Pediatric emergency care最新文献

Background: Pediatric early warning scores (PEWS) are designed to predict clinical deterioration and enhance patient management in emergency observation units. Several PEWS models exist, but few studies have compared their accuracy in predicting clinical outcomes. This study evaluated and compared the diagnostic performance of 4 PEWS models (Monaghan, Parshuram, Tibbals, Brilli) in our tertiary hospital's pediatric emergency department (PED).

Methods: A prospective observational cohort study was conducted from January to April 2023, involving 193 patients. The measured outcomes were discharge, ward admission, intensive care unit admission, and mortality. For each PEWS model, sensitivity, specificity, likelihood ratios, and the area under the receiver operating characteristic curve (AUC) were statistically analyzed.

Results: The median age of the patients was 4 years, with 57% males and 43% females. Primary diagnoses included respiratory, neurological, and gastrointestinal diseases. Ward admissions were 40.41%, and ICU admissions were 8.30%. Among the evaluated PEWS models, the one developed by Parshuram and colleagues exhibited the highest diagnostic accuracy in our PED. For ward admissions at a threshold score ≥4, the AUC was 0.678, with sensitivity 72.34% and specificity 63.27%. For ICU admissions at a threshold score ≥8, the AUC was 0.816, with sensitivity of 68.75% and specificity of 85.71%.

Conclusion: PEWS are valuable tools for outcome assessment in PEDs. The Parshuram model demonstrated superior diagnostic performance in the studied population. However, the selection of an appropriate PEWS model and determination of suitable threshold scores should be tailored to the specific sociodemographic and clinical characteristics of each health care center.

Objective: Abdominal pain is a common pediatric presentation in the emergency department (ED), and acute appendicitis (AA) is the most common surgical diagnosis. This study describes the management of suspected AA in a tertiary Australian pediatric ED.

Methods: A single-center prospective observational study was performed between November 2022 and May 2023. Children aged 5 to 15 years presenting to the ED with acute abdominal pain and clinician suspicion of AA were included. Clinical gestalt was measured using a 5-point Likert Scale before and after blood tests. Diagnosis of AA was confirmed on histopathology, and non-AA was confirmed with follow-up at 30 to 60 days.

Results: The study enrolled 481 children; AA was diagnosed in 146 (30.6%). Patients with AA were older (11.1 vs. 10.0 y) and more likely to be male (69.2% vs. 48.1%) compared with those without AA. Blood tests were performed in 449 (93.3%) children, with higher rates in AA cases (100% vs. 90.4%). Gestalt improved with blood test results, with overall diagnostic accuracy increasing from 65.9% pre-blood tests to 88.5% post-blood tests. Ultrasound (US) was performed in 361 (75.1%) children with a diagnostic accuracy of 90.6% and was frequently used even in patients deemed low-risk post-blood tests (65.7%). One hundred and fifty (31.2%) of suspected AA cases underwent surgery, with 3 negative appendectomies and 1 ovarian cystectomy without appendectomy. Median (IQR) hospital length of stay was significantly longer for AA cases than non-AA cases [50.8 (35.3 to 95.0) h vs. 7.1 (4.6 to 16.8) h].

Conclusions: This study reviews the management and outcomes of suspected AA in a high-volume Australian ED. It shows the importance of blood tests in improving diagnostic accuracy of clinician gestalt and highlights the potential overuse of US in low-risk patients. Future research should explore a more structured diagnostic approach to increase diagnostic accuracy, optimize resource utilization, and improve patient outcomes.

Objective: To develop and evaluate an internally validated natural language processing (NLP) model to determine guideline adherence of antibiotic decisions in the emergency department (ED) for skin and soft tissue infections (SSTIs).

Methods: This cross-sectional pilot study developed and applied a random forest (RF)/NLP model to classify clinical narratives of patients with skin infections as requiring either methicillin-resistant Staphylococcus aureus (MRSA) or non-MRSA antibiotic coverage. Conducted at a quaternary care children's hospital with an annual volume of 50,000 ED visits, our study included patients aged 1 to 18 years presenting for SSTIs to the ED from July 1, 2018, through June 30, 2023. Main outcomes included the NLP model's sensitivity, specificity, and receiver operator characteristic (ROC) curve compared to gold standard manual physician review of the medical records.

Results: A total of 1588 patients were part of the training data set, with an additional 423 patients utilized for validation. The RF model achieved an area under the curve (AUC) of 0.99, 97.0% sensitivity, and 94.9% specificity. In the validation data set, the model achieved 96.6% sensitivity and 90.1% specificity. Performance remained strong despite absent/missing patient history in certain narratives.

Conclusions: The NLP model demonstrated that automated analysis of clinical narratives for determining guideline adherence is feasible. Despite missing data in narratives, the model's high performance suggests potential for broader application. Given the rise in antibiotic-resistant infections and the role of judicious antibiotic use, developing automated systems through NLP can significantly contribute to health care delivery and patient safety. The methodology of this study provides a feasible, sustainable path for similar applications in the emergency setting.

Objective: Assess the clinical value of routine laboratory testing in the emergency department (ED) during behavioral disturbance evaluations in children with autism spectrum disorder (ASD).

Methods: A retrospective chart review of patients ages 3 to 21 years with ASD presenting to 3 pediatric EDs with behavioral disturbance from January 2019 to January 2020. Local laboratory standards were used to determine abnormal ranges in ED screening labs. Patients with abnormal findings were reviewed for medical significance, defined as the need for a medical intervention, inpatient observation, or the inclusion of a nonbehavioral diagnostic code due to an abnormal laboratory test result.

Results: A total of 209 eligible ED encounters were reviewed. Mean age was 14.5±3.1 years, and 84% were male. Of those, 84% (176/209) received venipuncture for screening labs per protocol, of which 97% (170/176) featured abnormal test results. Only 2 abnormal labs (1%) revealed clinically significant findings. Compared with whites, more patients of non-White race received venipuncture (90% vs. 73%, P=0.001) but less were admitted to psychiatric facilities (62% vs. 44%, P=0.01).

Conclusion: This study demonstrates that routine screening labs in asymptomatic children with ASD presenting to the ED with behavioral disturbances are often outside the range of normal, but without clinical relevance. This practice may lead to unnecessary and painful venipuncture. Children with ASD are a uniquely vulnerable population for whom we should choose wisely.

Objective: To examine Hispanic parental attitudes towards influenza vaccination, identify dimensions of vaccine hesitancy using the 4C framework (Calculation, Complacency, Confidence, Convenience), and assess parental willingness to have their child receive an influenza vaccine in the emergency department (ED).

Methods: In our multi-methods study, Hispanic Spanish-speaking (HS), Hispanic English-speaking (HE), and non-Hispanic White English-speaking (WE) parents answered a semi-structured interview and the Parent Attitudes about Childhood Vaccines (PACV) survey. We extracted themes from interviews using directed content analysis. We summarized PACVs using descriptive statistics (higher scores indicated higher vaccine hesitancy).

Results: From 58 sets of interviews and PACVs, we mapped parents' perceived benefits and barriers of child influenza vaccination to the 4Cs. When compared with WE parents (n=12), HS (n=26) and HE (n=20) parents had less knowledge about influenza and the vaccine, believed more vaccine myths, and were less likely to view influenza as a severe disease. HS and HE parents more often than WE parents expressed community health promotion as a vaccination benefit and poor health care access as a vaccination barrier. PACV scores showed that WE parents were least vaccine-hesitant (M=15.1, SD=15.1), followed by HE (M=22.8, SD=22.1) and HS (M=24.6, SD=14.8) parents. Most parents in all 3 groups expressed willingness to have their child receive the influenza vaccine in the ED.

Conclusions: Influenza vaccine hesitancy is greater among HS and HE parents compared with WE parents. Tailored education to different populations is warranted to increase influenza vaccination within the ED.

Cannabinoid hyperemesis syndrome (CHS), a recurring vomiting disorder triggered by long-term, frequent cannabis use, remains underdiagnosed and often leads to unnecessary diagnostic evaluations, increased health care utilization, and mental health burden. We present a large case series of CHS in pediatrics that includes data on treatment efficacy, health care utilization, and comorbidities.

Objectives: This study developed and validated a clinical scoring tool for predicting epilepsy development in pediatric patients with first-onset afebrile seizures using easily accessible clinical and laboratory parameters.

Methods: We conducted a retrospective, multicenter study involving pediatric patients aged 1 month to 18 years who presented to the EDs of 3 university hospitals in Korea with first-onset afebrile seizures between March 2018 and March 2021. Stepwise multivariable logistic regression analysis was performed to identify predictors of epilepsy. A point-based risk score was derived from the regression coefficients, and the performance of the prediction model was evaluated using a receiver operating characteristic (ROC) curve.

Results: In total, 328 children were included, of whom 132 (40.2%) developed epilepsy. Five variables remained significant in the final multivariable model: age group at onset, 2 or more seizures within 24 hours, lactate >2.27 mg/dL, total calcium <9.25 mg/dL, and abnormal brain imaging findings. The area under the ROC curve (AUROC) was 0.813 [95% confidence interval (CI): 0.763-0.859], and the mean AUROC from 5-fold cross-validation was 0.810 (95% CI: 0.760-0.857).

Conclusions: This clinical scoring tool may help stratify epilepsy risk in children with first-onset afebrile seizures in the ED. If prospectively validated, it could help identify high-risk patients early for appropriate referral and follow-up without requiring specialized equipment such as electroencephalography, thereby supporting clinical decision-making.

Concerns about the pediatric subspecialty workforce and financial impacts of subspecialty training have prompted national conversations regarding the optimal duration of pediatric subspecialty training. It is unknown whether accrediting bodies will change duration of training, and if so, which data/influences/drivers will inform those decisions. This special feature, assembled by a national group of pediatric emergency medicine educational leaders, compares the current 3-year training model with a shortened 2-year training duration for pediatric emergency medicine fellows. We discuss the rationale and potential impacts of each of these models in regard to recruitment, clinical competency, scholarly activity, and career preparation for fellows in this subspecialty. A balanced look at aspects of each model can help guide the national conversation and serve as a starting point to explore experiences and perceptions of key stakeholders-trainees and program leadership-in an effort to better inform future decisions about subspecialty training.

Objectives: The underrepresentation of racial and ethnic minorities in clinical research limits the generalizability of findings. This study examined how specific study design elements, such as follow-up requirements, stipends, and research procedures, were associated with participation refusal rates across racial and ethnic groups in a pediatric emergency department setting.

Methods: This retrospective cohort study analyzed recruitment outcomes from prospective studies conducted between 2012 and 2022 in a pediatric emergency department with approximately 70,000 annual visits. Studies requiring informed consent were included, excluding those targeting specific racial or ethnic groups. Demographic data were abstracted from the electronic health record using standard categories obtained by self-report during ED registration. Logistic regression assessed associations between study design elements and consent likelihood across racial and ethnic subgroups.

Results: Among 14,500 encounters, the median age was 12 years; 14.0% identified as Hispanic, 41.6% as Black, 55.7% as White, and 2.0% as Asian. Recruitment was successful in 71.5% of cases, with a 25.4% refusal rate. Moderate enrollment procedure time (6 to 15 min) were associated with higher consent odds for all groups, while very short (<6 min) or prolonged durations (>30 min) were linked to lower consent odds. High stipends (>$135) were associated with reduced likelihood of consent across all groups. Requirements for biobanking and lab work were more likely to be linked with refusal among Black and Asian participants. Hispanic participants were more likely to consent to medication trials (OR: 1.74, P=0.003). Follow-up requirements were associated with lower consent odds among Hispanic and White participants, with a stronger association for Hispanic participants (OR: 0.39, P=0.002).

Conclusions: Study design elements were significantly associated with recruitment outcomes, with notable variation across racial and ethnic groups. Transparent communication, culturally responsive engagement, and logistical flexibility may help reduce participation barriers and promote equity in pediatric clinical research.

Objectives: Gunshot wounds (GSWs) are the leading cause of death in children. This study defines pediatric firearm wound patterns and fatal organ injury to identify salvageability of injuries.

Methods: Survivor data were collected from an urban Level I pediatric trauma center and nonsurvivor data were collected from the medical examiner. All GSW patients aged 14 years and younger from 2011 to 2021 were included. Both survivors and nonsurvivors were analyzed for body area wounds. For nonsurvivors, trauma surgeons and medical examiners determined fatal organ injury. Wound patterns and fatal organ injury were compared with existing data on adult wound patterns and fatal organ injury.

Results: A total of 165 patients were analyzed, including 148 (90%) survivors. Nonsurvivors were younger (8 ± 4 vs. 10 ± 4 years old, P=0.04). Only 5% of survivors had a tourniquet placed, but none required operative control of hemorrhage. All nonsurvivors suffered head wounds, chest wounds, or both. Nonsurvivors had significantly more head wounds (71%) compared with survivors (9%) (P<0.001). Survivors had significantly more extremity wounds than nonsurvivors (68% vs. 12%, P<0.001). Nonsurvivors had significantly more brain (71% vs. 3%, P<0.001) and heart injuries (24% vs. 1%, P<0.001). No deaths were caused by exsanguination from peripheral vascular injury.

Conclusions: Pediatric firearm deaths are largely due to nonsurvivable brain injury. The best opportunity to lower pediatric firearm mortality is to prevent the injury itself, although this needs to be assessed in other cities and settings as well.