Pediatric emergency care最新文献

Background: Fever in infants under 60 days old raises concern for invasive bacterial infections. In 2021, the American Academy of Pediatrics (AAP) released updated guidelines, including revised recommendations for infants aged 22 to 28 days, to reduce unnecessary lumbar punctures (LP), hospitalizations, and antibiotic use. This study hypothesized that the guidelines would reduce LPs, specifically in the newly stratified age group.

Methods: We conducted a retrospective cohort study at a single pediatric emergency department of febrile infants aged 22 to 60 days presenting between October 1, 2019, and September 30, 2023, with October 1, 2021, being the division between groups. Infants were excluded if ill-appearing, <37 weeks of gestation, or had complex medical histories. The primary outcome was the proportion undergoing LP. Subgroup analysis was performed by age group, and those identified as low-risk by initial laboratory evaluation. Secondary outcomes included hospital admission, length of stay, and antibiotic use.

Results: A total of 132 infants met the inclusion criteria (52 pre-guidelines, 80 post-guidelines), and no exclusion criteria were applied. Following guidelines, the proportion of LPs had a statistically significant decrease ( P =0.02), with the reduction maintained in the 22- to 28-day subgroup ( P =0.002). The rate of hospital admission and antibiotics followed a similar statistically significant decrease post-guideline introduction, which also maintained for the 22- to 28-day subgroup. There was no statistically significant difference for length of stay or in the 29- to 60-day subgroup analyses. For infants identified as low-risk by laboratory risk-stratification, we discovered a statistically significant reduction in LP following the guidelines ( P <0.001).

Conclusions: Implementation of the 2021 AAP guidelines was associated with reduced LPs, hospitalizations, and antibiotic use in infants aged 22 to 60 days, with the greatest impact in the 22- to 28-day subgroup. These guidelines improve risk stratification and reduce invasive interventions while maintaining safe care. While the small sample size limits generalizability, these findings suggest a positive shift in clinical practice.

Objectives: Acute care settings often serve as the first point of contact for pediatric patients at risk of suicide, requiring clinicians to make complex decisions about care. There is significant variability in suicide risk management across pediatric emergency departments (EDs) in the United States. In this work, we examined the care provided to pediatric patients with suicide risk in the ED setting and whether this care varies by key demographic factors, such as age, race, sex, or income status.

Methods: In this retrospective analysis of electronic health record (EHR) data from 2 pediatric ED settings, we used a series of mixed multilevel regression models to evaluate differences in ED length of stay, admission, and the odds of ordered home psychotherapeutic medications or intramuscular restraint medications in patients with identified suicide risk.

Results: Among visits with identified suicide risk, patients with private insurance were more likely to have home psychotherapeutic medication ordered (aOR: 1.74, 95% CI: 1.25-2.43). Compared with White patients, Black patients had a 23% shorter LOS (aIRR: 0.77, 95% CI: 0.65-0.91), were 65% less likely to receive ED-ordered home psychotherapeutic medication (aOR: 0.35, 95% CI: 0.25-0.49), and were 48% less likely to be admitted (aOR: 0.52, 95% CI: 0.35-0.76). Hispanic/Latino patients had 72% lower odds of receiving ED-ordered home psychotherapeutic medication (aOR: 0.28, 95% CI: 0.16-0.49).

Conclusions: There is substantial variation in the emergency care of youth presenting with suicide risk. Our findings demonstrate significant differences in LOS, discharge disposition, and ED-medication management across insurance types and racial and ethnic groups.

Objectives: Pediatric ileocolic intussusception often presents without classic symptoms, making early diagnosis and management challenging. While the enema reduction is the standard treatment, failed reduction may lead to surgical intervention. This study aimed to identify predictors of reduction failure focusing on ultrasonographic features, to develop a predictive model and to assess capabilities of point-of-care ultrasound (POCUS).

Methods: We conducted a retrospective study at a pediatric emergency center from January 2020 to December 2024. Children who underwent air enema reduction for ileocolic intussusception were included. Univariable and multivariable logistic regression analyses were performed to identify predictors of reduction failure. A prediction model was constructed using ultrasound features and validated using a distinct cohort. Paired comparative analysis between POCUS and radiologist-performed ultrasound was performed.

Results: Among 179 children, 35 experienced failure. Most of the demographic and symptom-based variables were not significantly associated with outcomes. Radiologist-performed US revealed that lymph nodes around the lesion, greater invagination length, hypoechoic ring thickness, and suspected low vascularity were associated with failure. A multivariable logistic regression model using 6 ultrasound features demonstrated good predictive performance. External validation with 58 patients yielded good predictive performance and 100% sensitivity. Comparative analysis showed that radiologists more frequently assessed long-axis views and vascularity, identifying risk features more comprehensively than pediatric emergency physicians.

Conclusions: Ultrasound-based features are possibly more reliable predictors of enema reduction failure in pediatric emergency settings. Our validated model and comparative analysis highlight the importance of standardized ultrasound assessment and support the expanded role of POCUS.

Purpose: High-quality cardiopulmonary resuscitation (CPR) is crucial for improving survival in cardiac arrest. Effective airway management can enhance outcomes but remains challenging due to anatomical and physiological factors in children. However, whether endotracheal intubation is superior to bag-valve-mask ventilation during CPR remains uncertain. Video laryngoscopes have emerged as an alternative to direct laryngoscopes, offering enhanced visualization; however, their efficacy for pediatric CPR remains unclear. This systematic review and meta-analysis aimed to compare the efficacy of video laryngoscopes and direct laryngoscopes during pediatric CPR in simulation-based studies.

Methods: A systematic search of PubMed, Embase, and The Cochrane Library was conducted up to February 2025. Only randomized controlled trials conducted in simulation settings comparing video and direct laryngoscopes in pediatric CPR were included. The primary outcomes were the first attempt success rate and the overall success rate. The secondary outcomes included intubation time, Cormack and Lehane grade as an indicator of glottic visualization, and dental compression. The risk of bias for the included studies was assessed using the Cochrane Risk of Bias tool. Two reviewers independently evaluated each domain, and disagreements were resolved by consensus.

Results: Thirteen simulation-based studies with 2080 intubation attempts in manikins were included. Direct laryngoscopes demonstrated a 35% lower relative first-attempt success rate (RR: 0.65, 95% CI: 0.59-0.71) and a 17% lower relative overall success rate (RR: 0.83, 95% CI: 0.80-0.88) compared with video laryngoscopes. Intubation time was 8.13 seconds longer with direct laryngoscopes (MD: 8.13 s, 95% CI: 4.82-11.44). Furthermore, direct laryngoscopes were associated with a 39% lower relative likelihood of Cormack and Lehane grade 1 view (RR: 0.61, 95% CI: 0.49-0.76), and 6.05 times higher relative risk of dental compression (RR: 6.05, 95% CI: 2.93-12.52) compared with video laryngoscopes.

Conclusion: Video laryngoscopes significantly improve intubation success rates and reduce intubation time during simulation-based pediatric CPR. Future research should validate these findings in clinical settings and evaluate device-specific features to optimize outcomes.

Objectives: Implementing a new electronic health record (EHR) system in high-pressure, high-stakes environments, such as documenting during pediatric and neonatal cardiac and respiratory arrest scenarios, can be challenging for health care staff. Poorly designed tools or technology that don't align with existing workflows may lead to incomplete or inaccurate documentation. Lower adoption rates and continued reliance on paper forms for code documentation can result in gaps in patient data within the EHR, requiring the transcription of critical information after the event.

Methods: This project utilized human factors usability testing and systems-focused simulation evaluation methods to assess code documentation tools with end-users from critical care areas (ED, ICU, NICU) during the EHR design phase.

Results: A total of 202 recommendations to enhance the EHR's usability and functionality were made across the 3 testing cycles (2 rounds of usability testing and 1 cycle of systems simulation sessions). The majority of recommendations were focused on improvements to the software and technology of the code narrator tool directly. Post-launch assessment showed that nearly 2/3 of the usability recommendations were implemented within the first year of use.

Conclusions: Improving the design of these tools and ensuring seamless workflow integration is essential for increasing adoption and enhancing the accuracy of patient records.

Objectives: Pediatric emergency medicine (PEM) physicians deliver serious news (DSN) in stressful situations that impact both families and physicians. Our objective was to assess the impact of a PEM-focused workshop on DSN in improving the self-perceived preparedness, skill level, and stress management of PEM physicians.

Methods: We designed a simulation-based communication workshop, "PEMTalk," utilizing simulated parents to teach PEM attendings and fellows to effectively DSN. The workshop was conducted in a virtual and in-person format from 2018 to 2023. We developed 3 scenarios unique to PEM. Pre- and postintervention surveys were administered to assess the workshop's impact.

Results: A total of 74 participants completed surveys. Among the 34 first-time participants, there were improvements in provider's self-perceived ability to DSN (41% vs. 97%; P<0.001), respond to emotions (50% vs. 97%; P<0.001), and decrease in stress (47% vs. 21%; P=0.003) due to DSN. Among the 23 participants who participated in the study more than once, there were sustained improvements in their self-perceived ability to DSN (39% vs. 69%; P=0.02). Fellows (53% of participants) were more likely than attendings to report improvement in DSN [OR 6; 95% CI (1.05-41.67); P=0.04]. There was no difference in outcomes between in-person and virtual formats.

Conclusion: PEMTalk enhanced participants' self-reported comfort while reducing stress associated with DSN in a simulated setting. Next steps include incorporating objective assessments, evaluating the impact on patient care, and disseminating the workshop to the broader PEM community.

Objectives: To measure the association between overall workload and patient and family experience (PFE) in a pediatric emergency department (ED). Our secondary objective was to assess the construct validity of total ED Relative Value Units (RVUs) as an overall ED workload measure.

Methods: We performed a retrospective study from January 2022 to August 2023 using data from a large, urban, academic pediatric ED with approximately 85,000 patient visits annually. PFE was measured by surveys distributed to all patients discharged from ED. The association of overall ED workload with PFE was assessed using multivariate ordinal logistic regression. We examined the construct validity of total ED RVUs by replacing this measure with National Emergency Department Overcrowding Scale (NEDOCS) in the logistic regression model.

Results: Of 126,336 discharged visits, 7128 (5.6%) completed surveys. We found a statistically significant association between ED workload and PFE. For each 10 RVUs added to ED workload, the odds of more positive PFE decreased by 9% (95% CI: 8%-9%). The adjusted odds ratio of NEDOCS demonstrated a less pronounced association in the same direction; an increase of 10 points in NEDOCS was associated with 6% (95% CI: 5%-6%) decrease in the likelihood of higher PFE ratings.

Conclusions: High ED workload, as measured by overall RVUs, was significantly associated with negative PFE. Similar results were found when we substituted NEDOCS for overall RVUs. Our findings suggest that overall RVUs may be a useful measure of ED workload and might provide a quantitative target for quality improvement.

Background: Blunt cerebrovascular injury (BCVI), defined as an injury occurring to the carotid and/or vertebral arteries, occurs in ~1% of pediatric blunt trauma patients and is associated with morbidity and mortality. Our objective was to evaluate the sensitivity and specificity of the McGovern score, a pediatric-specific screening tool for BCVI, and describe the effect of its implementation on the use of additional imaging for BCVI and the detection of BCVI.

Methods: This was a retrospective cohort study of patients below 16 years old presenting with blunt trauma to the Pediatric Emergency Department of a tertiary care level 1 pediatric trauma center pre- (July 1, 2020, to November 30, 2021) and post- (December 1, 2021, to December 31, 2022) implementation of McGovern scoring into the clinical decision algorithm for blunt trauma. Patient characteristics, diagnostic studies used [including computed tomography angiography (CTA) or magnetic resonance angiography (MRA) of the neck vessels], and outcomes (BCVI, stroke, mortality), were obtained from the medical record and compared pre-McGovern versus post-McGovern score implementation.

Results: A total of 1189 patients were included in the study; 664 preimplementation of the McGovern scoring and 525 postimplementation. Median age was 6 years (IQR 2 to 11), and 668 (56%) were trauma activations (leveled traumas), with no significant differences in patient characteristics between the 2 cohorts. Imaging for BCVI was performed in 13 (2.0%) patients in the preimplementation group and 27 (5.0%) patients in the postimplementation group (P=0.003). BCVI was detected in 12/1189 patients overall (1.0%); 2 in the preimplementation group (0.3%), and 10 (1.9%) in the postimplementation group (P=0.007). In the postimplementation group, the sensitivity of the McGovern score was 90% while the specificity was 96.7%.

Conclusions: The implementation of the McGovern score into the pediatric trauma decision algorithm was associated with the detection of an increased number of BCVIs compared to the preimplementation group, with good sensitivity and specificity, but a significant increase in the use of imaging.

Objectives: The aim of this study was to investigate differences in utilization of diagnostic imaging between the adult and pediatric trauma teams when caring for adolescent trauma patients.

Methods: This was a retrospective observational study from 2015 to 2019 comparing pediatric trauma team activations for patients ages 12 to 14 and adult trauma team activations for patients ages 15 to 17 at a single institution verified as both a level I adult and a level I pediatric trauma center. Data were collected from a prospective trauma registry and manual chart review of the electronic medical records. The primary outcome was the frequency of whole body computed tomography (WBCT) and computed tomography (CT) imaging of individual body regions.

Results: We identified 191 adult and 100 pediatric trauma team cases, with similar proportions transferred from outside hospitals (40% vs. 43%). Among patients presenting directly from the scene, WBCT use was significantly higher in the adult trauma team group (64% vs. 12%; RR: 5.21; 95% CI: 2.57-10.58), as was CT of all individual body regions. For transferred patients, the adult trauma team more often performed WBCT and individual CT scans, excluding head CT. CT imaging rates before transfer did not differ between groups. No significant differences were observed in injury severity scores, altered mental status, length of stay, or missed injuries.

Conclusions: Among adolescents with similar injury severity, the adult trauma team more frequently utilizes WBCT and regional CT than the pediatric team. However, CT use before transfer from outside hospitals without dedicated pediatric trauma teams was similar across age groups.

Objectives: Describe the interactions of young people killed by firearms with the pediatric health care system, with a focus on emergency department care. Characterize victims' risk factors for firearm violence as documented in the medical record.

Methods: Subjects were identified by querying the Gun Violence Archive (GVA) for individuals aged 13 to 30 who were fatally shot in Washington, D.C. between January 1, 2018 and December 31, 2022. GVA victims were matched to medical records within our pediatric hospital system. Records were analyzed for demographics, violence risk factors, and health care utilization.

Results: A total of 352 patients met inclusion criteria. The most common risk factors ascertained from medical record review were accidental injury (70.5%), violent injury (45.4%), and involvement with the juvenile justice system (32.9%). Individuals with greater than 5 risk factors comprised only 9.4% of our population but accounted for more than a quarter of the total risk factors documented, including 46.8% of child abuse cases, 31.2% of firearm injuries, 25% of juvenile justice cases, and the majority of mental and behavioral health risk factors (89.4% of behavioral issues, 55.2% of mood problems, and 54.1% of ADHD cases). Conversely, thirty-eight subjects (10.8%) had no documented risk factors. Subjects visited our ED multiple times (mean 5.74 visits) and the majority (70.1%) visited an outpatient clinic.

Conclusions: Young victims of firearms had a range of risk factors for firearm violence and multiple interactions with our pediatric hospital system before death. Each interaction represents an opportunity to screen and intervene. This work also points to the opportunity to change the inequitable systems responsible for these risk factors. Further work must be done to evaluate which risk factors are most predictive and how they develop over time.