Pediatric emergency care最新文献

Objectives: Rapid brain MRI (rMRI) provides a radiation-free neuroimaging tool to screen children without sedation. Our objective was to retrospectively analyze clinical rMRI utilization by describing demographics, operational metrics, clinical indications, and temporal trends associated with rMRI utilization in the emergency department (ED).

Methods: We conducted a single-center, retrospective, cross-sectional study of children who underwent rMRI in the ED at an urban children's hospital between May 2014 and March 2024. We used descriptive statistics to examine operational metrics and trends in rMRI utilization over the study period. We performed a subgroup analysis of operational metrics by age and clinical indication.

Results: We included 2401 patients who underwent rMRI during their ED encounter. rMRI was frequently performed in infants and toddlers younger than 3 years old (n = 604, 25.1%), with a median patient age of 8.0 [interquartile range (IQR): 3.0 to 14.5] years. The median (IQR) time to scan was 3.5 (2.4 to 5.1) hours, and the median (IQR) ED length of stay was 7.5 (5.8 to 9.6) hours. Of the total, 1917 (79.8%) patients were initially triaged as "emergent," and 990 (41.2%) were discharged home from the ED. rMRI was predominantly used to evaluate ventricular shunt function (n = 2069, 86.1%) and traumatic brain injury (n = 214, 9.0%). Annual rMRI utilization increased by 80.8% between 2015 and 2023, with an average utilization rate increase of 46.1 scans annually between the years 2015 and 2019, and relatively static utilization rate from 2020 to 2023.

Conclusions: This work supports the feasibility of widespread rMRI in the high-volume ED care setting, including for young children. rMRI utilization increased over time, with the technique most frequently used to evaluate ventricular shunt function and traumatic brain injury.

Objectives: Unintentional injury is a leading cause of morbidity and mortality in children. The Accreditation Council for Graduate Medical Education (ACGME) requires competency in medical and trauma resuscitation in patients from newborn through adulthood. Yet there is a paucity of data regarding best practices for pediatric trauma training. The goal of this study was to evaluate knowledge gaps in pediatric trauma training, implement a trauma simulation curriculum, and evaluate changes in fellows comfort level with trauma skills preimplementation and postimplementation.

Methods: We utilized Kern's 6-step approach to design an innovative longitudinal trauma curriculum for Pediatric Emergency Medicine (PEM) fellows. A needs assessment was sent to PEM faculty, PEM fellows, pediatric surgery faculty, pediatric surgery fellows, and pediatric ED nursing. Learning objectives were derived and categorized as technical skills, nontechnical skills, and case-based medical knowledge. This guided a year-long curriculum including 11 simulation cases and 3 didactic sessions. The curriculum was assessed at Kirkpatrick levels 1 and 2 through preimplementation and postimplementation surveys. We assessed fellows' self-reported comfort and faculty perception of the supervision required.

Results: Fellows began with higher overall comfort with nontechnical skills compared with technical skills. Following implementation, there was a statistically significant improvement in fellow comfort in overall technical skills (P < 0.05), traction splint application (P < 0.05), and initiating massive transfusion protocol (P < 0.05). There were positive trends in obtaining access, placing pelvic binders, managing increased intracranial pressure, and leadership skills. There were no statistically significant findings noted in the surveys completed by the faculty.

Conclusions: This study presents a promising foundation for a comprehensive longitudinal pediatric trauma curriculum. Our study, while small, showed overall improvement in fellow comfort with trauma resuscitation at Kirkpatrick level 1, most notably with technical skills. Future areas of research include increased sample size, enhanced skills assessment methods, and expansion to other trauma team stakeholders.

Background: Patellar dislocations are frequently seen in the emergency department (ED). Almost all children with a reduced patellar dislocation will have a knee radiography, while only 10% have a fracture identified on x-ray.

Objective: The primary purpose of the study was to identify factors predicting osteochondral fractures among children with patellar dislocation reduced in the ED.

Methods: This was a retrospective cohort study of all children aged between 1 and 18 years old with patellar dislocation who needed a reduction in a tertiary care pediatric ED between 2019 and 2024. The primary outcome was the presence of a fracture identified by radiology (x-ray or MRI) during ED visit or follow-up at the orthopedic clinic. Multiple independent variables were evaluated as potential predictors. These were related to the patient (age, sex, previous patellar dislocation), the accident, and the physical examination before and after reduction, as well as finding at the follow-up at the orthopedic clinic. All charts were evaluated using a standardized form, and 10% were evaluated in duplicate to ensure interrater reliability. The primary analysis was the association between the independent variable and fracture using logistic regression.

Results: There was a total of 316 diagnoses of patellar luxation in 276 children with a median age of 14 years. Ninety-six children had their patellar dislocation reduced at the ED and were included in the study, of whom 19 (20%) had a fracture. Of all variables tested, only the persistence of knee swelling at orthopedic follow-up was associated with a higher risk of fracture (OR: 13.39; 95% CI: 1.70-105.32).

Conclusion: Approximately 20% of children who needed a reduction in the ED for patellar dislocation had a fracture. Persistent knee swelling at follow-up is a potential predictor of fracture.

Objectives: Acute agitation is a behavioral health emergency necessitating timely, effective intervention. Consensus guidelines recommend de-escalation techniques before restraint use. We examined the impact of de-escalation training on attitudes, knowledge, and behaviors of interdisciplinary staff caring for agitated patients in the pediatric emergency department (PED).

Methods: Asynchronous, multi-faceted de-escalation training interventions were delivered biweekly in an urban tertiary care PED as one facet of a quality improvement initiative to reduce disparities in physical restraint use. An electronic survey including the Management of Aggression and Violence Attitude Scale (MAVAS) plus questions on knowledge of and behaviors with pediatric agitation was distributed before and after the training interventions. Baseline and post-intervention survey results were compared, measuring changes in attitudes, knowledge, and self-reported behaviors.

Results: Sixty-one of 148 (41%) eligible participants completed the baseline survey and 44 (30%) completed the post-intervention survey. Post-intervention, participants were less likely to agree that it is difficult to prevent patients from becoming violent or aggressive (OR=0.31, 95% CI: 0.14-0.70) or that internal causative factors contribute to patient aggression (OR=0.50, 95% CI: 0.26-0.97). Post-intervention, respondents were more likely to recognize existing racial disparities in pediatric restraint use (OR=3.41, 95% CI: 1.64-7.09) and to believe that agitated patients were verbally de-escalated without restraint use often (OR= 2.11, 95% CI: 1.02-4.37).

Conclusions: After implementing asynchronous, multi-faceted de-escalation training, PED staff positively shifted their attitudes of children with acute agitation, improved knowledge about disparities in their care, and were more likely to believe that verbal de-escalation of agitated patients without restraint use was used often. De-escalation training can be easily implemented and impactful, and these data warrant further investigation into best de-escalation practices.

Objectives: Length of stay (LOS) and left without being seen (LWBS) rates are key measures of emergency department (ED) throughput. Few studies in the pediatric ED setting exist looking at the effect of rapid assessment team models on department operations/throughput. At our institution, a rapid assessment team was implemented to respond to patients who indicated a desire to leave before being evaluated, expedite assessment/treatment of lower-acuity cases that could be discharged directly, and initiate workups for patients experiencing excessive door-to-doctor times. We hypothesized that implementation of this team would be associated with decreased LOS, LWBS rates, and door-to-provider times in a pediatric ED.

Methods: We conducted a single-institution retrospective chart study to determine whether implementation of a rapid assessment team improved standard efficiency metrics (LWBS, LOS, door-to-provider time) within our pediatric ED. Data from a 4-year period (prerapid and postrapid assessment team implementation) were analyzed. Bivariate analyses (independent t test, Mann-Whitney U test, and χ2 test) were used to assess the association between baseline characteristics and primary outcomes. Multivariable logistic regression for the LWBS rate and linear regression for LOS examined the association between different time periods and outcomes while controlling for confounders.

Results: In total, 348,483 valid cases were analyzed. After implementation, the LWBS rate decreased from 0.7% to 0.5% (OR: 0.79, 95% CI: 0.72-0.87; P<0.001). Mean LOS decreased by 15.7 minutes (95% CI: 14.8-16.7; P<0.001), and door-to-provider time decreased by 19.2 minutes (95% CI: 18.8-19.6; P<0.001).

Conclusions: In our pediatric ED, implementation of a rapid assessment team was associated with reduced LOS, LWBS rates, and door-to-provider times.

Background: Incision and drainage (I&D) is the standard treatment for pediatric abscesses. However, discrepancies between estimated abscess volume, determined clinically or by point-of-care ultrasound (POCUS), and the actual volume expressed may result from poor ultrasound or I&D technique. These discrepancies may lead to inappropriate management decisions and unnecessary procedures.

Objective: To determine the prevalence of discrepancies between estimated and expressed abscess volumes during pediatric I&D.

Methods: We conducted a cross-sectional chart review at a tertiary care pediatric emergency department (ED) between 2017 and 2023. Patients younger than or qual to 21 years with an attempted I&D were identified using a natural language processing tool. We focused on 2 groups based off of documented abscess diameter: predicted volumes of ≤1 mL and ≥10 mL. Per author discretion, these values correspond with decision-making of 'not worth pursuing I&D' and 'definitely worth pursuing I&D', respectively. We considered a positive discrepancy if for an expected abscess volume of ≤1 mL, the documented volume expressed was ≥10 mL (underestimated), and if for an expected volume of ≥10 mL, the documented volume was ≤3 mL (overestimated). Prevalence and confidence intervals were calculated using descriptive statistics.

Results: Among 653 patients, 13.2% of sonographic and 7.6% of clinical estimates underestimated abscess volume, whereas 2.3% of sonographic and 19.6% of clinical estimates overestimated abscess volume. Combined assessment reduced discrepancies to 5.2% underestimated and 1.2% overestimated.

Conclusions: Combining clinical with POCUS assessment of pediatric abscesses provides better prediction of volume than reliance on a single method potentially reducing unnecessary procedures and missed I&D opportunities.

Objective: The purpose of this study was to describe the prehospital care for neonatal resuscitations (age <6 h) encountered by emergency medical services (EMS) in the United States.

Methods: We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 data sets. We included EMS activations related to a 9-1-1 scene response for patients <6 hours old with evidence of resuscitative efforts or an out-of-hospital cardiac arrest. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics.

Results: A total of 580 EMS encounters were included, of which 184 (31.7%) involved out-of-hospital cardiac arrest. Median patient age was 30 minutes (IQR: 5 to 60). Most responses were by advanced life support (93.1%), and median total prehospital time was 32.8 minutes (IQR: 24.0 to 45.9). The majority of encounters took place in a private residence (73.3%) in an urban setting (83.2%). The patient was left on scene in 3.1% of encounters, and all others were transported to the hospital. Basic airway management was most often required (74.3%), oxygen was delivered in 43.5% of cases, and advanced airway management was performed in 5.7% of encounters. Field delivery was performed in 20.5% of encounters, and compressions/defibrillation were performed in 21.2% of cases.

Conclusion: Prehospital neonatal resuscitation by EMS is uncommon but often requires advanced interventions rarely performed by EMS on newborn patients. These findings have important implications for EMS training and education, including the development of protocols, training programs, and other preparedness innovations for neonatal resuscitation specific to the prehospital setting.

Objectives: Abdominal pain is a common presenting symptom in the pediatric emergency department (ED), with appendicitis being the most common surgical emergency. Administration of analgesia, including opioids, has not been shown to delay the diagnosis of appendicitis, yet oligoanalgesia remains a common occurrence. We aimed to determine the proportion of any analgesia and opioid analgesia administration, the median time to first analgesia administration, and to identify factors associated with the administration of any analgesia and opioid analgesia in patients with suspected appendicitis.

Methods: We conducted a single-center cross-sectional study of children less than 18 years of age evaluated in the pediatric ED from June 2014 to June 2021 for suspected appendicitis. Deidentified data were extracted from the electronic record through a data repository. Our primary outcomes were the administration of analgesia and the median time to first analgesia administration. We used descriptive statistics and multivariate regression analysis to compare independent influences on analgesia administration.

Results: During the 8-year study period, 7065 children were evaluated for appendicitis. Overall, 4821 (68.2%) received some form of analgesia, 3157 (44.7%) received nonopioid analgesia only, and 1664 (23.6%) received opioid analgesia during their ED visit. Overall median time to first analgesia was 104 minutes. Median time to first nonopioid analgesia and first opioid analgesia was 94.5 minutes and 136 minutes, respectively. Moderate and severe pain scores, fever, tachycardia, and higher ESI level of acuity were significantly associated with analgesia administration.

Conclusions: Analgesia administration in children with suspected appendicitis varies considerably. Efforts to target more consistent and timely pediatric pain management practices are needed.

Objective: The objective of this study is to investigate differences in pain outcomes for pediatric trauma patients who receive Child Life Services versus pediatric trauma patients who do not.

Methods: Retrospective chart reviews were completed on patients birth to 21 years of age who were seen by trauma services in the Emergency Department and various inpatient units. These individuals were characterized into 2 groups: those seen by child life specialists and those who were not. Pain scores were recorded by using the following scales: face, legs, activity, cry, consolability (FLACC), The Wong-Baker FACES, the Verbal Numeric Rating Score, and Critical Care Pain Observation Tool (CPOT). Baseline data included age, sex, race, injury type, Injury Severity Score (ISS), pain score, and length of stay. Patients were matched using the initial pain score and ISS score. An ordinal logistic model was built regressing pain at discharge on group (CLS visit or no CLS visit). Significance was set at P≤0.05.

Results: One hundred ninety-six patients' data were used; 107 (54%) of them had been seen by child life specialists. The study groups had similar baseline demographics and injury severity scores. The pain score at discharge was significantly lower in children with child life services' visits (median=0, min=0, max=10) compared with those without [median=2, min=0, max=10; OR=0.48, 95% CI (0.28, 0.83), P=0.009].

Conclusions: Certified child life specialist involvement in pediatric trauma patients' care correlates to a lower pain score upon discharge.

Introduction: Acute epididymitis (AE) in children usually responds to conservative therapy. However, in rare cases (1% to 2%), it may progress to severe complications such as testicular infarction or necrosis due to vascular compromise. We report a case of progressive segmental testicular necrosis following presumed post-infectious AE after a recent viral respiratory illness.

Methods: An 8-year-old boy presented with a 2-day history of left testicular pain, swelling, and erythema. Initial Doppler ultrasound revealed epididymal enlargement, hyperemia, and reactive hydrocele without signs of torsion. Urine culture was collected, and empirical ibuprofen and trimethoprim-sulfamethoxazole were prescribed.

Results: Six days later, symptoms worsened with increased swelling and pain. Repeat Doppler ultrasound demonstrated hypoechoic avascular areas and reduced flow, consistent with necrosis. Urine, blood, and smegma cultures were negative. Surgical exploration revealed extensive testicular necrosis without torsion, leading to simple orchiectomy. Histopathology confirmed ischemic necrosis secondary to an inflammatory process. The observed evolution supports the concept of TCS, in which rising intratesticular pressure due to venous congestion and extraluminal compression within the noncompliant tunica albuginea leads to impaired microcirculatory perfusion and ischemic necrosis.

Conclusions: Testicular necrosis is an exceedingly uncommon but serious complication of AOE in children. Persistent pain, increasing testicular size, or poor clinical response should prompt early Doppler reassessment and consideration of surgical exploration. Recognition of TCS as a possible pathophysiological mechanism may help guide timely diagnosis and intervention to prevent irreversible ischemic injury.