Pediatric emergency care最新文献

This Special Feature article accompanies the manuscript "Site-Level Variation in Tracheal Intubation in the Pediatric Emergency Department: A Report from the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM)" and provides background on the formation, structure, and future directions of the NEAR4PEM collaborative. Established in 2021 as a subgroup of the National Emergency Airway Registry for Children (NEAR4KIDS), NEAR4PEM is a rapidly growing multicenter registry and collaborative focused on advancing the science and practice of airway management in pediatric emergency settings. Participating sites prospectively collect data on pediatric tracheal intubations to characterize practice variability, support quality improvement initiatives, and inform educational efforts in airway management. Since its inception, NEAR4PEM has expanded to include 20 sites across 3 countries, with many additional sites currently onboarding. This Special Feature outlines NEAR4PEM's mission, describes its integrated research, quality, and education initiatives, and highlights the collaborative's vision to expand its reach to a broader spectrum of emergency care settings, ensuring safe, evidence-based airway management for all children, regardless of where they receive care.

Objectives: Learners' pediatric emergency medicine experiences are variable. With computer simulation modules, learners experience rare or high-stakes scenarios on their own time and pace with repetition without the resources associated with traditional simulation. This study compares third-year medical students' knowledge and confidence acquisition after participating in an author-created serious game or analogous traditional in-person simulation of a pediatric septic shock scenario.

Methods: Participants were randomized to the traditional simulation or serious game. They completed a knowledge pretest, assigned simulation with corresponding debriefing, posttest, and survey.

Results: Ninety students enrolled in 11 sessions. While the groups' knowledge acquisition [game mean 4.46 (standard deviation 0.38) vs traditional 3.86 (0.38)] and self-perceived confidence change in managing septic shock ( P = 0.19) were similar, knowledge acquisition did not meet the prespecified threshold proving "noninferiority." The traditional group had greater confidence change in recognizing septic shock ( P = 0.03). The traditional group had higher levels of agreement with "The simulation was realistic" ( P < 0.001). However, both groups similarly agreed with "The simulation experience was enjoyable" ( P = 0.07) and "I would be interested in doing more simulations like this in the future for other medical topics" ( P = 0.36).

Conclusion: Third-year medical students randomized to the created serious game or traditional simulation had similar knowledge acquisition and change in self-perceived confidence for managing septic shock but not in confidence gain for recognizing septic shock. While the traditional group found the experience more realistic, both groups had comparable enjoyment and levels of interest in doing more similar simulations.

Objective: To determine the test characteristics of single breath count (SBC) in differentiating asthma from no asthma, exacerbations from no exacerbations, and to determine the ability of SBC to assess response to treatment.

Methods: This prospective observational study was conducted in the pediatric department of a tertiary care teaching hospital over a 2-year period. Children (6 to 16 y age) were divided into 3 groups: asthma with nonsevere exacerbation (group 1), asthma without exacerbation (group 2), and healthy children (group 3). Baseline tests (spirometry and SBC) were done for all the groups, and posttreatment tests were done for groups 1 and 2. Pulmonary score (PS) was measured in group 1. Receiver operating characteristic (ROC) curves and correlation coefficients were derived.

Results: One hundred sixty-four children (asthma=82, healthy=82) were enrolled (male, 59.8%). The median (IQR) SBC values of the 3 groups at baseline were as follows: group 1: 27 (25-31), group 2: 32 (28-36), and group 3: 35 (31-40). Posttreatment, significant change was noted in group 1 ( P <0.05). All the spirometry parameters showed a significant positive correlation with SBC. A strong negative correlation (ρ=-0.647) was seen between SBC and PS in group 1 ( P <0.001). The area under the curve (AUC) for SBC was 0.71 (95% CI: 0.62-0.84) for differentiating between "exacerbation" and "no exacerbation" ( P =0.014). The cutoff value of SBC was 28 for this differentiation.

Conclusions: SBC, like spirometry and PS, can differentiate asthma exacerbation from no exacerbation (a cutoff of 28 was suggestive). SBC can be used as a simple bedside test to monitor treatment response in children with nonsevere asthma exacerbation.

Objectives: Suicide is a leading cause of death among youth aged 10 to 24. Despite growing attention to suicide prevention, limited research has explored factors linked to persistent positive screens on the Ask Suicide-Screening Questions (ASQ) tool during repeat emergency department (ED) visits. This study aimed to identify sociodemographic and visit-related factors associated with persistent ASQ positivity among pediatric patients.

Methods: We conducted a retrospective chart review of pediatric patients (aged 11 to 18) presenting to a tertiary care children's hospital ED between October 2018 and June 2021. Eligible patients had a positive ASQ at the index visit and at least one subsequent ED visit more than 30 days later and before January 2022. Bivariate analyses and multivariable logistic regression were used to identify factors associated with persistent positive ASQ screening at the second visit.

Results: Of 319 encounters, 31% had persistent positive ASQ responses. Females had higher odds of persistent positivity than males (OR = 2.84, 95% CI: 1.50-5.38). Patients transferred to another facility at the index visit had significantly increased odds of persistent ASQ positivity (OR = 7.70, 95% CI: 1.66-35.71), as did those with at least one mental health follow-up visit (OR = 2.30, 95% CI: 1.14-4.67). Private insurance status and provision of inpatient psychiatric resources at the index visit were associated with persistent ASQ positivity in bivariate analysis.

Conclusions: While ASQ screening is effective for identifying suicide risk, persistent positivity suggests current interventions may be insufficient. Efforts to improve continuity of care, reduce systemic barriers, and implement targeted strategies for high-risk youth are warranted.

Objectives: Interventions to connect pediatric Emergency Department (PED) patients to primary care are needed to improve preventive care access and reduce ED overcrowding. This study aimed to assess the impact of a novel PED-to-primary care referral program on preventive care utilization and ED and hospital visit rates.

Methods: We instituted a new electronic referral program in which clinicians referred PED patients lacking or requesting a new primary care physician (PCP) to a partner federally qualified health center (FQHC) network. We then conducted a retrospective chart review of all referred patients between January 2020 (program inception) and June 2022 to evaluate the program in two ways. For all referrals, we assessed operational metrics: the number of patients referred, reached by phone, scheduled for an appointment, and completed an appointment. For the first 500 referrals, we further evaluated demographic characteristics associated with appointment completion, preventive care services received, and the number of post-referral ED visits and hospitalizations.

Results: Overall, the PED referred 1778 patients. FQHC family navigators successfully contacted 1293 patients within 3 days. Of those contacted, 576 had appointments scheduled, and 372 patients (20.9% of total referrals) completed an appointment within 30 days. Among the first 500 referrals, no demographic characteristics were associated with appointment completion. Patients who completed an appointment presented with immunization delays, abnormal hemoglobin or lead levels, and food insecurity. We found no reduction in ED or hospital utilization postreferral.

Conclusions: While less than one third of referred PED patients completed timely primary care physician appointments, those who did demonstrated significant preventive service needs. Further studies should explore the substantial attrition between PED referral and PCP appointment completion.

Objectives: The optimal approach to perinatal depression (PND) screening is poorly understood. PND is associated with increased health care utilization in children. Parental PND screening during infant pediatric emergency department (PED) visits may improve detection. We aimed to identify and characterize parents in the PED with a positive PND screen and absent previous screening.

Methods: We conducted a prospective survey study on a convenience sample of parents bringing their infants (<12 mo) to our tertiary PED from September to December 2022. We included parents with English or Spanish fluency. We excluded parents of infants who required medical stabilization. Participants completed a survey that included the Edinburgh Postnatal Depression Scale, a validated PND screen. A score of 10 was considered positive. We provided resources as appropriate. We used descriptive statistics, univariate analysis, and a generalized mixed effects model to identify factors associated with a positive screen and an absent previous screening.

Results: Of 452 enrolled parents [387 (85.6%) females, 52 (11.5%) males], 125 (27.7%) screened positive. Gender was not associated with positive screening results. While Asian/Asian American parents and those with a history of mental health conditions or symptoms were more likely to screen positive, about 1 in 4 parents had a positive screen across all parent subgroups. One in 3 subjects reported no previous PND screening.

Conclusions: PED visits offer a unique venue for PND screening, where high-risk parents who may otherwise go unscreened can be targeted. Our finding of a high proportion of positive screens across parent groups emphasizes the importance of universal screening in the PED setting. There is an urgent need to understand and improve the gaps in our current screening efforts.

Objectives: The primary objective was to determine the area under the curve of optic nerve sheath diameter >4.5 mm for detection of raised intracranial pressure in children aged 1 year to 12 years admitted to PICU with neurological signs and symptoms. Our secondary objectives were to compare optic nerve sheath values in study population with age and sex-matched controls and determine change after 30 minutes of osmotherapy.

Methods: One hundred twenty-five children (40 with raised intracranial pressure, 45 without raised intracranial pressure, and 40 non-neurological controls) were enrolled. Optic nerve sheath diameter using point of care ultrasound was measured at admission and 30 minutes after initiation of osmotherapy in patients who received osmotherapy.

Results: Mean optic nerve sheath diameter in children with raised intracranial pressure was 5.48 ± 0.48 mm, while that without raised intracranial pressure was 5.14 ± 0.57 mm and non-neurological controls was 4.54 ± 0.24 mm. A diameter of >4.5 mm was able to detect raised intracranial pressure with sensitivity of 100%, with area under the curve of 0.53. Best cutoff was determined to be 4.92 mm, with sensitivity of 90%, specificity of 46.67% and area under the curve of 0.68. Higher optic nerve sheath diameter was observed with increase in Friesen grading of papilledema. Also, a significant decrease in values was found after 30 minutes of osmotherapy, with no difference between 3% saline and 20% mannitol.

Conclusion: Optic nerve sheath diameter using ultrasound was able to detect raised intracranial pressure with high sensitivity, but low specificity, with optimal cutoff observed as 4.92 mm.

Objectives: Pediatric out-of-hospital cardiac arrest (OHCA) is rare but critical, requiring rapid and effective cardiopulmonary resuscitation (CPR). Delivering high-performance CPR (HPCPR) in the prehospital setting is challenging, especially for EMS clinicians with limited pediatric exposure. This study aimed to assess EMS clinicians' pediatric CPR experience, confidence in HPCPR, and access to CPR feedback systems. A secondary objective was to evaluate perceptions of augmented reality (AR) feedback systems.

Methods: A cross-sectional survey was distributed electronically to EMS clinicians in 5 Maryland counties from January to May 2024. The survey included items on demographics, CPR experience, confidence in pediatric resuscitation, feedback device usage, and opinions on AR-based guidance. Descriptive and comparative analyses were conducted based on clinician type, experience, and administrative role.

Results: Fifty-eight EMS clinicians participated. While 78% had performed pediatric CPR, experience differed significantly by clinician type and years of service. Paramedics (87%) and clinicians with >6 years' experience (87%) had greater exposure than EMTs (46%) and less experienced clinicians (42%) (P<0.05). Confidence in HPCPR was higher for adults (98%) than for infants (84%) and toddlers (83%). Only 52% had access to pediatric CPR feedback devices, although 97% of users reported improved CPR quality. Among those without access, 93% believed feedback would improve performance. Interest in AR feedback was moderate; barriers included cost, reliability, and training.

Conclusions: EMS clinicians vary in pediatric CPR experience and access to performance tools. Expanded pediatric training and real-time feedback technologies may improve prehospital resuscitation outcomes.

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: Acute gastroenteritis (AGE) is one of the most common diseases in children, and detecting dehydration status is important for managing it. Volume depletion and altered urate excretion through the gastrointestinal tract can cause hyperuricemia. This study aimed to evaluate the role of hyperuricemia in assessing the severity of dehydration in children.

Methods: This retrospective study included patients aged 7 to 18 years who were diagnosed with AGE. We used both the clinical dehydration scale and measured amount of weight loss at the time of emergency room visiting to evaluate the dehydration status. Age-based and sex-based reference values of uric acid were used to define hyperuricemia.

Results: Of the 95 patients with AGE, 40 (42.1%) showed moderate-to-severe dehydration. Hyperuricemia was observed in 44 (46.3%) patients and was more common (95.0 vs. 10.9%, P<0.001) in patients with moderate-to-severe dehydration than in those with mild dehydration. In multivariate analysis, hyperuricemia (OR: 5.13; 95% CI: 2.453-10.526) and bicarbonate levels <15 mmol/L (OR: 3.25; 95% CI: 0.225-7.259) were significant factors associated with moderate-to-severe dehydration.

Conclusions: Uric acid levels were correlated with dehydration in children with AGE.