Pediatric emergency care最新文献

Objectives: Casino shifts, which end at 4 AM and allow sleep during the circadian "anchor period," may improve sleep and reduce fatigue for pediatric emergency medicine (PEM) fellows working night shifts. We hypothesized that using a casino shift model would improve perceived fatigue levels and measured sleep metrics.

Methods: In this pilot prospective observational cohort study, fellows worked traditional night shifts for one month (control) followed by casino shifts for one month (intervention). Sleep data were collected using a validated wrist actigraph (ReadiBand), and subjective perceptions of fatigue were collected using surveys.

Results: Eight fellows participated in the study. Compared with the control month, the intervention month was associated with increased sleep quantity and sleep efficiency as measured by the actigraph. Fellows also reported reduced perceived fatigue and improved energy levels during the intervention month.

Conclusions: Switching to a casino shift schedule was associated with improvements in measured sleep and perceived fatigue among a cohort of PEM fellows in this pilot study. These preliminary findings warrant further investigation with larger samples and randomized scheduling to further explore the potential benefits and limitations of casino shift models in emergency medicine.

Introduction: Mild traumatic brain injuries (mTBI) are common in pediatric emergency departments (EDs), but inconsistent use of diagnostic labels leads to variable discharge instructions, especially with regard to concussion. Lack of age-appropriate guidance can increase parental anxiety and ED revisits and hinder recovery.

Objective: This quality improvement (QI) initiative aimed to increase the proportion of mTBI patients receiving age-appropriate discharge instructions to 50% over 13 months in an urban pediatric ED.

Methods: An interdisciplinary QI team conducted an observational time series study with sequential experimentation at a quaternary academic medical center over 13 months. Using a key driver diagram, they created SMART aim, measures, and designed interventions which were tested through 5 Plan-Do-Study-Act (PDSA) cycles. Interventions included an educational curriculum, e-reminders, workspace materials, and pre-written electronic medical record (EMR) templates (smart phrases) for age-specific discharge instructions (0 to 5 y, ≥6 y), and parent surveys were used on a subset of sample families to assess knowledge, behavior, and anxiety post-discharge. Outcome measures included the percentage of age-appropriate discharge instructions provided and use of the new EMR smart phrase. Balancing measures tracked head computed tomography (CT) utilization, ED revisits within 14 days of discharge, and neurology referrals. Process control charts and rules to detect special cause variation were used to analyze data. We use descriptive statistics to analyze survey data.

Results: Among 1263 patients, age-appropriate discharge instruction rates improved from 36% to 56%. Smart phrases were used in 58% of relevant cases (n=628). No changes were observed in CT orders, ED revisits, or neurology referrals. Among 37 surveyed parents (28% response rate), 95% (n=35) found instructions helpful, and 68% (n=25) reported reduced anxiety.

Conclusions: Implementing EMR smart phrases in a pediatric ED increased standardized, age-appropriate discharge instructions for children with mTBI. These low-cost interventions are scalable for broader ED use and other settings.

Objectives: This retrospective observational study evaluated the diagnostic efficiency of routine magnetic resonance imaging (MRI) in pediatric patients with facial palsy (FP) in the emergency department (ED).

Methods: Pediatric patients under 18 years of age who presented with FP at the ED of a single tertiary referral hospital between January 2010 and December 2022 were included. Clinical features were assessed and used for risk stratification, which informed the diagnostic utility of the MRI.

Results: A total of 134 pediatric patients were included [mean age, 99 mo; 53.7% male (n = 72)]. Seventeen patients (12.7%) were diagnosed with central FP (CFP). Among the clinical features, additional neurological examination abnormalities emerged as the most significant risk factor for CFP (odds ratio, 86.3; P < 0.001). Risk stratification based on neurological abnormalities, underlying conditions, and associated symptoms revealed that the diagnostic utility of MRI was significantly higher in the risk group than in the no-risk group ( P < 0.001; sensitivity, 100%; specificity, 84.6%). In contrast, patients in the no-risk group who underwent MRI experienced a mean increase of 294 minutes in the ED length of stay compared with those who did not undergo imaging.

Conclusions: Routine MRI is valuable for detecting CFP in pediatric patients with neurological signs. However, its use in low-risk cases may provide limited clinical benefit, prolonging ED stay and increasing unnecessary use of medical resources. Therefore, selective imaging based on clinical indicators is recommended.

Introduction: Trauma is a leading cause of pediatric emergency visits, yet training often underemphasizes nontechnical skills (NOTECHS). Simulation-based training can improve these skills, and targeted video review (TVR) may further enhance debriefings by enabling precise, case-based feedback. This study evaluated the combined impact of multidisciplinary, simulation-based training and TVR on technical performance and NOTECHS during pediatric trauma resuscitations.

Methods: This prospective educational quality improvement study was conducted at a level 1 pediatric trauma center from February 2023 to July 2023. Multidisciplinary teams participated in in situ pediatric trauma simulations followed by structured debriefings incorporating TVR. Video reviews of preintervention and postintervention trauma activations (n = 76) assessed changes in team behavior and clinical metrics, including time-to-vitals, imaging, emergency department (ED) length of stay (LOS), and time-to-operating room (OR). Trauma performance was evaluated using the Trauma Team Evaluation Tool and T-NOTECHS.

Results: Seventy-six trauma activations (21 preintervention, 55 postintervention) were reviewed. Postintervention, the proportion of cases without an identified team leader decreased (33% to 9.1%), and those with a defined disposition plan increased (66.7% to 100%). Overall team performance improved (6.52 to 7.60/10; P < 0.001), with significant gains in communication and situational awareness ( P = 0.012 and P = 0.033, respectively). Time-to-vitals decreased significantly ( P = 0.027); while imaging, ED LOS, and time-to-OR showed nonsignificant changes.

Conclusions: Simulation-based interdisciplinary training, paired with TVR improved teamwork, communication, and decision-making in pediatric trauma resuscitations. This approach reinforced protocol adherence and supported quality improvement. While effects on patient outcomes remain uncertain, these findings support simulation and TVR as strategies to enhance performance in high-acuity settings.

Background and objectives: Chest radiographs (CXRs) are often performed among children presenting to the emergency department (ED) with chest pain. Given the limited data on this practice, we sought to evaluate the risk of pneumonia among children presenting to an ED with chest pain and to further identify children at low risk of pneumonia.

Methods: We performed a secondary analysis of a prospective study enrolling children 5 to 18 years of age with chest pain who had a CXR performed for clinical suspicion of pneumonia. We compared the characteristics of children with and without pneumonia and used multivariable analyses to identify characteristics associated with radiographic pneumonia.

Results: A total of 240 children with chest pain undergoing CXR for clinical suspicion of pneumonia were enrolled [median age 11.5 years (IQR: 7.6, 15.4)]. Radiographic pneumonia was observed in 46 children (19%). The odds of pneumonia were higher among children with fever (aOR: 3.5, 95% CI: 1.6, 7.8), tachypnea (aOR: 2.7, 95% CI: 1.2, 6.2), crackles (aOR: 2.3, 95% CI: 1.1, 5.0), and diminished breath sounds (aOR: 2.5, 95% CI: 1.2, 5.1) on auscultation. A total of 45 of 46 children with pneumonia had one or more of the following: fever, tachypnea, crackles, or decreased breath sounds on auscultation (sensitivity 97.8%, 95% CI: 88.5%, 99.9%).

Conclusions: Approximately 1 in 5 children presenting with chest pain and undergoing CXR had radiographic pneumonia. Pneumonia may be safely excluded among children with chest pain if there is no fever, tachypnea, crackles, or diminished breath sounds on examination.

Point-of-care ultrasound (POCUS) plays a vital role in rapid diagnosis and management in emergency settings. We present a case of a 9-year-old male who presented after a high-speed motor vehicle collision with a negative focused assessment with sonography for trauma (FAST). However, the quality assurance (QA) review raised concerns for a splenic mass. Further imaging confirmed the finding, and the patient underwent elective splenectomy, revealing a rare benign littoral cell angioma. This case illustrates the importance of QA in identifying findings during POCUS exams, the limitations of POCUS compared with comprehensive imaging, and the value of a multidisciplinary approach to pediatric trauma care.

Introduction: Early recognition of severe sepsis and septic shock in the pediatric emergency department (PED) is crucial for the success of early targeted therapy. The shock index (SI) and pediatric age-adjusted shock index (SIPA) are promising noninvasive tools for early risk stratification. This study aimed to evaluate the predictive performance of SI, SIPA, and modified indexes in severe outcomes.

Methods: This single-center retrospective cohort study included 238 pediatric patients aged 1 month to 18 years who met systemic inflammatory response syndrome criteria. Clinical findings and vital signs were collected at presentation. SI, SIPA, and modified indices were calculated using heart rate and systolic blood pressure. Biomarkers, including lactate and immature granulocyte percentage (IG%), were also recorded.

Results: Of 238 patients, 49 (20.6%) had severe sepsis or septic shock. SI ≥1.81 showed an AUC of 0.815, sensitivity of 81.6%, and specificity of 67.7%. SIPA had a sensitivity of 91.8% but a lower specificity (45.0%). Pediatric Shock Index and Temperature-adjusted and Age-adjusted Mean Shock Index had AUCs of 0.443 and 0.734, respectively. Age-specific SI cutoffs improved predictive performance, particularly in younger children. Combining SI with IG% or lactate enhances diagnostic accuracy.

Conclusions: SI and SIPA are practical tools for early recognition of severe sepsis in children. Age-adjusted SI cutoffs improve accuracy. Diagnostic performance was further enhanced when combined with IG% and lactate, supporting their integration in PED clinical decision-making.

Objectives: Rapid brain MRI (rMRI) provides a radiation-free neuroimaging tool to screen children without sedation. Our objective was to retrospectively analyze clinical rMRI utilization by describing demographics, operational metrics, clinical indications, and temporal trends associated with rMRI utilization in the emergency department (ED).

Methods: We conducted a single-center, retrospective, cross-sectional study of children who underwent rMRI in the ED at an urban children's hospital between May 2014 and March 2024. We used descriptive statistics to examine operational metrics and trends in rMRI utilization over the study period. We performed a subgroup analysis of operational metrics by age and clinical indication.

Results: We included 2401 patients who underwent rMRI during their ED encounter. rMRI was frequently performed in infants and toddlers younger than 3 years old (n = 604, 25.1%), with a median patient age of 8.0 [interquartile range (IQR): 3.0 to 14.5] years. The median (IQR) time to scan was 3.5 (2.4 to 5.1) hours, and the median (IQR) ED length of stay was 7.5 (5.8 to 9.6) hours. Of the total, 1917 (79.8%) patients were initially triaged as "emergent," and 990 (41.2%) were discharged home from the ED. rMRI was predominantly used to evaluate ventricular shunt function (n = 2069, 86.1%) and traumatic brain injury (n = 214, 9.0%). Annual rMRI utilization increased by 80.8% between 2015 and 2023, with an average utilization rate increase of 46.1 scans annually between the years 2015 and 2019, and relatively static utilization rate from 2020 to 2023.

Conclusions: This work supports the feasibility of widespread rMRI in the high-volume ED care setting, including for young children. rMRI utilization increased over time, with the technique most frequently used to evaluate ventricular shunt function and traumatic brain injury.

Objectives: Unintentional injury is a leading cause of morbidity and mortality in children. The Accreditation Council for Graduate Medical Education (ACGME) requires competency in medical and trauma resuscitation in patients from newborn through adulthood. Yet there is a paucity of data regarding best practices for pediatric trauma training. The goal of this study was to evaluate knowledge gaps in pediatric trauma training, implement a trauma simulation curriculum, and evaluate changes in fellows comfort level with trauma skills preimplementation and postimplementation.

Methods: We utilized Kern's 6-step approach to design an innovative longitudinal trauma curriculum for Pediatric Emergency Medicine (PEM) fellows. A needs assessment was sent to PEM faculty, PEM fellows, pediatric surgery faculty, pediatric surgery fellows, and pediatric ED nursing. Learning objectives were derived and categorized as technical skills, nontechnical skills, and case-based medical knowledge. This guided a year-long curriculum including 11 simulation cases and 3 didactic sessions. The curriculum was assessed at Kirkpatrick levels 1 and 2 through preimplementation and postimplementation surveys. We assessed fellows' self-reported comfort and faculty perception of the supervision required.

Results: Fellows began with higher overall comfort with nontechnical skills compared with technical skills. Following implementation, there was a statistically significant improvement in fellow comfort in overall technical skills (P < 0.05), traction splint application (P < 0.05), and initiating massive transfusion protocol (P < 0.05). There were positive trends in obtaining access, placing pelvic binders, managing increased intracranial pressure, and leadership skills. There were no statistically significant findings noted in the surveys completed by the faculty.

Conclusions: This study presents a promising foundation for a comprehensive longitudinal pediatric trauma curriculum. Our study, while small, showed overall improvement in fellow comfort with trauma resuscitation at Kirkpatrick level 1, most notably with technical skills. Future areas of research include increased sample size, enhanced skills assessment methods, and expansion to other trauma team stakeholders.

Background: Patellar dislocations are frequently seen in the emergency department (ED). Almost all children with a reduced patellar dislocation will have a knee radiography, while only 10% have a fracture identified on x-ray.

Objective: The primary purpose of the study was to identify factors predicting osteochondral fractures among children with patellar dislocation reduced in the ED.

Methods: This was a retrospective cohort study of all children aged between 1 and 18 years old with patellar dislocation who needed a reduction in a tertiary care pediatric ED between 2019 and 2024. The primary outcome was the presence of a fracture identified by radiology (x-ray or MRI) during ED visit or follow-up at the orthopedic clinic. Multiple independent variables were evaluated as potential predictors. These were related to the patient (age, sex, previous patellar dislocation), the accident, and the physical examination before and after reduction, as well as finding at the follow-up at the orthopedic clinic. All charts were evaluated using a standardized form, and 10% were evaluated in duplicate to ensure interrater reliability. The primary analysis was the association between the independent variable and fracture using logistic regression.

Results: There was a total of 316 diagnoses of patellar luxation in 276 children with a median age of 14 years. Ninety-six children had their patellar dislocation reduced at the ED and were included in the study, of whom 19 (20%) had a fracture. Of all variables tested, only the persistence of knee swelling at orthopedic follow-up was associated with a higher risk of fracture (OR: 13.39; 95% CI: 1.70-105.32).

Conclusion: Approximately 20% of children who needed a reduction in the ED for patellar dislocation had a fracture. Persistent knee swelling at follow-up is a potential predictor of fracture.