was 11.9 (Interquartile range 4.5-15.5) for all patients and 12 (4.8-15.5) for injured patients. Of injured patients, 49 (38.3%) had a significant injury, and 27 (21.1%) received an intervention. Teenagers had the highest rate of significant injury (50%) and intervention (30%). Injuries were most frequently noted in the temporal (46.1%), frontal (45.3%), and parietal (45.3%) regions. Subarachnoid hemorrhage (29.7%) and subdural hematoma (28.9%) were the most common injuries observed.Intraparenchymal hemorrhage and cerebral edema were more prevalent in older age groups. The most common injury mechanism overall was fall from height (24.7%). Motor vehicle accidents and nonmotorized wheeled vehicle accidents were more common in older patients.

Conclusions: Serious injuries requiring intervention were rarely encountered in pediatric patients experiencing blunt head trauma. Mechanisms of injury, type of injury, and rates of intervention varied between developmental age groups.

Background: Although the reporting rate of child abuse is increasing every year, the child abuse detection rate is 3.81% as of 2019 in Korea, which is significantly lower than that of developed countries for child rights.

Objective: We investigated the associated factors with barriers that emergency physicians face in recognizing and reporting cases of child abuse.

Methods: From May to July 2022, 240 emergency physicians working in the 15 emergency department were asked to participate in the survey via email. The questionnaire included the respondent's basic information, treatment experience for child abuse, reasons for reporting or not reporting, and opinions on measures to increase the reporting rate. We conducted a logistic regression analysis to discern the factors contributing to underreporting.

Results: Seventy-one individuals were included in the analysis, after excluding those who had never encountered suspected cases of child abuse. A multivariable logistic regression was performed with the above variables, and although it was not statistically significant, there was a tendency for workers to report well when working at a pediatric emergency department (odds ratio [95% confidence interval], 3.97 [0.98-16.09]). The primary reason for reporting suspected abuse was the pattern of damage suspected of abuse. The first reason for not reporting suspected abuse was because they were not sure it was child abuse. Respondents answered that to report better, a quick and appropriate response from the police and confidentiality of the reporter were needed.

Conclusions: Physicians in pediatric emergency departments demonstrated a tendency for more proactive reporting suspected cases of child abuse.

Introduction: Adolescent overdoses have been rising over the past decade. Emergency department (ED) visits for both acute overdoses and for adolescents in opioid withdrawal have risen post-COVID. Urine drug screens have poor utility in the ED but are routinely obtained for medical clearance and in the management of patients with substance use disorder. Our primary goal was to measure the sensitivity of the opiate urine drug assay over time in opioid-related presentations to the ED.

Methods: We reviewed ED presentations at all EDs within our health system that were directly related to opioids from 1/1/2014 to 12/31/2022. For each patient included over the time frame, we identified whether a urine drug screen was obtained and the results from this screen. The urine drug screen available at all sites was an enzyme-multiplied immunoassay with an opiate screen (morphine antibody), but no fentanyl screen. The percent positivity for each drug category on enzyme multiplied immunoassay technique testing was calculated. Chi-squared tests were used to compare positivity rates between years.

Results: Opiate positivity declined over the last 9 years. Positivity rates from 2020 to 2022 were 5% ± 2% vs 82% ± 6% from 2014 to 2019 ( P < 0.001) Performance of UDS also declined over time (76% from 2014 to 2019 vs 46% from 2020 to 2022; P < 0.001). UDS was more likely to be performed in patients after a suicide attempt or when presenting after illicit use (66% vs 38%; P = 0.004).

Conclusion: Opiate screen positivity decreased the last 9 years and may reflect wider use of fentanyl among this population starting in 2020.

Objectives: Many children who require hospitalization are ideal candidates for care in pediatric observation units (POUs) rather than inpatient pediatric units. Differences in outcomes between children cared for in these 2 practice settings have not been thoroughly evaluated.

Methods: In this retrospective cohort study, children aged 0 to 18 years admitted to a POU at a community hospital or inpatient unit at a children's hospital were enrolled if they met specific clinical criteria. Information regarding the current illness, medical history, and hospital course was collected. Hospital length of stay (LOS) was analyzed as the primary outcome; secondary outcomes included conversion to inpatient care for the POU group and return to pediatric emergency department within 7 days. Subgroup analysis was conducted on children presenting with respiratory illnesses. Propensity scores were used as a predictor in the final model.

Results: One hundred eighty-one admissions, 92 to POU and 89 to an inpatient unit, were analyzed. Mean LOS was 24.4 hours (95% confidence interval [CI], 21.7-27.1) for observation and 43.2 hours (95% CI, 37.8-48.6) for inpatient ( P < 0.01). Among the 126 children admitted for respiratory illnesses, the mean LOS was 32.3 hours (95% CI, 26.0-38.6) for observation and 48.1 hours (95% CI, 42.2-54.0) for inpatient ( P < 0.01). Survival analysis demonstrated a 1.61 (95% CI, 1.07-2.42) fold shorter time to discharge among children admitted to observation compared with inpatient ( P = 0.02) and a 1.70 (95% CI, 1.07-2.71) fold shorter time to discharge from observation compared with inpatient for respiratory illnesses ( P = 0.03). Within 7 days of discharge, 2 (2%) patients from the observation group and 1 (1%) from the inpatient group returned to the pediatric emergency department.

Conclusions: These findings suggest that POU may provide the means toward efficient care for children in community settings with illnesses requiring brief hospitalizations. Future work including prospective investigations is needed to ascertain the generalizability of these findings.

Objectives: Youth suicide is a pressing global concern. Prior research has developed evidence-driven clinical pathways to screen and identify suicide risk among pediatric patients in outpatient clinics, emergency departments (ED) and inpatient hospital units. However, the feasibility of implementing these pathways remains to be established. Here, we share the results of a hospital-wide "youth suicide risk screening pathway" implementation trial at an urban academic pediatric hospital to address this gap.

Methods: A 3-tier "youth suicide risk screening pathway" using The Ask Suicide-Screening Questions (ASQ) was implemented for patients aged 10 to 26 years who received care at an urban academic pediatric hospital's emergency department or inpatient units. We retrospectively reviewed implementation outcomes of this pathway from January 1 to August 31, 2019. The feasibility of this implementation was measured by assessing the pathway's degree of execution, fidelity, resource utilization, and acceptability.

Results: Of 4108 eligible patient encounters, 3424 (83%) completed the screen. Forty-eight (1%) screened acute positive, 263 (8%) screened nonacute positive and 3113 (91%) screened negative. Patients reporting positive suicide risk were more likely to be older and female, although more males required specialty mental health evaluations. Pathway fidelity was 83% among all positive screens and 94% among acute positive screens. The clinical pathway implementation required 16 hours of provider training time and was associated with slightly longer length of stay for inpatients that screened positive (4 vs 3 days). Sixty-five percent of nurses and 78% of social work providers surveyed supported participation in this effort.

Conclusions: It is feasible to implement a youth suicide risk screening pathway without overburdening the system at an urban academic pediatric hospital.

Objectives: The aim of this study was to identify the incidence of adverse events of ketamine administration in the pediatric emergency department in patients aged 90 days or younger in order to demonstrate the safety and efficacy of administration in this patient population.

Methods: An 8-year retrospective chart review of patients aged 90 days or younger who received ketamine in the pediatric emergency department was conducted. All patients who met the age criteria were included in this study. Identified routes of ketamine administration included oral, intramuscular, and intravenous.

Results: Fourteen patients were identified who met the inclusion criteria and were included in the final analysis. The median age was 45 days old. Indications for ketamine administration included 7 cases for procedural sedation, 5 cases for RSI, and 2 cases for postintubation sedation. The average dose amount (mg/kg) of ketamine administered was 10, 4.43, and 1.59 for oral, intramuscular, and intravenous routes, respectively. Of the 14 patients, 1 patient was identified to have an adverse event to ketamine administration. A transient desaturation and bradycardic event due to laryngospasm was observed during laryngoscopy performed for RSI that was resolved with administration of anticholinergics and paralytics as well as successful intubation and ventilation.

Conclusions: In this study, 1 patient suffered an adverse event due to laryngospasm during intubation. In the pediatric population, the incidence of adverse events of ketamine administration has been found to be variable in the current literature, ranging from 0.71% to 7.26%. In our study, an adverse event occurred in 1 out of 14 administrations (7.1%). The incidence of adverse events associated with ketamine administration in our patients aged 90 days or less appeared to be similar to that reported in the general pediatric population.

Background: Pediatric patients often require sedation during magnetic resonance imaging (MRI) and computed tomography (CT) to ensure stillness and minimize stress. This meta-analysis compared the effectiveness and safety of 3 sedative agents-dexmedetomidine, midazolam, and chloral hydrate-for pediatric MRI/CT sedation.

Methods: Six studies with a total of 633 patients were included in the analysis. Quality assessment revealed varying levels of bias risk. Dexmedetomidine exhibited a significantly higher successful sedation rate compared to midazolam (risk ratio [RR] = 0.43, 95% confidence interval [CI] [0.29-0.64]), but no statistically significant difference compared to chloral hydrate (RR = 0.94, 95% CI [0.60-1.45]). Chloral hydrate also showed a higher successful sedation rate compared to midazolam (RR = 0.46, 95% CI [0.25-0.83]). The onset of sedation time did not significantly differ between the 3 agents.

Results: The dexmedetomidine group had a significantly higher incidence of bradycardia compared to the chloral hydrate group (RR = 0.17, 95% CI [0.05-0.59]), but no significant difference compared to the midazolam group (RR = 0.29, 95% CI [0.06-1.26]). No statistically significant differences were observed in the incidence of nausea and vomiting between the 3 groups.

Conclusions: Dexmedetomidine demonstrates effectiveness in pediatric MRI/CT sedation, offering advantages over midazolam and similar efficacy to chloral hydrate. Careful cardiovascular monitoring is essential during administration, particularly in patients with congenital heart disease. Sublingual and intranasal administration of dexmedetomidine is a viable option with high bioavailability. This meta-analysis contributes valuable insights into refining sedation protocols for pediatric imaging procedures, emphasizing efficacy and safety considerations.

Abstract: Synovial cell sarcoma is a rare mesenchymal tumor that typically originates from the soft tissues of the extremities of young adults. Only 3 cases of primary diaphragmatic synovial cell sarcoma have been described in the literature: 2 in adult males and 1 in a 12-year-old pediatric patient. 1-3 When this tumor is found in the mediastinum or pericardial region, prognosis is historically poor because of the advanced disease stage at time of diagnosis. The surgical course and pathology have been described in this 12-year-old boy. 3 This is the first case, to our knowledge, of the use of cardiac point-of-care ultrasound in the early identification and diagnosis of a primary diaphragmatic synovial sarcoma in a pediatric patient.

Purpose: Health care systems have historically struggled to provide adequate care for patients with complex care needs that often result in overuse of hospital and emergency department resources. Patients with complex care needs generally have increased expenses, longer length of hospital stays, an increased need for care management resources during hospitalization, and high readmission rates. Mayo Clinic in Arizona aimed to ensure successful transitions for hospitalized patients with complex care needs to the community by developing a complex care transition team (CCTT) program. With typical care management models, patients are assigned to registered nurse case managers and social workers according to the inpatient nursing unit rather than patient care complexity. Patients with complex care needs may not receive the amount of time needed to ensure an efficient and effective transition to the community setting. Furthermore, after transitioning to the community, patients with complex care needs often do not have access to care management resources if further care coordination needs arise.

Primary practice setting: Acute care hospital in the US Southwest.

Methodology and sample: The CCTT was composed of a registered nurse case manager, social worker, and care management assistant, with physician advisor support. The CCTT followed patients with complex care needs during their hospitalization and transition to the community for 90 days after discharge. The number of inpatient admissions and hospital readmission rates were compared between 6 months before and after enrollment in the CCTT program. Cost savings for decreased hospital length of stay, emergency department visits, and hospital readmissions were also determined.

Results: The CCTT selected patients according to a complex care algorithm , which identified patients who required high use of the health care system. The CCTT then followed this cohort of patients for an average of 90 days after discharge. A total of 123 patients were enrolled in the CCTT program from July 1, 2019, to April 30, 2021, and 80 patients successfully graduated from the program. Readmission rates decreased from 51.2% at 6 months before the intervention to 22.0% at 6 months after the intervention. This reduced readmission rate resulted in a cost savings of more than $1 million.

Implications for case management practice: The outcomes resulting from implementation of the multidisciplinary CCTT highlight the need for a patient-specific approach to transitioning care to the outpatient setting. The patient social determinants of health that often contributed to overuse of health care resources included poor access to outpatient specialists, difficulty navigating the health care system due to illness or poor health literacy, and limited social support. The success of the CCTT program prompted the implementation of oth

Objective: Persistent pulmonary hypertension of the newborn (PPHN) is one of the critical neonatal diseases associated with high morbidity and mortality. This study attempted to conduct a nomogram prediction model for performing early identification of PPHN and providing effective information for clinical practice.

Methods: A total of 456 newborns who first admitted to the hospital after birth were included in the analysis, including 138 newborns with PPHN and 318 newborns without PPHN (as controls). The optimal predictive variables selection was performed based on LASSO (least absolute shrinkage and selection operator) regression and multivariate logistic regression. Using the selected variables, a nomogram prediction model was developed. To validate the model, the model was assessed using the receiver operating characteristic curve, calibration plot, and clinical impact curve.

Results: Six predictors, namely, gestational age, neonatal respiratory distress syndrome, the levels of hemoglobin and creatine kinase-MB, gestational thyroid dysfunction, and Pa o2 , were identified by LASSO and multivariate logistic regression analysis from the original 30 variables studied. The constructed model, using these predictors, exhibited favorable predictive ability for PPHN, with an area under the receiver operating characteristic of 0.897 (sensitivity = 0.876, specificity = 0.785) in the training set and 0.871 (sensitivity = 0.902, specificity = 0.695) in the validation set, and was well calibrated, as indicated by the PHosmer-Lemeshow test values of 0.233 and 0.876 for the training and validation sets, respectively.

Conclusions: The model included gestational age, neonatal respiratory distress syndrome, the levels of hemoglobin and creatine kinase-MB, gestational thyroid dysfunction, and Pa o2 had good prediction performance for predicting PPHN among newborns first admitted to the hospital after birth.