Pediatric emergency care最新文献

Background: Pediatric ocular trauma is the leading cause of monocular blindness and comprises 7% of injuries. Prompt treatment is mandatory but may vary by facility type. This study investigates factors influencing treating facility, comparing level 1 and level 2 verified pediatric trauma centers (PTC) with other trauma centers (non-PTC).

Methods: The National Trauma Data Bank 2019 was examined for ages 1 to 18 years with ICD10 ocular trauma diagnoses. Descriptive statistics compared patients of PTCs versus non-PTCs. Logistic regression was used to examine the association between treatment at PTC and type of ocular injury, adjusting for age, race, ethnicity, sex, socioeconomic status, injury severity score (ISS), and suspicion of child abuse. A second logistic regression model evaluated the association between direct transfer from emergency department (ED) to operating room (OR) and injury type, and adjusted for confounders. End points included surgical intervention and discharge disposition.

Results: Of 645 patients with ocular trauma, 67.6% were male, 14% were Hispanic. Median age was 10 years at PTC versus 13 years non-PTC ( P =0.001). Two hundred eighty-two (44%) were treated in PTC. There was no difference in proportion with ISS >15 or mechanism of ocular injury. One hundred forty-six patients were taken directly to OR from ED, with no difference between PTC and non-PTC. The most common diagnoses for patients taken directly to OR were eye or adnexa contusion and laceration, globe or adnexal open wound, and orbital wall fractures. There was no association between type of injury and treatment at PTC versus non-PTC. 71 abuse reports were noted, of which 23 (32.4%) were treated in PTCs, compared with 48 (67.6%) treated at non-PTCs ( P =0.036). Logistic regression examination of direct to OR admission revealed only Hispanic ethnicity was significantly associated ( P =0.03).

Conclusions: Pediatric ocular traumas are treated at both PTCs and non-PTCs at a similar rate and level of severity. Younger children and more Hispanic children tended to be treated at PTCs. More abuse reports were noted in non-PTCs. Hispanic ethnicity was noted to be inversely associated with direct transfer to OR from ED. This study should form the background from which evaluation of outcomes can begin, to clarify the optimal treatment pathways for pediatric ocular trauma, and if there are disparities in outcomes.

Type of study: Retrospective cross-sectional study.

Study objective: To compare the efficacy, safety, and patient experience between cyanoacrylate tissue adhesive and conventional sutures for periorbital wound closure in children.

Methods: A prospective comparative study evaluated 145 pediatric patients with periorbital trauma treated with tissue adhesive (n=70) or conventional suturing (n=75) based on clinical assessment from September 2023 to October 2024. Primary outcomes were wound healing grades (grade I/II/III) and complication rates; secondary outcomes included procedure time (median, seconds), pain scores (mean, Wong-Baker FACES), Frankl behavioral compliance scores (mean), and parental satisfaction. Statistical analysis used t tests, Mann-Whitney U tests, and χ 2 tests.

Results: The adhesive group had significantly shorter procedure time (184 vs. 692 s, P <0.001), lower pain scores (2.8 vs. 5.6, P <0.001), and higher compliance (Frankl 3.1 vs. 2.3, P <0.01). No significant differences were observed in grade I healing rates (97.1% vs. 93.3%) or complication rates (2.9% vs. 4.0%, P =0.24).

Conclusions: In pediatric periorbital trauma, use of tissue adhesive was associated with reduced treatment time and pain scores, with similar healing outcomes compared with sutures, suggesting it may serve as a viable alternative.

Objectives: To describe the distribution of laboratory values for nonstandard inflammatory and cardiac biomarkers in otherwise healthy children presenting to the pediatric emergency department (PED) with fever and viral or nonspecific illness.

Methods: Single-center retrospective study of otherwise healthy children 3 months to 20 years presenting to the PED with fever and had a laboratory evaluation for multisystem inflammatory syndrome in children (MIS-C) between April 15, 2020 and January 24, 2022. All patients had NT-pro-b-natriuretic peptide (NT-proBNP) or troponin obtained (as part of an institutional pathway for MIS-C evaluation) during this period. Children with comorbidities, MIS-C, Kawasaki disease, myocarditis, or definitive non-viral illness were excluded. We summarized d-dimer, ferritin, troponin, and NT-proBNP distributions using descriptive statistics. One-way analysis of variance tested for differences among 3 disease categories: non-SARS-CoV-2 viral illness, fever not otherwise specified (NOS), and SARS-CoV-2 infection. Outlier values were identified as three times the interquartile range above the third quartile on box-and-whisker plots.

Results: Of 134 eligible patients, 50, 65, and 19 were categorized as non-SARS-CoV-2 viral illness, fever NOS, and SARS-CoV-2 positive illness, respectively. Median age was 2 years. Median fever duration was 4 days, with 124/134 (93%) described as well-appearing and 112/134 (84%) discharged home. The median values for all biomarkers were within institutional laboratory reference ranges, with all distributions skewed to lower values, and without statistically significant differences between disease categories ( P > 0.05). D-dimer values were above the institutional reference range in 43/97 (44%), ferritin was above the reference range in 24/114 (21%), NT-proBNP was above the reference range in 26/123 (21%), and troponin levels were outside the range in 4/123 (3%). Thirteen patients had extreme outlier values.

Conclusions: Otherwise healthy children presenting to the PED with a fever and viral or nonspecific illnesses may frequently have elevated serum d-dimer, ferritin, and NT-proBNP above institutional reference ranges. Troponin elevation was infrequent.

Objective: Adolescent use of cannabis in the United States is on the rise. Multiple toxicities and negative outcomes are possible with chronic or heavy cannabis use, including cannabinoid hyperemesis syndrome (CHS). This study analyzes a population of adolescent emergency department patients with cyclic vomiting onset after cannabis use, with a hypothesis that use patterns or biomarkers may offer insights into diagnostics, pathophysiology, or management of this disease.

Methods: This pilot prospective observational cohort study recruited pediatric emergency department patients aged 14 to 21 years with symptomatic cyclic vomiting onset after chronic cannabis use, and reassessed them at an asymptomatic follow-up visit. Cannabis use patterns were assessed with validated questionnaires, and blood profiles of cannabinoid metabolites and essential minerals and B vitamins were quantified and compared.

Results: We screened 869 adolescent ED patients and enrolled ten participants. All participants (n=10) had cannabis use disorder (n=9) or hazardous cannabis use (n=1) by the Cannabis Use Disorders Identification Test-Revised, and participants reported withdrawal symptoms when attempting to discontinue cannabis. There were significant differences in 11-hydroxy-delta-9-tetrahydrocannabinol between index [median 0.6 ng/mL (IQR: 0, 2.6)] and asymptomatic follow-up visits [median 4.2 ng/mL (IQR: 1.2, 10.1)]. Median vitamin and mineral concentrations were within reference ranges.

Conclusions: Symptomatic adolescent patients with suspected CHS had evidence of cannabis use disorder and had significantly lower blood concentrations of 11-hydroxy-delta-9-tetrahydrocannabinol when symptomatic. Further research is needed to better explore the pathophysiology and diagnostics in adolescent CHS, and exploration and treatment of cannabis use disorder should be considered in these patients.

Objectives: To compare low-value computed tomography (CT) use during pediatric emergency department (ED) visits by hospital type and physician specialty.

Methods: Repeated cross-sectional study using linked databases from Ontario, Canada. We reviewed pediatric ED discharges from 2010 to 2019 for 5 diagnoses with recommendations against routine CT use: abdominal pain, constipation, concussion, seizure, and headache. We evaluated CT use by hospital type (pediatric academic, adult academic, community with and without pediatric consultation) and provider specialty [pediatric emergency medicine (PEM), emergency medicine (EM), family medicine + EM, family medicine, pediatrician], using multivariable logistic regression, adjusting for patient, ED, and physician characteristics.

Results: We included 599,948 pediatric ED discharges [mean (SD) age 10.8 y (5.3); 55.4% females]: 5000 (1.2%) discharges for abdominal diagnoses included a CT, and 21,398 (11.4%) discharges for neurological diagnoses included a CT. Children had an increased adjusted odds ratio [aOR (95% CI)] of receiving a CT at all hospital types compared with pediatric academic hospitals: adult academic hospitals ranging from 1.10 (1.01 to 1.21) for headache to 3.46 (1.89 to 6.36) for constipation, community hospitals with pediatric consultation ranging from 1.54 (1.45 to 1.63) for concussion to 3.74 (2.38-5.90) for constipation, and community hospitals without pediatric consultation ranging from 1.24 (1.15 to 1.33) for concussion to 2.29 (1.36 to 3.87) for constipation. Those patients seen by nonpediatric providers (EM, family medicine + EM, family medicine) were more likely to receive CT scans than PEM physicians for all diagnoses.

Conclusions: Low-value CT use was higher among children treated in nonpediatric EDs and by nonpediatric providers. Improvement initiatives should target specific hospital types and specialties.

Objective: This study aimed to determine whether measured serum osmolality could serve as a reliable marker for assessing the severity and predicting outcomes of pediatric diabetic ketoacidosis (DKA).

Methods: We retrospectively analyzed pediatric patients (<19 y) admitted with hyperglycemic crises from 2009 to 2022. Patients were classified into isolated DKA (serum osmolality ≤320 mOsm/kg) and hyperosmolar DKA (>320 mOsm/kg). Clinical characteristics, laboratory results, severity indicators, and outcomes were compared. We further evaluated diagnostic accuracy between measured serum osmolality and calculated effective osmolality, the current marker used by International Society of Pediatric and Adolescent Diabetes guidelines.

Results: Among 135 DKA episodes, hyperosmolar DKA (n = 69, 51.1%) presented more severe clinical features than isolated DKA (n = 66, 48.8%), including higher incidences of altered mental status (43.5% vs 12.1%), intensive care unit (ICU) admission (31.9% vs 12.1%), acute kidney injury (AKI; 58.0% vs 12.1%), and prolonged hospitalization (11 vs 8 days). In multivariate logistic regression, higher measured serum osmolality was significantly associated with altered mental status [odds ratio (OR), 1.048; 95% CI, 1.007-1.090], ICU admission (OR, 1.062; 95% CI, 1.016-1.111), AKI (OR, 1.070; 95% CI, 1.027-1.112), and prolonged hospital stay (OR, 1.032; 95% CI, 1.001-1.064; all P < 0.05). Measured serum osmolality demonstrated superior predictive performance for altered mental status [area under the receiver operating characteristic curve (AUROC), 0.751] and AKI (AUROC, 0.856) compared with calculated osmolality.

Conclusion: Measured serum osmolality is strongly associated with clinical severity and outcomes in pediatric DKA. Incorporating it into clinical guidelines may improve risk stratification and management of pediatric hyperglycemic crises.

Objectives: Pediatric health care providers request electrocardiograms (ECGs) for diverse clinical presentations, and are understandably concerned when the corrected QT (QTc) interval is prolonged. Subsequent confirmation by pediatric cardiologists often finds that the unconfirmed QTc intervals previously displayed on ECGs were inaccurate. We evaluated the principal factors responsible for disparate QT/QTc intervals, and highlight the impact on decision-making. We include a straightforward approach to determine accurate QTc intervals for providers awaiting finalized interpretations.

Methods: Two hundred pediatric cardiologist-confirmed pediatric ECGs were analyzed to evaluate differences between automated unconfirmed and cardiologist-confirmed QT interval measurements. QTc intervals were calculated using Bazett formula (QTcB), and frequency of normal, borderline, and abnormally prolonged QTcB were compared between unconfirmed and confirmed interpretations. The mean QT interval and heart rate for the cohort were used to calculate QTc values using contemporary non-Bazett formulae.

Results: Automated QT and QTcB intervals were longer than confirmed values by ~25 ms and ~30 ms, respectively ( P < 0.0001). The QTcB of 19/200 (~10%) unconfirmed ECGs were borderline or abnormally prolonged, compared with a single confirmed ECG with a borderline QTcB. QTc values using common non-Bazett formulae were markedly shorter than QTcB.

Conclusions: The QTc values displayed on unconfirmed pediatric ECGs are often different from those subsequently adjudicated by cardiologists, and may substantially influence clinical impressions and decision-making by primary providers. Providers in the pediatric ED should be aware that variable methods and algorithms "behind the scenes" cause these variations, and have tools to confirm QTc values in advance of delayed confirmation by a cardiologist.

Measles is a highly contagious viral infection that resulted in significant morbidity and mortality before widespread vaccination efforts began in the 1960s. In 2000, measles was declared eliminated in the United States; however, continued global circulation combined with rising vaccine hesitancy has resulted in recent outbreaks of increasing severity. This review article highlights relevant epidemiology and prepares clinicians to differentiate measles infection from similar febrile exanthems of childhood. We review available diagnostics and the management of patients with or exposed to measles infection in an era of unfamiliarity with the condition.

Objectives: To describe the characteristics of injured children arriving at a Pediatric Level I Trauma Center via Emergency Medical Services (EMS) and determine predictive characteristics for children injured due to nonaccidental trauma (NAT).

Methods: A single-center retrospective cohort study was performed for children 5 years of age and younger arriving via EMS from January 2016 through December 2018. NAT finding was made by a Multidisciplinary Child Protection Team of child abuse clinicians, representatives from Child Protective Services, law enforcement, and District Attorney's offices. The rate of NAT was determined, and prehospital (ie, demographics) and hospital (ie, highest level of care) factor differences were explored between children with injuries sustained from NAT versus accidental trauma (AT). Additional subanalyses examined those among the cohort with head injuries.

Results: The sample included 352 children; 8.5% were found with injuries sustained from NAT. These children were younger, needed higher levels of care (ie, admission) and more likely to have EMS scene times >15 minutes (aOR 3.46) compared with those with AT. Among the population with head injuries (n=121), 9% were sustained from NAT. Like the full cohort, children were younger and more likely to have EMS scene times >15 minutes.

Conclusions: In our study, a substantial proportion of injured children arriving at the hospital via EMS were victims of NAT. These children were younger and had injuries warranting higher levels of care than those with AT. Significantly higher EMS scene times among the NAT group warrant more exploration.

Objectives: Casino shifts, which end at 4 AM and allow sleep during the circadian "anchor period," may improve sleep and reduce fatigue for pediatric emergency medicine (PEM) fellows working night shifts. We hypothesized that using a casino shift model would improve perceived fatigue levels and measured sleep metrics.

Methods: In this pilot prospective observational cohort study, fellows worked traditional night shifts for one month (control) followed by casino shifts for one month (intervention). Sleep data were collected using a validated wrist actigraph (ReadiBand), and subjective perceptions of fatigue were collected using surveys.

Results: Eight fellows participated in the study. Compared with the control month, the intervention month was associated with increased sleep quantity and sleep efficiency as measured by the actigraph. Fellows also reported reduced perceived fatigue and improved energy levels during the intervention month.

Conclusions: Switching to a casino shift schedule was associated with improvements in measured sleep and perceived fatigue among a cohort of PEM fellows in this pilot study. These preliminary findings warrant further investigation with larger samples and randomized scheduling to further explore the potential benefits and limitations of casino shift models in emergency medicine.