Pediatric emergency care最新文献

Background/objectives: Otoscopy is a fundamental yet challenging skill for pediatric trainees. Otoscopy can be uncomfortable for children, particularly if repeat examinations are required. Digital otoscopy (DO) allows clinicians to record and review otoscopic images. This study evaluated whether trainees' use of DO could reduce repeat examinations by supervisors, and its perceived educational value to trainees.

Methods: We conducted a prospective observational study in a pediatric emergency department in New York City. Pediatric, emergency medicine, and pediatric nurse practitioner trainees used DO to record ear exams in children presenting with fever, upper respiratory symptoms, or otalgia. Trainees presented all cases to a pediatric emergency medicine attendings or fellows who served as supervisors. Trainees completed pre- and postrotation surveys assessing confidence in otoscopy, ability to diagnose acute otitis media (AOM), and satisfaction with otoscopy education. The primary outcome was "first examine success" defined as the supervisor not needing to repeat the examination of the patient's tympanic membranes (TM). Logistic regression was used to identify factors associated with first-exam success. Ratings of DO's value as a diagnostic and teaching tool were also collected.

Results: Sixty-seven trainees and 368 patients were included. In 276 (75%) encounters, no repeat exam by the supervisor was needed. First-exam success was independently associated with age ≥2 years, higher training level, and >50% TM visualization. Trainee confidence in performing otoscopy, diagnosing AOM, and educational satisfaction increased significantly postrotation. Of all trainees, 66 (97%) and 57 (85%) agreed that DO was a superior teaching and diagnostic tool, respectively.

Conclusion: DO eliminated the need for repeated exams in the majority of patients. Trainees considered it a superior teaching and diagnostic tool compared with conventional otoscopy.

Objectives: Acute appendicitis and Familial Mediterranean Fever attacks are among the leading causes of acute abdominal pain in children and often present with overlapping clinical features. This study aimed to evaluate the diagnostic utility of the systemic immune-inflammation index in differentiating acute appendicitis from Familial Mediterranean Fever attacks and to assess whether combining this index with other hematological parameters improves diagnostic discrimination.

Methods: A retrospective diagnostic accuracy study was conducted at a tertiary pediatric surgery center between January 2019 and December 2024. Pediatric patients aged 1 to 18 years with histopathologically confirmed acute appendicitis or clinically defined Familial Mediterranean Fever attacks were included. Demographic characteristics and complete blood count parameters were recorded. The systemic immune-inflammation index was calculated using neutrophil, platelet, and lymphocyte counts. The neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were also calculated. Group comparisons were performed using nonparametric tests. Diagnostic performance was evaluated using receiver operating characteristic curve analysis, including a combined hematological model.

Results: A total of 90 patients were included, comprising 44 with acute appendicitis and 46 with Familial Mediterranean Fever attacks. Age and sex distributions were comparable between groups. Median systemic immune-inflammation index values were significantly higher in patients with acute appendicitis than in those with Familial Mediterranean Fever attacks. The neutrophil-to-lymphocyte ratio was also significantly higher in the acute appendicitis group, whereas the platelet-to-lymphocyte ratio did not differ significantly between groups. The combined hematological model demonstrated improved discriminative performance compared with the systemic immune-inflammation index alone.

Conclusions: The systemic immune-inflammation index is significantly elevated in pediatric patients with acute appendicitis compared with those experiencing Familial Mediterranean Fever attacks and shows good diagnostic performance in this differential setting. The combined use of hematological indices may further enhance diagnostic discrimination and serve as a supportive tool in the evaluation of children presenting with acute abdominal pain.

Background: Impalement injuries in children, though rare, pose unique diagnostic and surgical challenges due to unpredictable trajectories and frequent involvement of multiple organ systems. Literature is limited to isolated reports and small series, with few comprehensive analyses from pediatric populations.

Methods: We conducted a retrospective review of pediatric impalement injuries managed at a tertiary children's hospital over 10 years (July 2015-June 2025). These patients were first encountered by the general surgery and critical care team in the trauma center initially and were subsequently referred to Pediatric Surgery and respective specialities. Patients 12 years or below with impaled objects in situ or requiring operative exploration were included; minor punctures not requiring surgery were excluded. Data regarding demographics, mechanisms, injury sites, operative management, complications, and outcomes were analyzed descriptively.

Results: Twenty-one children (median age: 7 y; range 4 to 12; 13 males, 8 females) were managed. Mechanism was accidental in all, most commonly falls onto fixed objects (81%). Injury distribution was oral cavity (7, 33.3%), abdomen (5, 23.8%), thorax/thoracoabdominal (4, 19.0%), perineum (4, 19.0%), and neck (1, 4.8%). Eleven children required major operative intervention (6 laparotomies, 4 thoracotomies, 1 tracheostomy); the remainder underwent wound repair or examination under anesthesia. Gastrointestinal involvement occurred in 9 patients, with 5 requiring fecal diversion. Blood transfusions were needed in 52%, and massive transfusions in 3 cases. Complications were observed in 8 patients (38.1%), including intra-abdominal/pelvic abscess, salivary leak, atelectasis, wound infection, and urethral stricture. Three patients (14.3%) died, all with major thoracic or abdominal injuries. Among 18 survivors, follow-up (median 12 mo) demonstrated complete functional recovery, including continence after stoma reversal and preserved urinary/gynecologic function in pelvic injuries.

Conclusions: Pediatric impalement injuries, though infrequent, demand meticulous multidisciplinary management. Outcomes are favorable with adherence to trauma principles, delayed removal of impaled objects until surgical control, and judicious fecal diversion in anorectal or contaminated injuries. Mortality is concentrated in thoracic and complex abdominal impalements, underscoring the need for early resuscitation, controlled extraction, and prompt surgical expertise.

Objective: To systematically evaluate the impact of virtual reality (VR) technology on pediatric patients during venous access in the emergency departments (EDs).

Methods: Randomized controlled trials (RCTs) investigating the effects of VR technology on pediatric patients during venous access in the EDs were retrieved from databases including CNKI, Wanfang, VIP, CBM, PubMed, Cochrane Library, Embase, and Web of Science, with the search period spanning from inception to July 2025. Data analysis was performed using RevMan 5.2 software.

Results: A total of 8 RCTs involving 629 pediatric patients in the EDs were included. The analysis revealed that the VR technology group showed significantly better outcomes in pain scores compared with the control group (SMD=-0.73, 95% CI=-1.42 to -0.04, P =0.04). However, no significant differences were observed between the 2 groups in fear scores ( SMD =-0.94, 95% CI=-2.13 to 0.26, P =0.12) or first-attempt success rate (OR=1.01, 95% CI=0.60-1.72, P =0.96).

Conclusion: VR technology may help alleviate pain in pediatric patients during venous access in the EDs, but no significant improvements were found in reducing fear or increasing the first-attempt success rate.

Objective: Current scoring tools are suboptimal to predict care escalation in infants with bronchiolitis. Single-center studies suggest that respiratory oxygenation index (ROX) and ROX-heart rate (ROX-HR) may have predictive value. We evaluated the ability of these measures to predict care escalation in a multicenter cohort of infants with bronchiolitis initiated on high-flow nasal cannula (HFNC).

Methods: We performed a secondary analysis of a retrospective multicenter cohort study of infants with bronchiolitis initiated on HFNC at 3 pediatric emergency departments (EDs) between February 1, 2018 and March 1, 2020. ROX [(SpO2/FiO2)/RR] and ROX-HR (ROX/HR × 100) were calculated at triage and pre-HFNC initiation. We defined care escalation as the need for positive pressure ventilation or ICU care.

Results: Of 738 infants, 73 (9.9%) required care escalation. These infants had higher maximum heart and respiratory rate, greater proportion were hypoxemic and required higher HFNC support. While there were no significant differences in mean initial ROX [9.4 (3.1) vs 9.4 (3.0); P = 0.81], pre-HFNC ROX [9.4 (3.0) vs 9.0 (2.9); P = 0.24] and initial ROX-HR [6.4 (2.7) vs 6.4 (2.5); P = 0.94], there was a small difference in pre-HFNC ROX-HR (5.7±2.0 vs 5.4±2.0; P = 0.048) between those who did and did not require care escalation. AUROCs for initial and pre-HFNC ROX were 0.51 (95% CI, 0.43-0.58) and 0.54 (95% CI, 0.47-0.61), and initial and pre-HFNC ROX-HR were 0.50 (95% CI, 0.43-0.58) and 0.57 (95% CI, 0.49-0.64), respectively.

Conclusion: ROX and ROX-HR showed poor ability to predict care escalation in infants with bronchiolitis initiated on HFNC.

Objectives: Ultrasonographic measurement of optic nerve sheath diameter (ONSD) is emerging as a noninvasive method for assessing intracranial pressure (ICP) in children. However, its practical application is limited by the lack of adequate age-specific normative data for healthy children. This study aimed to establish age-specific reference ranges for ONSD in healthy children aged 4 to 18 years and assess how anthropometric factors such as body mass index (BMI), height, and weight affect ONSD measurements.

Methods: This cross-sectional study included 150 healthy children aged 4 to 18 years, with no suspicion of increased ICP or chronic illness. ONSD was measured bilaterally using standardized transorbital ultrasonography. Anthropometric z-scores were calculated and correlations and percentile-based reference intervals were determined.

Results: The mean ONSD was 3.67±0.50 mm, with higher values in the 11 to 18 years group compared with the 4 to 10 years group (3.80±0.45 mm vs. 3.51±0.51 mm, P<0.001). ONSD positively correlated with age, height, weight, and BMI in the overall sample. Subgroup analyses revealed that BMI was significantly associated with ONSD only in the 11 to 18 years group. The age-specific 97th percentile upper limits were 4.33 mm (4 to 10 y) and 4.40 mm (11 to 18 y).

Conclusions: This study provides age-specific normative reference intervals for ONSD in healthy children and shows the impact of BMI on ONSD measurements in adolescents. These findings enhance the clinical interpretation of ONSD in pediatric settings and support its integration into noninvasive ICP assessment protocols. Further multicenter studies are required to validate the reference values.

Objectives: This study explored the use of different applied machine learning (ML) classification algorithms to predict hospital admission for infants treated by emergency medical services (EMS) after a suspected brief resolved unexplained event (BRUE).

Methods: Data from a large regionalized pediatric care system were obtained for infants in which paramedic suspected a BRUE and who were transported between July 2017 and February 2021. After data pre-processing, a random 80%/20% split for training and testing was performed. First, a random forest ML classification model was used to identify and select the most important variables influencing the prediction of hospital admission. Then, multiple ML-based models and a statistical model were trained with this subset of variables and evaluated the performance of each to predict hospital admission. Model performance characteristics including the area under the receiver operator curve (AUROC) were reported.

Results: A total of 508 infants were included; 300 (59%) were admitted and 76 (15%) required critical care. The most important variables in predicting hospital admission were age, history of bystander interventions (ie, cardiopulmonary resuscitation and back blows), presence of past medical history, and a normal appearing examination. In the prediction of hospital admission, the support vector machine model achieved the highest AUROC of 0.85, with a sensitivity of 0.88 (95% CI: 0.80-0.96) and specificity of 0.71 (95% CI: 0.57-0.85). The predictive performance of the extreme gradient boosting, RF, and logistic regression models were similar (AUROC: 0.83 to 0.84).

Conclusions: The applied ML models demonstrated good predictive performance for hospital admission for EMS-treated infants with a paramedic suspected BRUE. ML and statistical models had similar predictive performance.

Objective: To externally validate a set of 9 ICD-10-CM billing diagnosis codes to identify pediatric ED encounters with agitation and aggression by determining their sensitivity and specificity compared with electronic health record (EHR) review.

Methods: We performed a retrospective cross-sectional single-test diagnostic accuracy study of mental health encounters in the pediatric ED of an academic urban children's hospital, utilizing EHR data for mental health encounters by children 6 to 18 years old from April 12, 2023, to December 30, 2023. The index test was the presence of any of 9 aggression-related diagnosis codes as utilized by Peleggi et al The reference test consisted of a structured EHR review to confirm that agitation/aggression was a reason for the visit. Sensitivity, specificity, positive predictive value and negative predictive value were calculated with 95% CIs.

Results: We identified 855 pediatric mental health encounters (63%, 13 to 18 y old, 59% female). The diagnosis code set identified agitation/aggression in 62 encounters (7%), compared with 118 encounters (14%) confirmed to have agitation/aggression based on clinician notes. The 9 diagnosis codes yielded a sensitivity of 40% (95% CI: 31%, 49%) and specificity of 98% (95% CI: 97%, 99%) compared with EHR review, with a positive predictive value of 76% (63%, 85%) and a negative predictive value of 91% (89%, 93%).

Conclusions: Upon external validation, a set of 9 billing diagnosis codes had poor sensitivity and excellent specificity for the identification of pediatric ED visits with agitation/aggression. Novel methods such as natural language processing may be needed to accurately identify pediatric ED visits with aggression/agitation.

Objective: To identify clinical and laboratory risk factors for invasive infection in febrile oncology patients seen in the Pediatric Emergency Department, depending on the type of cancer.

Methods: We conducted a prospective observational study of febrile oncology patients seen between 2016 and 2023 at the Pediatric Emergency Department of a tertiary teaching hospital. Invasive infection was defined microbiologically (isolation of a bacterial pathogen in sterile fluid or a commensal bacterial species in 2 different blood cultures) or clinically (death, meeting Phoenix criteria for sepsis, receiving inotropic support, or developing acute complications or sequelae). We performed separate multivariate analyses for hematologic cancers and solid tumors. Hematologic cancers were further classified considering the myelotoxicity of the chemotherapy received. We classified the following as high-risk hematologic cancers: acute lymphoblastic leukemia and non-Hodgkin lymphoma in the induction, reinduction, or consolidation phase or relapse, and acute myeloid leukemia in any phase.

Results: We included 471 episodes: 306 hematologic cancers and 165 solid tumors. The median age was 4 years (interquartile range: 2 to 10) and the median duration of fever was 2 hours (interquartile range: 1 to 3). Invasive infections were diagnosed in 69 cases (14.6%). The rate was higher among patients with high-risk hematologic cancers (n=45, 23.2%), than among those with solid tumors (n=18, 10.9%; P=0.002) or with low-risk hematologic cancers (n=6, 5.4%; P<0.001). Among patients with hematological cancers, presenting a high-risk cancer (OR: 6.006; 95% CI: 2.459-18.200) and elevated procalcitonin levels (OR: 1.668; 95% CI: 1.205-2.571) were predictors of invasive infection [AUC for the model: 0.718 (95% CI: 0.640-0.795)]. Only age (OR: 1.145; 95% CI: 1.036-1.267) was found to be an independent risk factor in patients with solid tumors.

Conclusions: In patients with hematologic cancers and very recent onset fever, the type of cancer and procalcitonin level are useful for predicting the risk of invasive infection.

Objective: To evaluate rates of critical illness and significant infection among children discharged from the emergency department (ED) with a pending blood culture.

Methods: We conducted a cross-sectional study of children 90 days to 18 years old discharged from one of 37 pediatric EDs between 2016 and 2024 with a complete blood count or C-reactive protein performed. Our primary outcome was a diagnosis of specific bacteremia on representation to the ED within 3 days. Secondary outcomes on 3-day return visit included: (1) sepsis, (2) intensive care unit admission, and (3) receipt of ≥3 days of systemic antibiotics. We evaluated for differences in outcomes based on the performance of a blood culture on the index visit.

Results: We included 416,357 discharges (median encounter age 6.3 y, IQR: 2.1 to 12.7). Of these, 229,269 (55.1%) had a blood culture collected. Among encounters with a blood culture, 0.1% (n = 151; 95% CI: 0.1-0.1) had specific bacteremia on return visit. Encounters with a blood culture at the index visit had higher odds of specific bacteremia [odds ratio (OR) 10.86, 95% CI: 5.8-20.34], sepsis (OR: 3.16, 95% CI: 1.88-5.30), intensive care unit admission (OR: 2.82, 95% CI: 1.94-4.12), and ≥3 days of systemic antibiotics (OR: 4.77, 95% CI: 4.17-5.46).

Conclusions: Children discharged with a pending blood culture have higher rates of significant bacteremia and other clinically important return visits than children discharged without a blood culture, though absolute rates of these outcomes were low. Improved guidelines are needed to better identify children who require blood cultures.