Pediatric emergency care最新文献

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.

Introduction: Mild traumatic brain injuries (mTBI) are common in pediatric emergency departments (EDs), but inconsistent use of diagnostic labels leads to variable discharge instructions, especially with regard to concussion. Lack of age-appropriate guidance can increase parental anxiety and ED revisits and hinder recovery.

Objective: This quality improvement (QI) initiative aimed to increase the proportion of mTBI patients receiving age-appropriate discharge instructions to 50% over 13 months in an urban pediatric ED.

Methods: An interdisciplinary QI team conducted an observational time series study with sequential experimentation at a quaternary academic medical center over 13 months. Using a key driver diagram, they created SMART aim, measures, and designed interventions which were tested through 5 Plan-Do-Study-Act (PDSA) cycles. Interventions included an educational curriculum, e-reminders, workspace materials, and pre-written electronic medical record (EMR) templates (smart phrases) for age-specific discharge instructions (0 to 5 y, ≥6 y), and parent surveys were used on a subset of sample families to assess knowledge, behavior, and anxiety post-discharge. Outcome measures included the percentage of age-appropriate discharge instructions provided and use of the new EMR smart phrase. Balancing measures tracked head computed tomography (CT) utilization, ED revisits within 14 days of discharge, and neurology referrals. Process control charts and rules to detect special cause variation were used to analyze data. We use descriptive statistics to analyze survey data.

Results: Among 1263 patients, age-appropriate discharge instruction rates improved from 36% to 56%. Smart phrases were used in 58% of relevant cases (n=628). No changes were observed in CT orders, ED revisits, or neurology referrals. Among 37 surveyed parents (28% response rate), 95% (n=35) found instructions helpful, and 68% (n=25) reported reduced anxiety.

Conclusions: Implementing EMR smart phrases in a pediatric ED increased standardized, age-appropriate discharge instructions for children with mTBI. These low-cost interventions are scalable for broader ED use and other settings.

Objectives: This retrospective observational study evaluated the diagnostic efficiency of routine magnetic resonance imaging (MRI) in pediatric patients with facial palsy (FP) in the emergency department (ED).

Methods: Pediatric patients under 18 years of age who presented with FP at the ED of a single tertiary referral hospital between January 2010 and December 2022 were included. Clinical features were assessed and used for risk stratification, which informed the diagnostic utility of the MRI.

Results: A total of 134 pediatric patients were included [mean age, 99 mo; 53.7% male (n = 72)]. Seventeen patients (12.7%) were diagnosed with central FP (CFP). Among the clinical features, additional neurological examination abnormalities emerged as the most significant risk factor for CFP (odds ratio, 86.3; P < 0.001). Risk stratification based on neurological abnormalities, underlying conditions, and associated symptoms revealed that the diagnostic utility of MRI was significantly higher in the risk group than in the no-risk group ( P < 0.001; sensitivity, 100%; specificity, 84.6%). In contrast, patients in the no-risk group who underwent MRI experienced a mean increase of 294 minutes in the ED length of stay compared with those who did not undergo imaging.

Conclusions: Routine MRI is valuable for detecting CFP in pediatric patients with neurological signs. However, its use in low-risk cases may provide limited clinical benefit, prolonging ED stay and increasing unnecessary use of medical resources. Therefore, selective imaging based on clinical indicators is recommended.

Introduction: Trauma is a leading cause of pediatric emergency visits, yet training often underemphasizes nontechnical skills (NOTECHS). Simulation-based training can improve these skills, and targeted video review (TVR) may further enhance debriefings by enabling precise, case-based feedback. This study evaluated the combined impact of multidisciplinary, simulation-based training and TVR on technical performance and NOTECHS during pediatric trauma resuscitations.

Methods: This prospective educational quality improvement study was conducted at a level 1 pediatric trauma center from February 2023 to July 2023. Multidisciplinary teams participated in in situ pediatric trauma simulations followed by structured debriefings incorporating TVR. Video reviews of preintervention and postintervention trauma activations (n = 76) assessed changes in team behavior and clinical metrics, including time-to-vitals, imaging, emergency department (ED) length of stay (LOS), and time-to-operating room (OR). Trauma performance was evaluated using the Trauma Team Evaluation Tool and T-NOTECHS.

Results: Seventy-six trauma activations (21 preintervention, 55 postintervention) were reviewed. Postintervention, the proportion of cases without an identified team leader decreased (33% to 9.1%), and those with a defined disposition plan increased (66.7% to 100%). Overall team performance improved (6.52 to 7.60/10; P < 0.001), with significant gains in communication and situational awareness ( P = 0.012 and P = 0.033, respectively). Time-to-vitals decreased significantly ( P = 0.027); while imaging, ED LOS, and time-to-OR showed nonsignificant changes.

Conclusions: Simulation-based interdisciplinary training, paired with TVR improved teamwork, communication, and decision-making in pediatric trauma resuscitations. This approach reinforced protocol adherence and supported quality improvement. While effects on patient outcomes remain uncertain, these findings support simulation and TVR as strategies to enhance performance in high-acuity settings.

Background and objectives: Chest radiographs (CXRs) are often performed among children presenting to the emergency department (ED) with chest pain. Given the limited data on this practice, we sought to evaluate the risk of pneumonia among children presenting to an ED with chest pain and to further identify children at low risk of pneumonia.

Methods: We performed a secondary analysis of a prospective study enrolling children 5 to 18 years of age with chest pain who had a CXR performed for clinical suspicion of pneumonia. We compared the characteristics of children with and without pneumonia and used multivariable analyses to identify characteristics associated with radiographic pneumonia.

Results: A total of 240 children with chest pain undergoing CXR for clinical suspicion of pneumonia were enrolled [median age 11.5 years (IQR: 7.6, 15.4)]. Radiographic pneumonia was observed in 46 children (19%). The odds of pneumonia were higher among children with fever (aOR: 3.5, 95% CI: 1.6, 7.8), tachypnea (aOR: 2.7, 95% CI: 1.2, 6.2), crackles (aOR: 2.3, 95% CI: 1.1, 5.0), and diminished breath sounds (aOR: 2.5, 95% CI: 1.2, 5.1) on auscultation. A total of 45 of 46 children with pneumonia had one or more of the following: fever, tachypnea, crackles, or decreased breath sounds on auscultation (sensitivity 97.8%, 95% CI: 88.5%, 99.9%).

Conclusions: Approximately 1 in 5 children presenting with chest pain and undergoing CXR had radiographic pneumonia. Pneumonia may be safely excluded among children with chest pain if there is no fever, tachypnea, crackles, or diminished breath sounds on examination.