Pediatric emergency care最新文献

Introduction: Adolescent overdoses have been rising over the past decade. Emergency department (ED) visits for both acute overdoses and for adolescents in opioid withdrawal have risen post-COVID. Urine drug screens have poor utility in the ED but are routinely obtained for medical clearance and in the management of patients with substance use disorder. Our primary goal was to measure the sensitivity of the opiate urine drug assay over time in opioid-related presentations to the ED.

Methods: We reviewed ED presentations at all EDs within our health system that were directly related to opioids from 1/1/2014 to 12/31/2022. For each patient included over the time frame, we identified whether a urine drug screen was obtained and the results from this screen. The urine drug screen available at all sites was an enzyme-multiplied immunoassay with an opiate screen (morphine antibody), but no fentanyl screen. The percent positivity for each drug category on enzyme multiplied immunoassay technique testing was calculated. Chi-squared tests were used to compare positivity rates between years.

Results: Opiate positivity declined over the last 9 years. Positivity rates from 2020 to 2022 were 5% ± 2% vs 82% ± 6% from 2014 to 2019 ( P < 0.001) Performance of UDS also declined over time (76% from 2014 to 2019 vs 46% from 2020 to 2022; P < 0.001). UDS was more likely to be performed in patients after a suicide attempt or when presenting after illicit use (66% vs 38%; P = 0.004).

Conclusion: Opiate screen positivity decreased the last 9 years and may reflect wider use of fentanyl among this population starting in 2020.

Abstract: Synovial cell sarcoma is a rare mesenchymal tumor that typically originates from the soft tissues of the extremities of young adults. Only 3 cases of primary diaphragmatic synovial cell sarcoma have been described in the literature: 2 in adult males and 1 in a 12-year-old pediatric patient. 1-3 When this tumor is found in the mediastinum or pericardial region, prognosis is historically poor because of the advanced disease stage at time of diagnosis. The surgical course and pathology have been described in this 12-year-old boy. 3 This is the first case, to our knowledge, of the use of cardiac point-of-care ultrasound in the early identification and diagnosis of a primary diaphragmatic synovial sarcoma in a pediatric patient.

Background: Pediatric patients often require sedation during magnetic resonance imaging (MRI) and computed tomography (CT) to ensure stillness and minimize stress. This meta-analysis compared the effectiveness and safety of 3 sedative agents-dexmedetomidine, midazolam, and chloral hydrate-for pediatric MRI/CT sedation.

Methods: Six studies with a total of 633 patients were included in the analysis. Quality assessment revealed varying levels of bias risk. Dexmedetomidine exhibited a significantly higher successful sedation rate compared to midazolam (risk ratio [RR] = 0.43, 95% confidence interval [CI] [0.29-0.64]), but no statistically significant difference compared to chloral hydrate (RR = 0.94, 95% CI [0.60-1.45]). Chloral hydrate also showed a higher successful sedation rate compared to midazolam (RR = 0.46, 95% CI [0.25-0.83]). The onset of sedation time did not significantly differ between the 3 agents.

Results: The dexmedetomidine group had a significantly higher incidence of bradycardia compared to the chloral hydrate group (RR = 0.17, 95% CI [0.05-0.59]), but no significant difference compared to the midazolam group (RR = 0.29, 95% CI [0.06-1.26]). No statistically significant differences were observed in the incidence of nausea and vomiting between the 3 groups.

Conclusions: Dexmedetomidine demonstrates effectiveness in pediatric MRI/CT sedation, offering advantages over midazolam and similar efficacy to chloral hydrate. Careful cardiovascular monitoring is essential during administration, particularly in patients with congenital heart disease. Sublingual and intranasal administration of dexmedetomidine is a viable option with high bioavailability. This meta-analysis contributes valuable insights into refining sedation protocols for pediatric imaging procedures, emphasizing efficacy and safety considerations.

Objective: Pediatric sepsis screening is becoming the standard of care for children presenting to the emergency department (ED) and has been shown to improve recognition of severe sepsis, but it is unknown if these screening tools can predict progression of disease. The objective of this study was to determine if any elements of a sepsis triage trigger tool were predictive of progression to hypotensive shock in children presenting to the ED with fever and tachycardia.

Methods: This study is a retrospective case-control study of children ≤18 years presenting to an ED with fever and tachycardia, comparing those who went on to develop hypotensive shock in the subsequent 24 hours (case) to those who did not (control). Primary outcome was the proportion of encounters where the patient had specific abnormal vital signs or clinical signs as components of the sepsis triage score. The secondary outcomes were the proportion of encounters where the patient had a sepsis risk factor.

Results: During the study period, there were 94 patients who met case criteria and 186 controls selected. In the adjusted multivariable model, the 2 components of the sepsis triage score that were more common in case patients were the presence of severe cerebral palsy (adjusted odds ratio, 9.4 [3.7, 23.9]) and abnormal capillary refill at triage (adjusted odds ratio, 3.1 [1.4, 6.9]).

Conclusions: Among children who present to a pediatric ED with fever and tachycardia, those with prolonged capillary refill at triage or severe cerebral palsy were more likely to progress to decompensated septic shock, despite routine ED care.

Objective: Persistent pulmonary hypertension of the newborn (PPHN) is one of the critical neonatal diseases associated with high morbidity and mortality. This study attempted to conduct a nomogram prediction model for performing early identification of PPHN and providing effective information for clinical practice.

Methods: A total of 456 newborns who first admitted to the hospital after birth were included in the analysis, including 138 newborns with PPHN and 318 newborns without PPHN (as controls). The optimal predictive variables selection was performed based on LASSO (least absolute shrinkage and selection operator) regression and multivariate logistic regression. Using the selected variables, a nomogram prediction model was developed. To validate the model, the model was assessed using the receiver operating characteristic curve, calibration plot, and clinical impact curve.

Results: Six predictors, namely, gestational age, neonatal respiratory distress syndrome, the levels of hemoglobin and creatine kinase-MB, gestational thyroid dysfunction, and Pa o2 , were identified by LASSO and multivariate logistic regression analysis from the original 30 variables studied. The constructed model, using these predictors, exhibited favorable predictive ability for PPHN, with an area under the receiver operating characteristic of 0.897 (sensitivity = 0.876, specificity = 0.785) in the training set and 0.871 (sensitivity = 0.902, specificity = 0.695) in the validation set, and was well calibrated, as indicated by the PHosmer-Lemeshow test values of 0.233 and 0.876 for the training and validation sets, respectively.

Conclusions: The model included gestational age, neonatal respiratory distress syndrome, the levels of hemoglobin and creatine kinase-MB, gestational thyroid dysfunction, and Pa o2 had good prediction performance for predicting PPHN among newborns first admitted to the hospital after birth.

Objectives: This study aims to examine the association between primary care practice characteristics (enhanced access services) and practice-level rates of nonurgent emergency department (ED) visits using ED and practice-level data. Survey data suggest that enhanced access services within a child's primary care practice may be associated with reduced nonurgent ED visits.

Methods: We performed a cross-sectional analysis of nonurgent ED visits to a tertiary pediatric hospital in Western Pennsylvania with nearly 85,000 annual ED visits. We obtained patient encounter data of all nonurgent pediatric ED (PED) visits between January 2018 and December 2019. We identified the primary care provider at the time of the study period. For each of the 42 included offices, we determined the number of unique children in the office with a nonurgent PED visit, allowing us to determine the percentage of children in the practice with such a visit during the study period. We then stratified the 42 offices into low, intermediate, and high tertiles of nonurgent PED use. Using Kruskal-Wallis tests, logistic regression, and Pearson χ 2 tests, we compared practice characteristics, enhanced access services, practice location Child Opportunity Index 2.0, and PED visit diagnoses across tertiles.

Results: We examined 52,459 nonurgent PED encounters by 33,209 unique patients across 42 outpatient offices. Primary care practices in the lowest ED visit tertile were more likely to have 4 or more evenings with office hours (36% vs 14%, P = 0.04), 4 or more evenings of weekday extended hours (43% vs 14%, P = 0.05), and at least 1 day of any weekend hours (86% vs 29%, P = 0.01), compared with practices in other tertiles. High PED use tertile offices were also associated with lower Child Opportunity Index scores.

Conclusions: Primary care offices with higher nonurgent PED utilization had fewer enhanced access services and were located in neighborhood with fewer child-focused resources.

Objective: Ketamine is a safe and widely used sedative and analgesic in children. The purpose of this study is to evaluate the response to sedoanalgesia for painful procedures in the pediatric emergency department.

Methods: A retrospective study was conducted in children younger than 16 years who underwent painful procedures with intravenous/intranasal ketamine between January 2016 and December 2022. We collected demographic variables, effectiveness, route of administration, indication, dose, sedation strategy, duration of procedure, and associated adverse effects.

Results: A total of 671 ketamine sedation procedures (411 males/260 females) were included, with a mean age of 7.2 years. Closed reduction was the most common painful procedure (53.8%), followed by burn healing (24.6%). Ketamine was administered intravenously in 93.4% of procedures and intranasally in 6.6%. The result of sedoanalgesia was satisfactory in 84.9% and unsatisfactory in 15.1%. The percentage of cases with unsatisfactory analgesia was higher with intranasal administration (36.4%; P < 0.001). In the intravenous group, the percentage of cases with unsatisfactory effectiveness (28.7%) was higher for patients younger than 2 years of age ( P < 0.001). Arthrocentesis procedures were associated with the highest percentage of unsatisfactory sedoanalgesia failures among patients receiving intravenous ketamine (39.3%; P < 0.001). Intranasal ketamine patients who received a dose between 3.6 and 4 mg/kg had a significantly higher percentage of unsatisfactory sedoanalgesia (66.7%; P = 0.048). Patients receiving intravenous ketamine had significantly higher rates of unsatisfactory sedoanalgesia when the initial dose interval was 1.6 to 2 mg/kg (11.8%; P = 0.002) and when the final total dose was also 1.6 to 2 mg/kg (17.6%; P = 0.002).

Conclusions: This study concludes that intravenous/intranasal ketamine can provide safe and successful analgesia in pediatric patients in the ED. At intravenous doses of 1-1.5 mg/kg, good effectiveness was achieved in almost 90% of cases. Arthrocentesis had the highest percentage of unsatisfactory results. Repeat dosing should be considered for procedures longer than 20 minutes.

Objective: This study aimed to identify predictive biomarkers for unscheduled emergency department (ED) revisits within 24 hours of discharge in infants diagnosed with acute bronchiolitis (AB).

Methods: A retrospective observational study was conducted on infants diagnosed with AB who visited 3 emergency medical centers between January 2020 and December 2022. The study excluded infants with comorbidities, congenital diseases, and prematurity and infants who revisited the ED after 24 hours of discharge. Demographic data, vital signs, and laboratory results were collected from the medical records. Univariable and multivariable logistic regression analyses were performed on factors with P of less than 0.1 in univariable analysis. Receiver operator curve analysis was used to assess the accuracy of lactate measurements in predicting ED revisits within 24 hours of discharge.

Results: Out of 172 participants, 100 were in the revisit group and 72 in the discharge group. The revisit group was significantly younger and exhibited higher lactate levels, lower pH values, and higher pCO 2 levels compared to the discharge group. Univariable logistic regression identified several factors associated with revisits. Multivariable analysis found that only lactate was a variable correlated with predicting ED revisits (odds ratio, 18.020; 95% confidence interval [CI], 5.764-56.334). The receiver operator curve analysis showed an area under the curve of 0.856, with an optimal lactate cutoff value of 2.15.

Conclusion: Lactate value in infants diagnosed with AB were identified as a potential indicator of predicting unscheduled ED revisits within 24 hours of discharge. The predictive potential of lactate levels holds promise for enhancing prognosis prediction, reducing health care costs, and alleviating ED overcrowding. However, given the study's limitations, a more comprehensive prospective investigation is recommended to validate these findings.