Clinical Pediatric Emergency Medicine最新文献

While injury is the leading cause of death for children, unlike many other fatal disease states injury is also particularly amenable to prevention efforts to decrease its morbidity and mortality. Pediatric emergency medicine physicians have a particularly important vantage point from which to craft and deliver injury prevention interventions. Here we interviewed successful physician advocates in order to summarize collective wisdom for those interested in increasing their own advocacy work or simply wanting to best support those who are. Key themes included the importance of each of the following; clinical experience informing advocacy efforts, use of multiple streams of data to drive research, frequent reassessments of efforts, overcoming funding obstacles, combined interventions, building trust in the community, and learning from previous successes. In addition, experts offered specific advice for advocacy at the individual, community, and national level. All physicians should seek to include advocacy, or the support of advocacy efforts, in their own practice. By seeking out the wisdom of experts we can identify the methods most likely to be effective in changing behaviors and ultimately decrease the impact of injury on our pediatric patients.

More than 80% of pediatric patients who seek emergency care in the United States are seen in general emergency departments. Yet, emergency care systems evolved to address time-sensitive adult-focused conditions such as trauma, stroke, and myocardial infarction, not pediatric-specific needs. Yet, children with emergency conditions also experience significant morbidity and mortality when not managed safely and effectively. This article details the development of emergency care systems and the impact of advocacy efforts on pediatric emergency care, including authorization of the Emergency Medical Services for Children Program. Although significant strides have been made to ensure every emergency department has the infrastructure and competency to care for pediatric patients, high-quality pediatric emergency care depends on the advocacy efforts of clinicians, researchers, educators, and families.

We describe a 5-week-old infant who presented in cardiac arrest and was later found to have intracranial hemorrhage due to late vitamin K deficiency bleeding. The infant had not received vitamin K prophylaxis following a home birth. Because of worsening direct hyperbilirubinemia and transaminitis, she was subsequently found to have biliary atresia. This case allows us to review the differential diagnosis of intracranial hemorrhage in infants and underscores the importance of considering whether infants presenting with any source of bleeding had received vitamin K prophylaxis. As refusal of vitamin K prophylaxis has increased in the United States over the last decade, pediatricians now play an increasingly vital role in promoting strong adherence to universal prophylaxis for newborns in their practice.

Injury is the leading cause of death in children over 1 year of age, causes considerable morbidity, and is a significant source of health care cost. Injury prevention methodology has helped to decrease pediatric injuries over the last several decades; however, significant room for improvement remains. Emergency medicine providers have the expertise and opportunity to participate in injury prevention. Injury risk identification and injury prevention interventions in the emergency department have been increasingly explored over the last decade. This review discusses promising emergency department–based approaches such as safety behavior screening; screening for suicide risk, violence risk, and exposure to firearms; education and interventions; and advocacy opportunities.

Amidst the opioid crisis, acute pain management in pediatric trauma is complicated by the fact that children respond differently to pain than adults. This is largely due to incomplete development of neural networks and immature mechanisms in verbalizing distress. Much of the literature emphasizes that adequate and timely analgesic relief in pediatric patients is necessary to avoid complications of chronic pain. This article analyzes current strategies in nonpharmacologic and pharmacologic alternatives to opioid management in the setting of pediatric trauma. We also acknowledge that, albeit having a lower incidence than in the adult population, opioid use disorders (OUD) are a serious consequence of narcotic prescriptions in adolescent patients, and emergency and primary care providers must remain vigilant of the signs and symptoms of OUD.

Despite recommendations to limit the use of neuroimaging for evaluation of minor head injury and atraumatic headache in children, many children receive unnecessary imaging without clear history or physical exam indications in the emergency department (ED) or other outpatient settings. This overuse of neuroimaging has not previously been explored across clinical settings, nor for the diagnosis of atraumatic headache.

We convened a multi-stakeholder design meeting to discuss reasons for overuse of neuroimaging in children and brainstorm potential interventions to reduce overuse. The meeting included didactic sessions on the risks and benefits of neuroimaging and quality improvement methodology. There were also small group discussions of challenges and potential interventions.

Participants included ED physicians and nurses, radiologists, Medicaid health plan representatives, a pediatric neurologist, a pediatric primary care provider and a parent. Reasons for overuse included family anxiety and expectations for neuroimaging, pediatric phone triage protocols directing patients to the ED for evaluation, time pressures within primary care and the ED clinics, and reluctance among payers to institute prior authorization for ED-based imaging studies. Several potential interventions were identified and organized into three key driver diagrams: one each for primary care, the ED, and Medicaid health plans.

Convening a multi-stakeholder meeting was feasible and resulted in the identification of common reasons for overuse of neuroimaging in children and many potential interventions across clinical settings. Similar multidisciplinary approaches may be helpful for others interested in reducing the overuse of imaging in children.

Discussions from a multi-stakeholder meeting with representation from primary care, pediatric emergency departments, and Medicaid health plans resulted in the identification of common reasons for overuse of neuroimaging in children and many potential interventions across clinical settings.

Vomiting is a common pediatric complaint seen frequently in both pediatric and general emergency departments. Obstructive causes of vomiting are rare outside of the newborn period compared to more benign causes such as viral gastroenteritis. Timely recognition of these rarer causes of obstruction is essential for optimal care. This case highlights a severe presentation of chronic isolated vomiting caused by obstruction. It serves as a strong reminder to emergency care providers that obstruction can occur outside of the newborn period and, if unrecognized, can result in significant morbidity.

Pediatric emergency centers treat millions of unintentional injuries cases every year, and many of these injuries could have potentially been avoided by proper counseling about trauma safety and prevention. Through such discussions, clinicians have the ability to meaningfully decrease the number of these unintentional injuries. Not enough attention has been placed on critically injured children and adolescents who have a substantial burden on health care resources and morbidity. Emergency medicine providers and pediatricians have the responsibility to educate patients and families about proper child passenger safety and to remain up to date on this information. However, numerous barriers still exist for physicians to fully counsel patients and their families about firearms. Pediatric emergency medicine physicians can play a foundational role in the safety, prevention, and treatment of childhood injuries. Clinicians can become effective instructors for injury prevention by using the Haddon Matrix: host, agent, and environment; and the 3 Es of injury prevention: education, engineering, and enforcement of strategies. Legislative changes, educational approaches, and product modifications must come together to effectively achieve this goal. Although the idea of educating families in the emergency department may seem ideal because the immediacy of the current injury may make the families more receptive to the counseling, the integration of primary care physicians is beneficial for regular follow-ups and maintenance.

This is the case of an 11-year-old girl who presented to the emergency department in status epilepticus. The patient had a 2-week prodromal illness of intermittent fevers, malaise, right lower quadrant pain, and right hip pain. Prior laboratory and radiographic evaluations had yielded no etiology for her symptoms. An in-depth social history revealed a recent cat scratch, and bedside ultrasound identified right-sided deep inguinal lymphadenopathy. The suspected diagnosis of Bartonella encephalopathy was confirmed by serology. This report reviews the broad differential for seizures and highlights the importance of a thorough history to provide direction. Additionally, atypical manifestations, diagnosis, and treatment recommendations of cat-scratch disease are reviewed.