PEM Fellows Journal Watch Quarterly
Your up-to-date summaries of relevant pediatric emergency medicine literature from the comfort of you home
Editor-in-Chief – Jeremiah Smith
All Articles are archived @ http://www.cmcedmasters.com/pem-journal-watch.html
“No, research isn’t a self-inflicted injury”
Emergency Department Visits for Self-Inflicted Injuries in Adolescents
Synopsis – This study analyzed the National Trauma Data Bank for the years 2009 to 2012 to examine trends in self-inflicted injury mechanisms and to identify factors associated with increased risk for self-inflicted injuries. ED visits for SII increased from 1.1% to 1.6% but self-inflicted firearm visits decreased from 27.3% to 21.9% though this was still the most common mechanism in males (females were cut/pierce). Odds of SII were higher in females, older adolescents, adolescents with comorbid conditions, and Asian adolescents but lower in African American adolescents. Adolescents with public or self-pay insurance had higher odds for SII than those with private insurance. If the adolescent had a history of previous SII, the odds of death from another injury is 12.9 (95% CI 6.78-24.6).
"Anyone else realize that Chad could smile"
Simulation in Pediatric Emergency Medicine Fellowships
Synopsis – This was a survey developed by consensus methods distributed to PEM program directors via anonymous online survey to describe the use of simulation and its barriers for implementation in PEM fellowship programs. They found that 97% of PEM fellowship programs use simulation-based training and the remaining 3% planned to use it within 2 years. The largest barriers to implementation seen were lack of faculty time, faculty simulation experience, limited support for learner attendance, and lack of established curricula. Most focus on resuscitation, procedures, and teamwork/communication.
“They should’ve looked at the OR for subtle nystagmus that only Randy can see”
Prevalence of and Risk Factors for Intracranial Abnormalities in Unprovoked Seizures
Synopsis – This was a 6-center prospective study attempting to determine the prevalence and risks factors associated with clinically relevant intracranial abnormalities in children with first time, unprovoked seizures. They found that 11.3% (95% CI 8%-14.6%) had clinically relevant intracranial abnormalities but only 0.8% (95% CI 0.1%-1.8%) required emergent/urgent intervention. Using logistic regression analysis, they found a high-risk past medical history had an OR of 9.2 (95%CI 2.4-35.7) and any focal aspect to seizure had an OR of 2.5 (95% CI 1.2-5.3).
“Okay, now I understand why Chad was smiling”
Quality Improvement Effort to Reduce Cranial CTs for Children With Minor Blunt Head Trauma
Synopsis – This was a designed and implemented QI effort using an evidence-based guideline as well as individual feedback to decrease head CT use for children with minor head injuries. They had an initial head CT rate of 21% and had an absolute reduction of 6% (95% CI 3% - 9%) in head CT rates by implementing their evidence based guideline and an additional absolute reduction of 6% (95% CI 4%-8%) using individual provider feedback with providers continuing to order head CTs in children with minor head injuries. None of the children discharged from the ED required repeat admission within 72 hours of initial evaluation.
“Every time a CG4 is ordered, an Emily rolls her eyes”
Use of Serum Bicarbonate to Substitute for Venous pH in New-Onset Diabetes
Synopsis – This is a retrospective study using linear regression to assess serum HCO3 as a predictor of venous pH and to classify severity of DKA. Using a HCO3 cutoff of <18 mmol/L had a sensitivity of 91.8% and specificity of 91.7% for detecting a pH <7.3 (used to diagnosis DKA). A HCO3 < 8 had a sensitivity of 95.2 % and specificity of 96.7 % for detecting a pH <7.1 (severe DKA).
Pediatric Emergency Care
“Magill is from Florida, I’m just saying”
Child Mental Health Services in the Emergency Department: Disparities in Access
Synposis – This was a retrospective study using data from a publicly available deidentified data set to evaluate the use of the pediatric ED for mental health services in Florida. In Florida, 2.4% of all ED visits by children with Medicaid were for a psychiatric complaint though this is thought to be an understatement. Unsurprisingly, the uninsured and underinsured were more likely to use the ED for psychiatric issues. White children were found to use the ED for psychiatric complaints more often and the most common diagnosis was non-dependent drug abuse. Males were also more often to be evaluated in the ED for a mental health issue.
“An electrifying read!”
The Use of Automated External Defibrillators in Infants - A Report From the American Red Cross Scientific Advisory Council
Synopsis - This was a retrospective literature review of the Cochrane Review and PubMed by the American Red Cross evaluating the sensitivity of AEDs for pediatric rhythms, accuracy of evaluation, and how often the AED advised shock when appropriate and when not appropriate. They also attempted to determine if there was a "toxic dose" of electricity when shock was applied since pediatric pads are not always readily available. VF was recognized accurately in 95-100% of cases with a sensitivity up to 100% but only 50-100% sensitivity for rapid VT (though small numbers in the case of 50% sensitivity). No shock was advised in non-shockable rhythms in 95-100%. Most AEDs also recognized SVT most of the time. Most studies showed 2J/kg to be sufficient for defibrillation unless the arrest was prolonged. Few studies evaluating proper dosage of electricity but a few studies showed myocardial dysfunction after biphasic shocks that normalized after 4 hours.
“Anyone care to show me where D2.5 is on the 90% page”
Effects of Rapid Intravenous Rehydration in Children With Mild-to-Moderate Dehydration
Synopsis - This was a prospective, observational, descriptive study in 2 tertiary care hospitals in Spain evaluating admission rates of children with mild to moderate dehydration after rapid IV bolus with 2.5% dextrose in the children's ED. IV rehydration was successful in 83.1% of patients but 16.8% required hospitalization for persistent vomiting. They did find a statistically significant decrease in the level of ketonemia and uremia but no change in sodium, chloride, potassium, or osmolarity values.
“I still think a lollipop is better”
Expedited Delivery of Pain Medication for Long-Bone Fractures Using an Intranasal Fentanyl Clinical Pathway
Synopsis - This was initially a retrospective chart review looking at usage of intranasal fentanyl in the children's ED prior to protocol implementation. After this, they instituted a prospective single center study comparing intranasal fentanyl vs intravenous morphine. They found that 20% more patients who received intravenous morphine required a second dose vs 9% for intranasal fentanyl. A pain score decrease within 10 minutes was found in 14% of children receiving morphine and 26% with fentanyl but the study was underpowered for this outcome. There was a statistically decreased time to administration for fentanyl and a higher percentage of the fentanyl children were taken to the OR.
Academic Emergency Medicine
“Is there anything ultrasound can’t do”
Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis
Synopsis - This was a systematic review evaluating ultrasound characteristics (sensitivity and specificity) when evaluating for soft tissue foreign body. They found an overall sensitivity of 72% (95%CI 57-83%) and specificity 92% (95% CI 88-95%). They found that it had a sensitivity of 96.7% (95%CI 90-99.1%) and specificity of 84.2% (95%CI 72.6-92.1%) for a wooden foreign body. The articles had a high degree of heterogeneity (I2 90% 95%CI 80-100%). They found that the overall sensitivity and specificity found was equivalent or slightly better than history and radiograph.
“Only Canada can have “after-hours” surgery”
Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals
Synopsis - This was a multi-center retrospective chart review across 12 tertiary care Canadian hospitals evaluating practice variations around diagnosis and management of pediatric appendicitis in children admitted from an emergency department. The primary outcome evaluated was performance of appendectomy after hours (00:01-08:00) and secondary outcomes included: negative appendectomy rate, perforation rate, rate of laboratory or imaging studies, rate of analgesia use in ED, and rate of antibiotics use in ED. They found 13.9% (95%CI 7.1-21.6%) received after-hours surgery and the overall perforation rate was 17.4% but not associated with rates of after-hour surgery. ~97% of patients received CBC and 80% had a UA performed. CRP and BCx were performed in <20% of patients. Imaging was performed in 77.5% of patients and 67% of those were ultrasound and 3.6% were abdominal CT. >33% of children went to the OR for appendectomy without imaging and the negative appendectomy rate was 6.8%. Only 43% received narcotic pain control and 67% received antibiotics in the ED. There was considerable practice variability among all sites.
“Real men of genius question that head CT use”
Emergency Department Visits and Head Computed Tomography Utilization for Concussion Patients From 2006 to 2011
Synopsis - This was a cross-sectional analysis of the Nationwide Emergency Department Sample (NEDS) from 2006-2011 looking at the epidemiology of concussion and rates of head CT. They found a national incidence of concussion visits has increased 28.1% and is now 239 visits per 100,000 person-years. Head CT use has increased by 36% though overall injury severity decreased 66.4%. Patients discharged from the ED with a concussion increased from 78% to 87%.
“Pre-procedural checklist at bedside, check”
Continuing Medical Education Activity in Academic Emergency Medicine
Synopsis – This is a single center before-and-after evaluation of intubation related complications in trauma patients with the implementation of a pre-procedural checklist. They found 1.5% intubation-related complications during the post-checklist time period compared to 9.2% before the checklist was implemented. Adherence to safety measures also improved from 17.1% to 69.2%. Paralysis-to-intubation time decreased post-checklist though their IQRs did overlap.
Ultrasound Accurately Identifies Soft Tissue Foreign Bodies in a Live Anesthetized Porcine Model
Synopsis – This study inserted wood, metal, or glass foreign bodies into anesthetized pigs to examine the test characteristics of US for foreign body evaluation in living tissue and whether hematoma or edema improved diagnostic accuracy. Physical exam and radiographs miss up to 38% of retained foreign bodies but they found ultrasound had a sensitivity of 85-88% (95%CI 79-94%) and specificity of 83-86% (95%CI 73-98%). Two hours after placement of the foreign body, the sensitivity was 87% (95%CI 82-93#) and specificity was 89% (95%CI 81-97%) with only 8% of them developing surrounding edema.
Annals of Emergency Medicine
“I like money, I have a little in a jar on my fridge. I want more money, that’s where you come in”
Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations
Synopsis - This was a prospective, block-randomized crossover simulation study evaluating the use of color-coded prefilled medical syringes decreased medical errors and time to treat. The author has a pending patent using prefilled medical syringes that color coded using the Broselow Tape coloring coding scheme. Errors were made in 26% (95%CI 19-35%) of patients using the conventional method and 65% of those were considered critical errors. Errors were made in only 4% (95%CI 1-9%) when using the pre-filled color coded medicine syringes. Time from preparation to delivery was 19 seconds vs 47seconds using the color coded syringes vs conventional method as well.
“Nothing like a contrast chaser to go with some abdominal pain”
Use of Oral Contrast for Abdominal Computed Tomography in Children With Blunt Torso Trauma
Synopsis - This was a secondary analysis using the PECARN dataset for blunt abdominal trauma evaluating the accuracy of identifying intra-abdominal injuries in children after blunt abdominal trauma using CT scans with IV contrast alone vs IV and PO contrast. 20% of patients received both IV and PO contrast and 80% received IV alone. 13% of patients with both had intra-abdominal injuries and 14% with IV contrast only. No significant differences were found in sensitivity of IV alone (97.7% 95%CI 96.1-98.8%) vs IV + PO (99.2% 95%CI 95.7-100%). Specificity for IV + PO was 84.7% (95%CI 82.2-87%) and IV alone was 80.8% (95%CI 79.4-82.1%)
“What a pain in the neck”
Can a Clinical Prediction Rule Reliably Predict Pediatric Bacterial Meningitis?
Synopsis - This was a systematic review attempting to assess if there is a clinical guideline that would reliably identify patients with true bacterial meningitis. They found that cases of bacterial meningitis have significantly decreased since H. flu and S. Pneumonia vaccinations and most patients are ultimately diagnosed with aseptic meningitis after receiving empiric antibiotics. None of the articles found were able to reliably predict bacterial vs viral meningitis. LP and empiric antibiotics are still necessary while awaiting culture results.
“Haven’t they heard of heal with steel”
Can Children With Uncomplicated Acute Appendicitis Be Treated With Antibiotics Instead of an Appendectomy?
Synopsis - This was a literature review that evaluated the use of non-operative management for uncomplicated acute appendicitis. They found that there was a 2.6-5.7% complication rate associated with non-perforated appendectomies. They found that 4 studies have been performed that have evaluated non-operative management as opposed to appendectomy. They found an initial failure rate using antibiotics alone of 6-25% and a 1 year failure rate of 19% (95%CI 7-43%). One study found a shorter out-of-school time with antibiotics vs appendectomy and appendectomy was not found to have a statistically significant absolute risk reduction.
Journal of Trauma
“New study shows your head and your body probably shouldn’t go to the same hospital”
Concordance of performance metrics among US trauma centers caring for injured children
Synopsis - This was an observational study collecting data from 150 US trauma centers to evaluate center-level performance relative to peers is consistent across four performance metrics: in-hospital mortality, non-operative management of blunt splenic injury, use of ICP monitors after severe TBI, and craniotomy for children with severe TBI and associated subdural/epidural hematoma. Multivariable regression was used to obtain center-specific odds ratios comparing each quality indicator to mortality. They found that only three centers performed similarly in all four metrics. Overall there was a general lack of concordance among indicators with the greatest variety being seen with ICP monitoring.
“One dataset to rule them all”
Management of children with solid organ injuries after blunt torso trauma
Synopsis - This was a secondary analysis from a prospective observational study conducted by PECARN to determine solid organ injury that required acute intervention and disposition from the ED. They found that 5% had solid organ injury and splenic injuries were the most common. Isolated solid organ injuries were identified in 69% of these patients and treatment included: laparotomy 4.1%, angiographic embolization 1.4%, and blood transfusion 11%. Laparotomy rates were higher in free-standing children's hospitals. The rate of ICU admission was 9-73% and only 3% were sent directly home and an additional 4% had ED observation. There was a low rate of intervention associated with solid organ injuries and considerable variation in ED disposition, differing from published guidelines. Interestingly, they found that 75% of children with an isolated solid organ injury had intraperitoneal fluid but only 25% had a finding on FAST exam.
“Sort of unsure why the pathway didn’t work, really unsure why you throw on the 1 yard line”
Pediatric solid organ injury operative interventions and outcomes at Harborview Medical Center, before and after introduction of a solid organ injury pathway for pediatrics
Synopsis - This was a retrospective chart review that attempted to compare the proportion of patients undergoing operative intervention before and after the implementation of a clinical pathway developed to standardize care of solid organ injury. Secondary outcomes included length of stay and mortality. They found that the proportion of patient with spleen injury undergoing splenectomy and the proportion of patients undergoing abdominal operative intervention did not change with implementation of a clinical pathway. They did find that institution of a clinical pathway decreased mortality among children with non-isolated injury as well as median length of stay. They were unsure if this could be attributed to the implementation of the clinical pathway.
Pediatric EM Blog
Pediatric EM Fellows at CMC/Levine Children's Hospital.
Disclaimer: All images are the sole property of CMC Emergency Medicine Residency and cannot be reproduced without written consent. Patient identifiers have been redacted/changed or patient consent has been obtained. Information contained in this blog is the opinion of the authors and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.