Pediatric emergency care最新文献

Objectives: Telemedicine is a growing field, with limited data around its utility supporting pediatric emergency care telephone triage. We instituted telemedicine physician support for nurse telephone triage decisions. When the nursing protocols recommended urgent or emergent care, a telemedicine physician reviewed and modified care urgency if appropriate. Our primary study objectives were to evaluate the proportion of patients who were downgraded to less urgent care and assess for potential harm related to the downgrade in care urgency.

Methods: We conducted a retrospective observational cohort study of pediatric telephone calls to the Mayo Clinic Health System nurse triage line that were directed to the emergency department telemedicine physician from January 1, 2019, to December 31, 2019. Electronic medical records of patients whose care urgency was downgraded and presented to medical care within 72 hours of the triage call were reviewed.

Results: There were 8559 nurse line calls regarding pediatric patients, 882 of which were referred to the telemedicine physician. Among these, 396/882 (44.9%, 95% confidence interval 41.6-48.3) were downgraded. Of downgraded cases, 198 (50.0%) patients sought care within 72 hours of the original call, of which 193 (97.5%) patients were discharged home from that medical visit and 5 (2.5%) patients required admission. No patients were determined to have suffered harm due to the downgrade of visit urgency.

Conclusions: Our data suggests that telemedicine physicians can safely downgrade nurse triage care recommendations for pediatric patients. Most downgraded patients sought outpatient care, avoiding unnecessary utilization of the emergency department without evidence of associated harm.

Abstract: Identification of a neonatal horseshoe kidney in the emergency department is uncommon but has implications for future healthcare planning for patients. We present a case of a neonate with bloody diapers who was evaluated with renal point-of-care ultrasound (POCUS) that identified a horseshoe kidney. The ultrasound was remarkable for its clear visualization of the isthmus of the horseshoe kidney in the midline abdomen. Midline interrogation is not part of the routine technique for ultrasound imaging of the kidney but should be considered when the limits of the lower pole of bilateral kidneys are difficult to visualize. This case highlights the importance of understanding normal anatomical landmarks when performing renal POCUS to identify renal anomalies.

Abstract: We report the use of point-of-care ultrasound to identify a hydropneumothorax in a 6-year-old previously healthy girl arriving at the emergency department in severe respiratory distress. The use of point-of-care ultrasound in this instance allowed for the expedient management and stabilization of the hydropneumothorax with emergent thoracentesis. The patient was ultimately found to have Streptococcus pyogenes bacteremia and necrotizing pneumonia.

Study objective: Traumatic brain injury (TBI) during early childhood (before 6 years) is prevalent, accounting for rising rates of emergency department visits. These injuries may lead to postconcussive symptoms, which may be subtle and difficult to diagnose in young children. Inadequate discharge counseling may lead to prolonged duration of symptoms and possible developmental delays. We aimed to explore pediatric emergency medicine (PEM) physicians' perspectives on "concussion" terminology, diagnosis, and management, specifically in a young child with mild TBI.

Methods: We conducted semistructured interviews using open-ended questions involving a hypothetical scenario. We recruited currently practicing PEM physicians by a snowball sampling method. A research team recorded, transcribed, and analyzed the interviews. Using social constructionism as the philosophical framework, we developed and refined codes and derived themes until reaching thematic saturation. Peer debriefing with an expert collaborator aided with revisions of themes.

Results: A single PEM researcher interviewed 13 participants. Three primary themes emerged. Our first theme identified the role of guidelines and tools in the diagnostic workup. Most participants utilized a clinical prediction tool for neuroimaging but no clinical symptom scales. Our second theme described the difficulties and inconsistencies in the approach to diagnosis of concussion, largely due to young age, lack of verbal skills and unreliable examinations. Our last theme focused on the difficulty in providing clear discharge instructions to parents. Many participants described difficulty providing activity restrictions, instead allowing self-modulation, and lack of counseling for educational tasks.

Conclusions: Variability exists among PEM physicians in diagnosis and management of concussions in young children. Discomfort with lack of reliability of symptoms and underappreciation of typical early childhood characteristics may account for findings. Educational initiatives, age-appropriate clinical tools and treatment-guided outcomes research are needed to guide PEM physicians in the care of young children with head injuries.

Objectives: The Surgical Intervention for Traumatic Injuries (SITI) scale is intended to predict the likelihood of needing surgical decompression among patients with traumatic brain injury (TBI). We sought to examine the performance of the SITI score to predict likelihood of acute neurosurgical intervention for children with TBI.

Methods: We conducted a cross-sectional, retrospective, observational study of children diagnosed with TBI as determined by International Classification of Diseases codes, presenting to a single level 1 pediatric trauma center, between June 1, 2003, and May 31, 2018. The main outcome was decompressive craniotomy or craniectomy within 24 hours of arrival. Data for SITI scoring were abstracted by research assistants, and all cases were scored by a physician who was blinded to the outcome. The SITI scale performance was evaluated using receiver operating characteristic curve and by calculating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results: There were 656 encounters with TBI, of which 39 (5.9%) underwent surgical decompression. The mean SITI scores were 4.15 for the operative group and 0.40 for the nonoperative group (P < 0.001). A cutoff of 2 or greater for a positive score gave the best performance with a sensitivity of 0.79, specificity of 0.90, PPV of 0.34, and NPV of 0.99. The area under the receiver operating characteristic curve was 0.89 (95% confidence interval, 0.83-0.96). In sensitivity analysis excluding 75 cases with depressed skull fractures, a score of 2 or greater had a sensitivity of 0.96, specificity of 0.91, PPV of 0.31, and NPV of 1.00. The area under the receiver operating characteristic curve was 0.98 (95% confidence interval, 0.97-1.00).

Conclusions: A SITI score of less than 2 is associated with nonoperative management. However, clinicians should not be falsely reassured by a low score in patients with depressed skull fractures.

Context: The pediatric emergency department (PED) is increasingly being used for non-urgent reasons. This impacts PED input and throughput, and contributes to overcrowding. To identify solutions, it is essential to identify and describe the approaches that have been trialed.

Objective: We completed a scoping review to identify and then describe the design and outcomes of all initiatives undertaken to reduce the impact of non-urgent visits on the PED.

Data sources: We searched 4 databases (MEDLINE, EMBASE, EBM, and CINAHL) to identify research published from the database inception until March 31, 2024.

Study selection: Studies met our inclusion criteria if they focused on the pediatric ED, defined non-urgent visits, described an intervention (hypothesizing it would reduce the impact of non-urgent visits on the PED), and reported on the interventions impact.

Data extraction: The title and abstract of each study were independently screened for inclusion by 2 reviewers (E.Q., K.N.), and disagreements were resolved by deliberation until consensus was achieved. This process was then repeated for the full text of all articles.

Results: In total, we screened 11,600 articles and 20 were included. Nine interventions focused on PED input, 10 on PED throughput, and 1 on both PED input and throughput. Definitions of non-urgent visits and outcomes measures used to assess the effectiveness of an intervention differed between studies. Three types of strategies employed to reduce the impact of non-urgent visits on the PED were identified, these include (1) engaging nonpediatric emergency medicine clinicians by including them into the PED or connecting non-urgent patients to community locations for care, (2) reorganizing PED operations in anticipation of non-urgent visits, and (3) providing education to prevent future non-urgent visits.

Conclusions: Consistent definitions of non-urgent visits and standardized outcome measures may allow for more precise comparisons between studies. We identify 3 commonly employed strategies that may help reduce the impact of non-urgent visits on the PED.

Objectives: To compare the ability to perform basic life support (BLS) skills on children and infants in a moving ambulance whether or not they are properly secured to the stretcher.

Methods: Emergency Medicine Services provider ability to perform BLS skills was measured in moving ambulances on a closed course using an analog for child and infant cardiac arrest. Data were compared for child and infant manikins secured to the stretcher via different methods in simulated patient resuscitations performed by 24 participants.

Results: We found that there was no significant difference in mean rate (P = 0.104), depth (P = 0.21), or chest compression fraction (P = 0.92) between tests on restrained and unrestrained pediatric manikins. For infants, there was a 4-mm difference in compression depth (P = 0.0018). The clinical significance of this difference is not readily apparent. Infant tests did not show a difference in compression rate (P = 0.35) or compression fraction (P = 0.26). Across all tests, the rate and depth of compressions were adequate, but compression fraction was not adequate in the infant simulations. There were no differences in ventilations between restrained and unrestrained simulations (child P = 0.15; infant P = 0.13) but both were less than the American Heart Association recommendation.

Conclusions: In this simulation study, it was found that there was no significant difference noted in BLS adequacy between unrestrained pediatric patients and those restrained with commercial devices. Overall, the ability to perform appropriate BLS on children was equivocal and our simulations suggested BLS could not be adequately performed on infants regardless of restraint type/status.

Objective: This pilot study aimed to assess the effectiveness of a "room of horrors" (RoH) simulation in identifying patient safety threats in a pediatric emergency department (PED) and to evaluate health care workers' (HCWs') perceptions of the experience.

Methods: We developed an RoH simulation featuring 25 potential safety hazards derived from actual PED incidents and "never events." The teams of physicians and nurses who participated in the simulation identified as many hazards as they could within a 10-minute window followed by a debriefing session during which errors were corrected and missed hazards were pointed out. The participants' perceptions were measured on a 5-point Likert scale of a questionnaire.

Results: Twenty sessions that included a total of 45 participants were conducted. The teams identified an average of 23 of 25 safety threats, yielding a mean detection rate of 86% for electronic medical record errors, 95% for physical space errors, and 97% for communication errors. The simulation received high ratings for overall positive experience (4.88/5) and impact on daily activities (4.68/5).

Conclusion: The RoH simulation experience was effective in evaluating the level of retention of earlier training and the ability of multidisciplinary teams to correctly identify major safety threats in a PED setting. The participants found the experience valuable and engaging. Future research should focus on other means by which the retention of learned skills can be reinforced and new safety threats can be identified with a high level of alertness.

Objectives: We conducted an unblinded, randomized control trial to determine if immersive virtual reality (VR) goggles decrease pain and fear scores in children undergoing laceration repair in the pediatric emergency department (PED) compared to the standard of care. Secondary outcomes included duration of procedure, physical holding, anxiolytic usage, and desire to use VR goggles again.

Methods: Ninety-one patients aged 6-17 years in a PED with simple lacerations sutured by PED staff completed surveys. Eligible patients were randomized to receive either VR or standard of care. Guardians and providers also completed surveys. Self-reported pain scores were assessed by the Wong-Baker Faces Pain Scale and fear scores by Children's Fear Scale.

Results: There were significant reductions in pain and fear scores for VR goggles compared to standard of care. Patients rated their mean pain score as 3.7 in controls and 2.3 in the VR group, and mean fear score of 3.0 and 2.2. The likelihood of physical holding was significantly lower among those who used VR goggles (adjusted odds ratio = 0.34, 95% confidence interval [0.13-0.92], P = 0.033). The likelihood of receiving anxiolytics was lower among the 12- to 17-year-olds (adjusted odds ratio = 0.27, 95% confidence interval [0.11-0.69], P = 0.006). There was no significant difference in the procedure duration (P = 0.06). A total of 97.9% of parents, 93.6% of patients, and 95.7% of providers would use VR again.

Conclusion: Virtual reality goggles are an effective tool for distraction for simple laceration repairs. Their use leads to decreased pain and fear. Children who used VR goggles did not require to be held as often for sutures. There was no significant difference in anxiolytics or duration of procedure.