Pediatric emergency care最新文献

Objectives: Pediatric out-of-hospital cardiac arrest (OHCA) is rare but critical, requiring rapid and effective cardiopulmonary resuscitation (CPR). Delivering high-performance CPR (HPCPR) in the prehospital setting is challenging, especially for EMS clinicians with limited pediatric exposure. This study aimed to assess EMS clinicians' pediatric CPR experience, confidence in HPCPR, and access to CPR feedback systems. A secondary objective was to evaluate perceptions of augmented reality (AR) feedback systems.

Methods: A cross-sectional survey was distributed electronically to EMS clinicians in 5 Maryland counties from January to May 2024. The survey included items on demographics, CPR experience, confidence in pediatric resuscitation, feedback device usage, and opinions on AR-based guidance. Descriptive and comparative analyses were conducted based on clinician type, experience, and administrative role.

Results: Fifty-eight EMS clinicians participated. While 78% had performed pediatric CPR, experience differed significantly by clinician type and years of service. Paramedics (87%) and clinicians with >6 years' experience (87%) had greater exposure than EMTs (46%) and less experienced clinicians (42%) ( P <0.05). Confidence in HPCPR was higher for adults (98%) than for infants (84%) and toddlers (83%). Only 52% had access to pediatric CPR feedback devices, although 97% of users reported improved CPR quality. Among those without access, 93% believed feedback would improve performance. Interest in AR feedback was moderate; barriers included cost, reliability, and training.

Conclusions: EMS clinicians vary in pediatric CPR experience and access to performance tools. Expanded pediatric training and real-time feedback technologies may improve prehospital resuscitation outcomes.

Objectives: Testicular torsion is a surgical emergency in which a timely diagnosis under 6 hours can significantly increase the survivability of the testicle. This study aims to retrospectively analyze cases of testicular torsion to determine whether the use of point-of-care ultrasound (POCUS) expedites care compared with radiology department ultrasound (RADUS). We evaluated POCUS effect on emergency department (ED) workflow, urological consultation time, and time to the operating room (OR).

Methods: We conducted a retrospective review of patients diagnosed with testicular torsion between January 2021 and October 2024. Inclusion criteria were patients confirmed to have testicular torsion intraoperatively. Demographics were taken of each patient as well as multiple time intervals of events such as radiologic imaging, consult time, and time to surgery. Patients were grouped into 3 cohorts, POCUS only, POCUS followed by RADUS, and RADUS only. Mann-Whitney U tests were performed for pairwise comparisons between groups.

Results: Sixty-five patients were eligible for the study. The time between physician initial assessment (PIA) to the OR in the subgroups of POCUS only, POCUS/RADUS, and RADUS only were 97, 141, and 195 minutes, respectively. A 98-minute difference in the PIA to OR time between POCUS-only and RADUS-only groups (P < 0.001) was found to be statistically significant.

Conclusion: With a difference in PIA to OR time of close to 100 minutes between POCUS-only and RADUS-only groups, our findings suggest that POCUS significantly reduces time to urological consultation and has the potential to expedite surgical intervention if POCUS can reliably replace RADUS. These results highlight the value of integrating POCUS into ED workflows for testicular torsion.

Objectives: Acute gastroenteritis (AGE) is one of the most common diseases in children, and detecting dehydration status is important for managing it. Volume depletion and altered urate excretion through the gastrointestinal tract can cause hyperuricemia. This study aimed to evaluate the role of hyperuricemia in assessing the severity of dehydration in children.

Methods: This retrospective study included patients aged 7 to 18 years who were diagnosed with AGE. We used both the clinical dehydration scale and measured amount of weight loss at the time of emergency room visiting to evaluate the dehydration status. Age-based and sex-based reference values of uric acid were used to define hyperuricemia.

Results: Of the 95 patients with AGE, 40 (42.1%) showed moderate-to-severe dehydration. Hyperuricemia was observed in 44 (46.3%) patients and was more common (95.0 vs. 10.9%, P <0.001) in patients with moderate-to-severe dehydration than in those with mild dehydration. In multivariate analysis, hyperuricemia (OR: 5.13; 95% CI: 2.453-10.526) and bicarbonate levels <15 mmol/L (OR: 3.25; 95% CI: 0.225-7.259) were significant factors associated with moderate-to-severe dehydration.

Conclusions: Uric acid levels were correlated with dehydration in children with AGE.

Objectives: Adolescence is a critical period of growth and development, shaped by the social conditions in which youth are immersed. Many adolescents use emergency departments (EDs) as their primary source of care, often bypassing routine health care systems where preventative screenings and counseling are provided. This may lead to missed opportunities to address social or mental health needs. Partners in Equity and Empowerment through Resources and Support (PEERS), based out of Boston Medical Center's pediatric ED, bridges the gap between patients' health-seeking behaviors and the ED's capacity to provide preventive care. PEERS engages medical and public health students to conduct social and mental health screenings, connecting adolescent and young-adult (AYA) patients with community-based resources that support their holistic health needs.

Methods: From 2021 to 2023, medical and public health students performed bedside screenings of 13- to 23-year-old pediatric ED patients using a blended survey developed from validated screening tools for social drivers of health (SDoH) (e.g., food insecurity, housing, employment, sexual health, substance use) and mental health. Following verbal consent/assent, survey screenings, and brief negotiated interviews, patients were referred to curated, need-specific resources for further support.

Results: During our 28-month pilot, 246 AYA patients were screened, with 97.2% reporting at least one SDoH need and 93.1% referred to at least one community-based resource. The most commonly requested resources were education (46.3%), employment (38.6%), and mental health (32.9%). Younger age was associated with higher requests for educational resources (OR: 1.38; 95% CI: 1.10-1.79), while male gender was linked to fewer mental health resource requests (OR: 0.27; 95% CI: 0.07-0.88).

Conclusions: An interprofessional, student-led team can provide AYA patients with the necessary SDoH resources to bridge care gaps without disrupting ED workflow, supporting the feasibility and benefit of this innovative program to promote health.

Objectives: Intussusception is a medical emergency requiring reduction with a pneumatic or hydrostatic enema. Although evidence supports the safety of medications to reduce distress during the procedure, their use remains limited. This quality improvement (QI) project aimed to provide analgesic and anxiolytic medications to all eligible patients undergoing pneumatic reduction within 1 year.

Methods: A multidisciplinary team developed a standardized clinical pathway to provide both intranasal fentanyl and midazolam for all patients undergoing intussusception reduction. The interventions included staff education, team engagement, and process interventions through sequential Plan-Do-Study-Act cycles. The primary outcome measure was pathway provision. Process measures included documentation of pain and sedation scores, while balancing measures assessed adverse events, failed reductions, and perforation rates.

Results: Over the project period, 25 patients were diagnosed with intussusception. Two patients with lead points proceeded directly to surgery. Among the 23 patients with planned pneumatic reduction, 19 (82%) had successful reductions, 2 had spontaneous reductions, and 2 required surgical intervention due to failed reductions. Pathway provision improved from 0% at baseline to 100% by the project's end. Pain score documentation reached 100%. No cases of serious adverse events or intestinal perforation were reported. Pathway compliance remained at 100% during the sustainment period. The interval number of days between patients who did not receive analgesia and anxiolysis was short initially but progressively lengthened.

Conclusions: This QI initiative improved rates of analgesic and anxiolytic provision to reduce distress in patients undergoing intussusception reduction, without adverse outcomes. This project highlights the effectiveness of structured interventions in optimizing pediatric procedural pain management and potentially serves as a model for spread to other pediatric emergency departments.

Background: Fascia iliaca compartment nerve blocks (FICNB) have been shown to be an effective management strategy for pediatric femur fractures in the emergency department, but they can be performed using different techniques. Our main objective was to evaluate the association between needle tip distance to the femoral nerve and pain score reduction following ultrasound-guided FICNB in pediatric patients with acute femur fractures.

Methods: We conducted a secondary analysis of a prospective, multicenter observational study conducted in the United States and Australia. Participants were children aged 4 to 17 years with isolated femur fractures who received a FICNB, divided into 2 groups based on ultrasound visualization of needle tip distance from the femoral nerve: ≥5 mm or <5 mm. The main outcome was a comparison of the mean pain score reduction between groups using the Faces Pain Scale-Revised (FPS-R). The FPS-R is a validated 0 to 10 continuous scale in which participants self-report their pain intensity. Pain scores were taken immediately before the nerve block (t 0 ) and 60 minutes postprocedure (t 60 ). In addition, adverse events were recorded. Differences in mean pain scores were analyzed using t tests, and categorical variables were compared with Fisher exact test.

Results: Of the 54 participants who received a FICNB (31 with needle tip ≥5 mm from the femoral nerve, 23 with needle tip <5 mm), 49 had a t 60 pain score available for analysis (30 in the ≥5 mm group, 19 in the <5 mm group). Pain scores at t 0 were similar between both groups. Both groups experienced a reduction in mean pain score at t 60 [≥5 mm group 3.5 vs <5 mm group 4.6, difference between groups: 1.1 (95% CI, -0.6 to 2.7)]. No serious adverse events were reported.

Conclusion: In pediatric patients with acute femur fractures, needle tip distance from the femoral nerve does not seem to be associated with a difference in pain score reduction or the occurrence of serious adverse events.

Objective: To evaluate the association of emergency department (ED) ondansetron with hospitalization with acute gastroenteritis (AGE) in children.

Methods: We conducted a retrospective study using the PECARN Registry of children with AGE. Within a sample matched on vital signs, demographics, clinical severity, imaging performance, and intravenous fluids provision, we used conditional logistic regression to assess associations between administration of ondansetron and hospitalization. We compared rates of 7-day return visits with significant diagnoses between children who did and who did not receive ondansetron on their initial encounter.

Results: We included 543,541 encounters, of which ondansetron was administered in 39.7%. After matching, hospital admission occurred in 11.8% and 17.7% of children who did and did not receive ondansetron, respectively, with standardized mean differences <0.1. Ondansetron was negatively associated with hospitalization (OR: 0.61, 95% CI: 0.60-0.63). Children given ondansetron on their index visit had a higher percentage of 7-day return visits with appendicitis (absolute percentage difference, +0.05%, 95% CI: +0.03%, +0.07%), but a lower percentage of return visits with sepsis or bacteremia (-0.03%, 95% CI: -0.05%, -0.01%) compared with children not given ondansetron on their index visit.

Conclusions: Children receiving ondansetron for AGE in the ED had an ∼40% lower odds of hospitalization. While appendicitis was diagnosed more frequently within 7 days among children given ondansetron compared with those not given ondansetron, sepsis or bacteremia were less frequently diagnosed. These findings align with prospective studies demonstrating the beneficial impact of ondansetron use in pediatric AGE.

Objectives: The primary objective was to compare adenosine administration time with the single syringe (SS) versus double syringe (DS) method in a simulated pediatric emergency department (ED) patient. Secondary objectives were to compare preparation time, preparation errors, administration errors, and participant preference/perception.

Methods: This was a prospective, randomized, crossover simulation study. Adenosine doses were prepared by a pharmacist and administered by a physician. The primary outcome was administration time. Secondary outcomes were preparation times, participant preference, pharmacist-rated ease of preparation, and physician-rated ease of administration.

Results: Sixteen pharmacist-physician pairs were included. The SS method had a shorter administration time versus the DS method [SS, median (IQR): 13 (10 to 15.8) s versus DS, median (IQR): 26 (20.8 to 31.3) s, P <0.001; median difference (95% CI): -13 (-22.5 to -9) s]. There were no significant differences in preparation times or pharmacist-rated ease of administration between the SS and DS methods. The SS method had a higher physician-rated ease of administration and was preferred by 68.8% of study participants.

Conclusions: The SS method had a faster adenosine administration time versus the DS method in a simulation setting, while also having similar preparation time, preparation errors, and administration errors. The SS method was rated easier to administer and preferred by most participants. Further study is required, as this study is limited by its simulation design and lack of clinical outcomes.

Objectives: The objective of this study was to determine the prevalence of gender identity and gender incongruence among adolescents who screened positive for behavioral health concerns in a pediatric emergency department. The study aimed to assess the relationship between gender incongruence, emotional distress, and suicidality.

Methods: This cross-sectional study was conducted in a single academic pediatric emergency department. Adolescents aged 13 to 18 years with positive behavioral health screens were approached for anonymous participation via electronic tablet without caregivers present. A validated self-report tool, the Gender Preoccupation and Stability Questionnaire-2 (GPSQ-2), was used to determine gender identity and sexual orientation. The primary outcomes were the prevalence of gender incongruence and gender identity. Secondary outcomes included levels of distress and suicidal ideation. Descriptive statistics and χ 2 or Fisher exact test were used for analysis.

Results: Among 131 eligible adolescents, 102 (78%) completed the study between August 2023 and August 2024 (mean age 15.1 y; 59% female at birth). Gender incongruence was reported by 16.6% (n=17), and 37% identified as nonheterosexual. Distress levels were significantly greater among gender-incongruent individuals compared with gender-congruent peers ( P <0.001). No statistically significant difference in suicidal ideation was observed between groups ( P =0.204).

Conclusions: A higher than expected proportion of adolescents presenting with behavioral health concerns in a pediatric emergency setting reported gender identity and incongruence with associated psychological distress. If further studies confirm our results, these findings support incorporating inclusive screening practices and tailored mental health interventions in emergency care settings for adolescents at risk of self-harm.

Background: Fever in infants under 60 days old raises concern for invasive bacterial infections. In 2021, the American Academy of Pediatrics (AAP) released updated guidelines, including revised recommendations for infants aged 22 to 28 days, to reduce unnecessary lumbar punctures (LP), hospitalizations, and antibiotic use. This study hypothesized that the guidelines would reduce LPs, specifically in the newly stratified age group.

Methods: We conducted a retrospective cohort study at a single pediatric emergency department of febrile infants aged 22 to 60 days presenting between October 1, 2019, and September 30, 2023, with October 1, 2021, being the division between groups. Infants were excluded if ill-appearing, <37 weeks of gestation, or had complex medical histories. The primary outcome was the proportion undergoing LP. Subgroup analysis was performed by age group, and those identified as low-risk by initial laboratory evaluation. Secondary outcomes included hospital admission, length of stay, and antibiotic use.

Results: A total of 132 infants met the inclusion criteria (52 pre-guidelines, 80 post-guidelines), and no exclusion criteria were applied. Following guidelines, the proportion of LPs had a statistically significant decrease ( P =0.02), with the reduction maintained in the 22- to 28-day subgroup ( P =0.002). The rate of hospital admission and antibiotics followed a similar statistically significant decrease post-guideline introduction, which also maintained for the 22- to 28-day subgroup. There was no statistically significant difference for length of stay or in the 29- to 60-day subgroup analyses. For infants identified as low-risk by laboratory risk-stratification, we discovered a statistically significant reduction in LP following the guidelines ( P <0.001).

Conclusions: Implementation of the 2021 AAP guidelines was associated with reduced LPs, hospitalizations, and antibiotic use in infants aged 22 to 60 days, with the greatest impact in the 22- to 28-day subgroup. These guidelines improve risk stratification and reduce invasive interventions while maintaining safe care. While the small sample size limits generalizability, these findings suggest a positive shift in clinical practice.