Pediatric emergency care最新文献

Objectives: The BIG score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Score]) was compared with the Pediatric Trauma Score (PTS) for predicting mortality in pediatric patients with multiple trauma.

Methods: This retrospective, single-center study included 318 consecutive pediatric patients (aged 1-18 years) with multiple trauma who were admitted to the emergency department between January 1, 2021, and December 31, 2023. The demographic characteristics, clinical characteristics, and trauma scores (BIG score and PTS) were compared between survivors and nonsurvivors to identify factors associated with mortality.

Results: A PTS of 7 had 100% sensitivity and 81.03% specificity for predicting mortality, with an area under the curve of 0.97 (95% confidence interval 0.9-0.99). Although the positive predictive value (PPV) was low (33.7%), the negative predictive value (NPV) was 100%. A BIG score of 13.7 was identified as the cutoff for mortality, with 92.86% sensitivity and 95.52% specificity (area under the curve 0.98, 95% confidence interval 0.96-0.99). The PPV was 66.7% and the NPV was 99.3%.

Conclusions: Both the PTS and the BIG score were strong predictors of mortality in pediatric patients with multiple trauma. The BIG score had a higher specificity and PPV, whereas a PTS of 7 had 100% sensitivity and a higher NPV.

Objectives: During the COVID-19 pandemic, there was a marked shift toward telesimulation in medical education. Limited studies exist comparing the effectiveness of online and offline simulation education. The goals of this study are to evaluate active learners' perceived effectiveness of telesimulation versus in situ simulation and to identify potential shortcomings of existing online teaching platforms.

Methods: Through participant evaluations after a simulation, we compared telesimulation using the Virtual Resus Room (VRR) to in situ simulation in the domains of (1) self-efficacy, (2) fidelity, (3) educational value, and (4) teaching quality. Study subjects included medical and pharmacy residents and medical students completing their pediatric emergency medicine rotation at two children's hospitals as well as nurses, nurse practitioners, and physician assistants who were recently hired and orienting to their new roles in the emergency department. Learners used a modified Michigan Standard Simulation Experience Scale to evaluate either a telesimulation or in situ simulation case. Survey responses were compared using Wilcoxon rank sum tests with Bonferroni correction for multiple comparisons.

Results: In overall assessment, in situ simulation was rated higher than telesimulation. There were significant differences noted related to perceived realism, utility in training device-related skills, and utility in training team-building skills. All P values were less than 0.0036. There were no significant differences between simulation types in perception of physical examination fidelity, instructor adequacy, or self-efficacy.

Conclusions: Telesimulation using the VRR is comparable to in situ simulation in learners' perception of improvement in self-efficacy and of teaching quality for pediatric emergency medicine topics. However, participants felt less able to practice tactile and communication skills virtually. Further innovation is needed to improve learners' experience with fidelity and educational value.

Background: Acetaminophen and ibuprofen are the most common agents involved in adolescent self-poisoning. With increasing suicidality observed during the COVID-19 pandemic, we sought to compare overdose trends, severity, and outcomes for both agents.

Methods: We performed a retrospective analysis of the National Poison Data System for acetaminophen and ibuprofen single-substance exposures in teenagers 13-19 years of age from 2017-2022. Acetaminophen and ibuprofen overdoses (per 100,000 persons) were plotted by year. Medical outcomes, clinical effects, and therapies were compared to determine if there were differences in overdose severity between the 2 agents.

Results: From 2017 to 2022, US poison centers recorded 50,902 single-substance acetaminophen exposures and 41,674 single-substance ibuprofen exposures in teenagers. Cases peaked in 2021 with 40.0 versus 29.1 cases (per 100,000 persons) for acetaminophen and ibuprofen, respectively. Acetaminophen self-poisoning was significantly more likely to result in death (odds ratio, 13.92; 95% confidence interval, 2.18-581.75; P < 0.001) or inpatient admission (odds ratio, 7.38; 95% confidence interval, 7.10-7.66; P < 0.001) compared with ibuprofen. Abdominal pain and vomiting were the most common clinical effects for both agents, and unsurprisingly, acetaminophen was more likely to cause transaminitis and liver dysfunction, whereas ibuprofen was more likely to cause central nervous system depression and metabolic acidosis. For the acetaminophen group, 19 teenagers underwent organ transplantation.

Conclusions: Given the increased hospitalization and treatment resources needed for acetaminophen overdoses compared with ibuprofen, it is time to implement acetaminophen packaging policy change to protect US adolescents.

Objectives: The aim was to evaluate the current status of point-of-care ultrasound (POCUS), perceptions, education, training, and barriers to using POCUS in pediatric emergency departments (PEDs) and pediatric intensive care units (PICUs) in Turkey.

Methods: A descriptive, multicenter, cross-sectional study through an online survey was developed using the REDCap online platform. The survey was distributed through the Turkish Society of Pediatric Emergency and Intensive Care e-mail group. Each survey was answered only once by each PED/PICU and by the clinical chief of the department.

Results: A total of 19 PEDs and 26 PICUs responded to the survey. Among them, 84.2% of PEDs and 100% of PICUs reported the clinical use of POCUS. For diagnostic applications, the most common areas for PEDs and PICUs were thoracic (93.7%/100%) and cardiovascular (62.5%/65.4%) assessment, and in the procedural use of POCUS, the most frequent applications were those for vascular access (75.0%/92.3%) and thoracentesis (31.2%/65.4%). The most commonly reported clinical benefits were rapid diagnosis, rapid treatment, and decreased complications during procedural applications for PEDs and PICUs. Evaluating the barriers to POCUS use in PEDs and PICUs, the most common reasons for insufficient use were the lack of ultrasound machines and/or equipment, a shortage of manpower, lack of awareness, and lack of training. For PEDs (68.4%) and for PICUs (84.6%), participants agreed that POCUS training should be mandatory during fellowship programs.

Conclusions: Most participants were aware of the need for POCUS. However, lack of education, equipment, manpower, and infrastructure still emerged as barriers to the use of POCUS. To further promote POCUS use, it would be helpful to improve accessibility by ensuring sufficient numbers of ultrasound devices together with sufficient numbers of appointed physicians and by expanding POCUS education in PEDs and PICUs.

Objective: Our objective was to identify the hospital- and community-related factors associated with the hospital-level rate of potentially unnecessary interfacility transfers (IFTs) for pediatric patients with asthma exacerbations.

Methods: We analyzed California Emergency Department (ED) data from 2016 to 2019 to capture ED visits where a pediatric patient (age, 2-17 years) presented with an asthma exacerbation and was transferred to another ED or acute care hospital. The primary outcome was hospital-level rate of potentially unnecessary IFTs, defined as a visit where length of stay after transfer was <24 hours and no advanced services (eg, critical care) were used. Hospital- and community-related characteristics included urbanicity, teaching hospital status, availability of pediatric resources in the sending facility and patient's community, pediatric patient volume, and Social Vulnerability Index. We described and compared hospitals in the top quartile of potentially unnecessary IFT rate versus all others and used a multivariable modified Poisson model to identify factors associated with potentially unnecessary IFT.

Results: A total of 325 sending hospitals were included, with a median 573 pediatric asthma visits (interquartile range, 183-1309) per hospital annually. Nearly half of the hospitals (145/325, 45%) sent a potentially unnecessary IFT. Most (90%) hospitals were urban, 9% were teaching hospitals, 5% had >500 beds, and 22% had a pediatric ED on-site. Factors associated with higher adjusted prevalence of potentially unnecessary IFT included availability of pediatric telehealth (prevalence ratio [PR], 1.5; 95% confidence interval [CI], 1.2-2.0), increased pediatric volume (eg, <1800 vs ≥10,000 visits: PR, 2.6; 95% CI, 1.4-4.7), and higher community Social Vulnerability Index (PR, 1.5; 95% CI, 1.1-1.9).

Conclusions: Several hospital- and community-related factors were associated with potentially unnecessary IFTs among pediatric patients presenting to the ED with asthma exacerbations. These findings provide insight into disparities in potentially unnecessary IFT across communities and can guide the development of future interventions.

Objectives: Over the past decade, there has been a significant effort to decrease radiation exposure in pediatric trauma patients. The objective of this study was to determine if trauma centers (TCs) and nontrauma centers (non-TCs) are practicing in line with this effort. We hypothesized that TCs would demonstrate a significant decrease in the use of chest computed tomography (CT) during the study period, whereas non-TC would show no change in chest CT use.

Methods: We queried a state-wide database from 2010 to 2020 for pediatric trauma encounters at TCs and non-TCs within a single large health system. All transfer encounters were excluded. Chest CTs and chest radiographs (CXRs) were performed, and injury diagnosis codes were extracted for each encounter. Chest CT use and incidence of thoracic injuries were compared between TCs and non-TCs.

Results: A total of 13,014 encounters were included, of which 85.8% occurred at TCs and 14.2% occurred at non-TCs. There were significant differences between TC and non-TC encounter demographics. During the study period, the percentage of trauma encounters in which chest CT was obtained increased yearly at both TCs and non-TCs. Among encounters where both modalities were performed in the first 24 hours, chest CT was performed before CXR in 0.4% of TC and 0.1% of non-TC encounters (P = 0.086). Among encounters without thoracic injury, chest CT was performed in 5.2% of cases at non-TCs and 4.5% of cases at TCs (P < 0.001).

Conclusions: In the trauma encounters studied, chest CT was performed prior to CXR more frequently at TCs compared to non-TCs. These data may reflect regional trauma triage protocols, availability of chest CT, or differences in education between institutions. Whereas TCs may see more severely injured patients more frequently, education regarding conservative CT imaging principles should be reinforced through multidisciplinary efforts.

Objectives: At our institution, level 2 trauma (L2T) activations are primarily managed by pediatric emergency medicine (PEM) physicians, whereas level 1 activations are co-managed by pediatric surgery and PEM. Starting in September 2019, the response to L2T activations due to all-terrain vehicles or motorized cycles (ATVs/MCs) changed to include surgical assessment upon patient arrival due to increased likelihood of significant injuries and need for higher level of care. The impact of PEM/surgery co-management of ATV/MC L2T patients on time to an admission decision is unknown.

Methods: We retrospectively reviewed patients <18 years of age presenting to our American College of Surgeons-verified level 1 pediatric trauma center as L2T activations with ATV/MC mechanism between 1/2016 and 10/2022. Patient demographics, injury characteristics, details of imaging, interventions, and emergency department (ED) course were recorded. The χ2 and Fisher exact tests were performed.

Results: One hundred fifty-five patients met the inclusion criteria prior to augmenting our response to include surgical presence at L2T-ATV/MC activations, and 216 patients were treated after our protocol change. There were no statistically significant differences in age, sex, race, transfer status, vehicle subtype, or Injury Severity Scores between groups. Trauma surgery was involved in the care of 74.8% of L2T-ATV/MC patients before protocol augmentation and 87% after (P = 0.003). Time to an admission decision significantly decreased by 22.5 minutes (117 minutes [interquartile range, 72-178] vs 94.5 minutes [interquartile range, 60-139]; P = 0.023) after protocol augmentation. There was a trend toward increased completion of mandated postsecondary survey communication huddles after protocol change (84.6% to 91.2%, P = 0.089). The median total ED length of stay did not differ between admitted and discharged patients.

Conclusions: Early surgical assessment for pediatric patients with ATV/MC injuries improved time to an admission decision and trauma communication huddle compliance. Next steps include identifying process improvement opportunities to decrease ED total length of stay for patients with ATV/MC injuries.

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.

Abstract: Distal forearm fractures are frequently encountered in the pediatric emergency department and often require reduction. Procedural sedation is commonly used to facilitate reduction of these injuries, although it can be associated with potentially severe complications, particularly in patients with cardiorespiratory comorbidities. The ultrasound-guided hematoma block has been gaining popularity as an analgesic alternative in adult patients, but literature supporting its use in pediatric patients is limited. We describe a point-of-care ultrasound-guided hematoma block used to facilitate successful reduction of a distal radius fracture in an adolescent patient with a history of a difficult airway for whom procedural sedation would have posed considerable risk.

Objectives: Obtaining urine samples in younger children undergoing urinary tract infection (UTI) screening can be challenging in busy emergency departments (EDs), and sterile techniques, like catheterization, are invasive, traumatizing, and time consuming to complete. Noninvasive techniques have been shown to reduce catheterization rates but are variably implemented. Our aim was to implement a standardized urine bag UTI screening approach in febrile children aged 6 to 24 months to decrease the number of unnecessary catheterizations by 50% without impacting ED length of stay (LOS) or return visits (RVs).

Methods: After forming an interprofessional study team and engaging key stakeholders, a multipronged intervention strategy was developed using the Model for Improvement. A urine bag screening pathway was created and implemented using Plan, Do, Study Act (PDSA) cycles for children aged 6 to 24 months being evaluated for UTIs. A urine bag sample with point-of-care (POC) urinalysis (UA) was integrated as a screening approach. The outcome measure was the rate of ED urine catheterizations, and balancing measures included ED LOS and RVs. Statistical process control methods were used for analysis.

Results: During the 3-year study period from January 2019 to June 2022, the ED catheterization rate successfully decreased from a baseline of 73.3% to 37.7% and was sustained for approximately 2 years. Unnecessary urine cultures requiring microbiology processing decreased from 79.8% to 40.7%. The ED LOS initially decreased; however, it increased by 17 minutes during the last 8 months of the study. There was no change in RVs.

Conclusion: A urine bag screening pathway was successfully implemented to decrease unnecessary, invasive catheterizations for UTI screening in children with only a slight increase in ED LOS. In addition to the urine bag pathway, an ED nursing champion, strategic alignment, and broad provider engagement were all instrumental in the initiative's success.