Pediatric emergency care最新文献

Abstract: Tongue-base cysts, which are occasionally categorized as vallecular cysts, are a rare yet potentially life-threatening cause of stridor in pediatric patients. Studies reporting the use of point-of-care ultrasound (POCUS) to identify tongue-base cysts are lacking. We present the case series of four infants in whom tongue-base cysts were detected using neck POCUS.

Background: The lower clinical exposure of Pediatric Emergency Medicine (PEM) fellows to critical procedures may impede skill acquisition. We sought to determine the tracheal intubation learning curve of PEM fellows during training and compared PEM fellow success against standards for tracheal intubation success.

Methods: This was a retrospective, video-based study of a cohort of PEM fellows at a single academic pediatric emergency department (PED). All forms of tracheal intubation were included (rapid sequence intubation and crash or no medication). The cohort consisted of 36 PEM fellows from all or part of 5 consecutive fellowship classes. Data were collected by structured review of both existing ceiling-mounted videos and the electronic medical record. The main outcome was PEM fellows' success on the first or second attempt. We used cumulative summation to generate tracheal intubation learning curves. We specifically assessed the proportion of PEM fellows who reached 1 of 4 thresholds for procedural performance: 90% and 80% predicted success on the first and the first or second attempt.

Results: From July 2014 to June 2020, there were 610 patient encounters with at least 1 attempt at tracheal intubation. The 36 PEM fellows performed at least 1 attempt at tracheal intubation for 414 ED patient encounters (65%). Median patient age was 2.1 years (interquartile range, 0.4-8.1). The PEM fellows were successful on the first attempt for 276 patients (67%) and on the first or second attempt for 337 (81%). None of the 36 PEM fellows reached the 90% threshold for either first or second attempt success. Four fellows (11%) met the 80% threshold for first attempt success and 11 (31%) met the 80% threshold for first or second attempt success.

Conclusions: Despite performing the majority of attempts, PEM fellows often failed to reach the standard thresholds for performance of tracheal intubation. Clinical exposure alone is too low to ensure acquisition of airway skills.

Objectives: In the United States, studies are inconclusive regarding the indications for polyvalent antivenom administration for crotaline envenomation. We compared polyvalent antivenom administration versus observation used at 2 separate institutions. We hypothesized that deferring antivenom leads to increased hospital length of stay and surgical interventions.

Methods: Retrospective chart review of children who presented to Le Bonheur Children's Hospital (LBCH) in Memphis, Tennessee, and Monroe Carell Jr Children's Hospital at Vanderbilt (MCJCHV) in Nashville, Tennessee, from 2009 to 2021. Patient demographics, treatment utilization, bite location, and outcomes from both sites were statistically examined.

Results: A total of 183 patients met the inclusion criteria (123 at LBCH, 60 at MCJCHV). At LBCH, mean age was 9.2 years, 54% were male, and 79% of known snakes identified as copperheads. At MCJCHV, mean age was 8.9 years, 65% were male, and 88% of known snakes identified as copperheads. The most commonly envenomated areas for both sites were the foot (42%), hand (27%), and ankle (26%). Patients at LBCH were managed with antivenom only 25% of the time, whereas 75% were observed; 82% of MCJCHV patients were managed with antivenom ( P < 0.001). There were no significant differences in length of stay (mean, 1.5 days at LBCH and 1.8 days at MCJCHV; P = 0.136) or surgical intervention (3.3% of LBCH encounters, 5.0% of MCJCHV encounters; P = 0.685). Secondary outcomes aside from coagulopathy and admission location (intensive care unit vs floor) were also not significant.

Conclusions: The use of antivenom did not impact hospital length of stay or surgical interventions. Our results should be interpreted cautiously as our study reflects regional experiences with snake species in the Southeast United States and not North America as a whole. Other institutional differences in management and smaller n at MCJCHV may have contributed to different outcomes. Further study is needed to determine intermediate and long-term effects of deferring antivenom use.

Background: Diabetic ketoacidosis (DKA) is a common presentation to an emergency department (ED), with the majority presenting to community EDs. Adherence to clinical guidelines in these EDs can reduce morbidity and mortality. Few methods to describe practice gaps for DKA management have been reported.

Objectives: We hypothesized that high-fidelity in situ simulation can be used to measure and compare the quality of the care provided to pediatric patients with DKA presenting to community EDs in the state of Indiana.

Methods: This observational study examined multiprofessional teams caring for a simulated pediatric patient who presented with DKA to community EDs. The primary outcome was overall adherence to pediatric DKA guidelines as measured by a validated performance checklist. A composite adherence score (CAS) was calculated using the sum of 9 checklist performance parameters. Multivariable logistic regression was used to examine the impact of ED volume and characteristics on the scores.

Results: A 49 multiprofessional teams from 13 sites were enrolled. Of the 252 participants, 26 (10.3%) were physicians, 143 (56.7%) registered nurses, 25 (9.9%) respiratory therapists, and 58 (23.0%) were other. The overall CAS for all sites was 55.6% (25th, 75th interquartile range, 44.4%, 66.7%). Excessive intravenous fluid boluses were given by 53.1%, whereas 30.6% and 26.5% incorrectly administered insulin and sodium bicarbonate boluses, respectively. Only 10.2% used an appropriate intravenous fluid rate, and 57.1% performed an hourly glucose. No significant difference in the CAS was found due to pediatric ED volume or presence of an inpatient pediatric service.

Conclusions: Using validated in situ simulation; we revealed high variability in adherence to the pediatric DKA management guidelines at a wide range of community EDs. A statewide education initiative focused on decreasing variation and improving adherence to pediatric DKA guidelines is necessary for patient safety.

Abstract: Sexually transmitted infection rates continue to rise in adolescents and young adults. Treatment of patients and their partners is vitally important to prevent reinfection and morbidity. Expedited partner therapy (EPT) is a legally available option for clinicians. EPT is endorsed by the Centers for Disease Control and Prevention and allows clinicians to prescribe medication for certain STIs for their patients' partner(s) without an evaluation of the partner(s). However, EPT is underutilized, and multisystem-level barriers exist to successful EPT exist. This article reviews the indications of EPT, common barriers to EPT and solutions to overcome these barriers, and practical considerations when prescribing EPT.

Abstract: Point-of-care ultrasound has been shown to be effective in diagnosing many types of fractures, including nasal fractures, but it is not commonly used in pediatrics to diagnose mandibular fractures. We describe a case of a mandibular fracture diagnosed by point-of-care ultrasound in the pediatric emergency department. Additional studies are needed in the pediatric population to determine if point-of-care ultrasound can diagnose mandibular fracture rapidly and accurately, expediting diagnosis and potentially minimizing exposure to ionizing radiation in patients with no point-of-care ultrasound evidence of mandibular fracture.

Abstract: Pediatric cardiac arrest is a rare but time-critical event that poses significant challenges to health care providers. Initiation of point-of-care ultrasound (POCUS) early in resuscitation can help optimize the location of chest compressions, identify inadequate compressions, evaluate for sonographic pulse, and help direct management. Although several algorithms currently exist to incorporate POCUS into adult cardiac arrest, none, to our knowledge, currently exist for the pediatric population. We propose a novel protocol for POCUS use as an adjunct to existing standard-of-care measures in pediatric cardiac arrest, which we call the Pediatric Ultrasound for Life-Supporting Efforts protocol.

Objective: Addressing the acute mental healthcare needs of children is a national crisis. Despite the ongoing crisis, there are limited prior studies that capture caregiver perspectives on acute pediatric mental healthcare, notably in a general emergency department (ED) in a rural state. Based on these knowledge gaps, our objective was to assess caregiver opinions and perspectives of acute management for children boarding with mental health conditions.

Methods: Semistructured interviews were conducted with caregivers of patients (under 18 years old) with a primary mental health condition boarding in a general ED (length of stay ≥24 hours) within a qualitative grounded theory approach. An interview guide was developed a priori and reviewed among key stakeholders. A trained study team performed the interviews. A coding tree was developed through an iterative process that included double-coding transcripts and monitoring of interrater reliability to perform thematic analysis.

Results: Fourteen interviews were conducted to reach thematic saturation. Key themes elicited from caregivers included mental healthcare delivery, access to mental healthcare services, care setting, and level of support for families and caregivers. Most caregivers focused on the following challenges and suggestions: access to appropriate, evidence-based mental healthcare, improved communication between all stakeholders involved, and staff education on mental healthcare for children.

Conclusions: Caregivers face considerable challenges in attaining timely and appropriate acute mental health care for their children. Immediate and innovative resource allocation is needed across the healthcare continuum to bolster the acute mental healthcare services currently offered to children and families, especially in the general ED setting.