Pediatric emergency care最新文献

Abstract: The diaphragm is the major muscle of inspiration accounting for approximately 70% of the inspired tidal volume. Point-of-care diaphragmatic ultrasound offers the ability to quantitatively assess diaphragmatic function, perform serial evaluations over time, and visualize structures above and below the diaphragm. Although interest in point-of-care ultrasound (POCUS) of the diaphragm is developing in the emergency medicine, assessment of the diaphragm and its function is not recognized as a core application by national organizations or expert guidelines. As a result, it is infrequently performed, and its potential value in research or clinical practice may not be fully appreciated. The purpose of this review is to describe the developmental aspects of the diaphragm as it pertains to POCUS, discuss the POCUS techniques for evaluating diaphragmatic function, address competency acquisition in this POCUS application, summarize relevant research in the ED, and provide a summary of recommendations for further research and clinical utilization of POCUS in diaphragm evaluation.

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.

Purpose: Diagnosis of acute appendicitis is more difficult in children aged 0-4 years due to atypical clinical presentation, leading to delay in diagnosis and higher incidence of complications. Nonvisualization of the appendix on ultrasound increases diagnostic challenge. We examined the utility of standardized reporting of sonographic secondary signs of appendicitis in children younger than 5 years with nonvisualization of the appendix.

Methods: A retrospective cohort study of children younger than 5 years who underwent appendectomy following nonvisualization of the appendix on ultrasound from 2016 to 2022 was performed. Primary outcome was comparison of ultrasound and intraoperative findings. Two-sample t test and Wilcoxon sum-rank test compared continuous variables, and Fisher exact test compared categorical variables. Univariate and multivariate logistic regression analyses were performed to assess risk factors for complicated appendicitis in those with category 3 ultrasounds.

Results: Overall, 92 patients whose appendix was not visualized on ultrasound were included: 26 without secondary signs (category 2) and 66 with secondary signs (category 3). Significant differences in intraoperative findings between category 2 and category 3 patients existed ( P < 0.001). On intraoperative assessment of patients with ultrasound category 2, 3.8% had no appendicitis, 46.2% had simple appendicitis, 34.6% had complicated appendicitis, and 15.4% underwent interval appendectomy. Conversely, of category 3 patients, 0% had no appendicitis, 7.6% had simple appendicitis, 48.5% had complicated appendicitis, and 43.9% underwent interval appendectomy. On logistic regression, in children with category 3 ultrasounds, presence of both fluid collection and free fluid as secondary signs was associated with intraoperative findings of complicated appendicitis. However, number of secondary signs was not significantly associated with increased likelihood of complicated appendicitis intraoperatively.

Conclusion: Presence of secondary signs without visualization of the appendix was shown to be indicative of appendicitis, with high suspicion for complicated appendicitis, in patients younger than 5 years. Further validation of the presence of secondary signs on right-lower-quadrant ultrasound may lead to more expedient diagnosis, reduction in cross-sectional imaging, and earlier treatment of complicated appendicitis.

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.

Context: Family-centered care is a critical component of critical care interfacility and medical retrieval transport (MRT) services. These services provide a critical bridge for a physiologically and psychologically unique population often best served in specialized, tertiary centers. Caregivers often wish to accompany patients during MRT. However, there is currently little research on the impact of caregiver accompaniment on MRT.

Objective: The aim of the study is to determine: 1) What are caregiver attitudes to accompanied and unaccompanied MRT? 2) What are healthcare provider attitudes to caregiver presence? 3) What are patient attitudes to caregiver presence? and 4) Are there differences in patient outcome depending on caregiver presence?

Data sources: Data sources are MEDLINE, Embase, and CINAHL.

Study selection: Studies with a focus on patient, caregiver, or family-oriented care practices in MRT. Reviewed articles were not restricted unless they discussed neonatal transport, palliative transport, were non-English, or were conference proceedings.

Data extraction: We screened 1373 articles, with 45 full-text articles reviewed. After removal of duplicates and abstract-only results, 25 articles remained. Three additional articles were found in references of reviewed articles.

Results: Articles generally supported caregiver presence on MRT, with caregivers and providers in agreement. However, for many services, space was a limiting factor controlling when caregivers could travel.

Limitations: There is a paucity of literature on this topic, and studies were entirely from English-speaking countries.

Conclusions: Caregivers and healthcare providers largely prefer caregiver accompaniment on MRT services. There is little data on patient perspectives and transport-related adverse events affecting patient outcomes.

Objective: Controversy exists surrounding which agents best provide analgesia in children with fractures. Prior studies have demonstrated that ED visits for fracture-related pain have the highest rates of opioid prescribing. Studies have also found that NSAIDs are equivalent at controlling acute fracture-related pain. In a time when one must balance the risk of inadequate pain control with potential opioid misuse, providers have little data to guide them in terms of the best recommendations for adequate pain control at home.

Methods: This prospective observational study investigates parental pain management practices after ED discharge for children who underwent a forearm fracture reduction. Surveys filled out by parents were used to gather data on the proportion of children discharged with an opioid prescription, the number of doses of opioid that were administered after discharge, and parental satisfaction with their child's pain control.

Results: We analyzed data for 61 patients who completed the postdischarge survey. Of these, 62% received a prescription for oxycodone at discharge, and 50% used at least 1 dose of oxycodone at home. The median number of doses administered at home, 1.5 (IQR, 0-3), was significantly lower than the number of doses of oxycodone prescribed, 10 (IQR, 5-12) ( P < 0.001). Parents reported a high level of satisfaction with the medications received at discharge with nearly all ranging between 4 (satisfied) and 5 (very satisfied) (median, 5; IQR, 4-5). No significant difference was detected in the satisfaction between families who received a prescription for oxycodone at discharge (median, 5; IQR, 4-5) and those who did not (median, 5; IQR, 4-5) ( P = 0.28).

Conclusions: We observed a large range in the number of doses of oxycodone prescribed at discharge and a significant difference between the number of doses being prescribed and those being used by families. A prescription of 2 doses of oxycodone would be sufficient to treat postreduction pain in the majority of children.

Introduction: Scorpion envenomation is a leading cause of envenomation in our region. Antivenom has been used successfully to treat the systemic manifestations of envenomations inflicted by toxic scorpions. Toxic scorpions common in our area include Leiurus quinquestriatus , Androctonus australis , and Buthus occitanus . This study describes the outcomes of children envenomated by these scorpions, and treated with SCORPIFAV, a polyvalent scorpion antivenom F(ab') 2 (equine), used since 2016 at our institution.

Methods: A retrospective chart review of all children admitted with symptoms and signs of scorpion envenomation to Soroka University Medical Center, between September 1, 2019, and December 1, 2020, who received antivenom SCORPIFAV. Our center has a protocol mandating antivenom therapy for all patients manifesting autonomic excitation, agitation, and anxiety, or more pronounced symptoms, following suspected scorpion envenomation.

Results: Three hundred patients were seen in the pediatric emergency department for scorpion envenomation during the study period, and 49 required antivenom (SCORPIFAV) as per departmental policy. Four of 49 developed allergic reactions during antivenom treatment: 2 manifested minor skin rashes treated with antihistamines only, and a further 2 required intramuscular adrenaline. There were no deaths in the study cohort and all patients recovered fully, with complete resolution of symptoms, signs, and laboratory features.

Conclusions: Patients treated with antivenom exhibited rapid resolution of symptoms without severe hypersensitivity. We recommend broadened availability of antivenom at sites where it is needed.