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Shelmerdine SC, Arthurs OJ. How to report perinatal and paediatric postmortem CT. Insights Imaging 2024; 15:129. [PMID: 38816589 PMCID: PMC11139809 DOI: 10.1186/s13244-024-01698-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/13/2024] [Indexed: 06/01/2024] Open
Abstract
Postmortem CT (PMCT) has become increasingly accepted alongside skeletal surveys as a critical part of investigation in childhood deaths, either as part of a suite of non-invasive investigations through parental choice, or comprehensive evaluation in a forensic setting. Whilst CT image acquisition and protocols have been published and are relatively standardised, CT imaging reporting remains highly variable, largely dependent upon reporter experience and expertise. The main "risk" in PMCT is the over-interpretation of normal physiological changes on imaging as pathological, potentially leading to misdiagnosis or overdiagnosis of the disease. In this article, we present a pragmatic standardised reporting framework, developed over a decade of PMCT reporting in children in our institution, with examples of positive and negative findings, so that it may aid in the interpretation of PMCT images with those less experienced in paediatric findings and postmortem imaging. CRITICAL RELEVANCE STATEMENT: Standardised reporting using a common framework with a sound understanding of normal postmortem changes that occur in children are crucial in avoiding common reporting errors at postmortem CT. KEY POINTS: Familiarity with postmortem imaging is required for useful image reporting, and reporting standards vary. Understanding normal postmortem change from significant abnormalities requires training and experience. Following a template may remind reporters what to include and help improve performance.
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Affiliation(s)
- Susan C Shelmerdine
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
- UCL Great Ormond Street Institute of Child Health, London, UK.
- Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK.
| | - Owen J Arthurs
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
- Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
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Runkle AP, Gray J, Cabrera-Thurman MK, Frey M, Hoehn EF, Kerrey BT, Vukovic AA. Implementation of a Pediatric Emergency Department Cardiopulmonary Resuscitation Quality Bundle. Pediatrics 2022; 150:188524. [PMID: 35909151 DOI: 10.1542/peds.2021-055462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We have previously demonstrated that standardized handoff from prehospital to hospital clinicians can improve cardiopulmonary resuscitation performance for out-of-hospital cardiac arrest (OHCA) patients in a pediatric emergency department (ED). We leveraged our previous quality improvement initiative to standardize performance of a bundle of 5 discrete aspects of resuscitation for OHCA patients: intravenous or intraosseous catheter (IV/IO) access, epinephrine administration, advanced airway placement, end-tidal capnography (ETCO2) application, and cardiac rhythm verbalization. We aimed to reduce time to completion of the bundle from 302 seconds at baseline to less than 120 seconds within 1 year. METHODS A multidisciplinary team performed video-based review of actual OHCA resuscitations in our pediatric ED. We designed interventions aimed at key drivers of bundle performance. Interventions included specific roles and responsibilities and a standardized choreography for each bundle element. To assess the effect of the interventions, time to performance of each bundle element was measured by standardized review of video recordings from our resuscitation bay. Balancing measures were time off the chest and time to defibrillator pad placement. RESULTS We analyzed 56 cases of OHCA from May 2019 through May 2021. Time to bundle completion improved from a baseline of 302 seconds to 147 seconds. Four of 5 individual bundle elements also demonstrated significant improvement. These improvements were sustained without any negative impact on balancing measures. CONCLUSIONS Standardized choreography for the initial minutes of ED cardiac arrest resuscitation shows promise to decrease time to crucial interventions in children presenting to the pediatric ED with OHCA.
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Affiliation(s)
- Anne P Runkle
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James Gray
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Mary Frey
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin F Hoehn
- Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Adam A Vukovic
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Besserer F, Kawano T, Dirk J, Meckler G, Tijssen JA, DeCaen A, Scheuermeyer F, Beno S, Christenson J, Grunau B. The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest. Resuscitation 2021; 167:49-57. [PMID: 34389454 DOI: 10.1016/j.resuscitation.2021.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/10/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. METHODS We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. RESULTS There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86). CONCLUSIONS Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.
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Affiliation(s)
- Floyd Besserer
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada.
| | - Takahisa Kawano
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
| | - Justin Dirk
- School of Medicine, Queen's University, Ontario, Canada
| | - Garth Meckler
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Department of Pediatrics, University of British Columbia, Canada
| | - Janice A Tijssen
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Paediatrics, Western University, Canada
| | - Allan DeCaen
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Paediatrics, University of Alberta, Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
| | - Suzanne Beno
- Department of Paediatrics, University of Toronto, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
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Capobianco S, Weiss M, Schraner T, Stimec J, Neuhaus K, Neuhaus D. Checking the basis of intraosseous access-Radiological study on tibial dimensions in the pediatric population. Paediatr Anaesth 2020; 30:1116-1123. [PMID: 32720412 DOI: 10.1111/pan.13979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malposition of intraosseous needles in pediatric patients is frequently reported. Incorrect needle length and penetration depth related to the puncture site and level are possible causes. AIMS Aim of this study was to analyze anatomic dimensions of the proximal tibia in the pediatric population with respect to intraosseous needle placement and needle tip position. METHODS Plain lower leg radiographs of children aged from birth to 16 years of age were analyzed. Pretibial tissue layer, cortical bone thickness, and the diameter of the medullary cavity were measured at two different puncture levels. Data were analyzed as descriptive statistics and by polynomial regression plots and set in context to commonly used EZ-IO® needle lengths of 15 and 25 mm. RESULTS Radiographs from 190 patients (104 boys/86 girls) were included. When fully inserted to skin level, up to 10.5% of needles do not reach medullary cavity at one and 18.5% at two patient's fingerbreadths distal to tibial tuberosity. The opposite cortical wall is touched or penetrated in 16% and 25%, respectively. Up to 96% of too deep needle tip positions occur in children younger than 24 months, as do too superficial tip positions in 59%. CONCLUSIONS Puncture level and needle length have a great influence on potential needle tip positions. Infants and toddlers are at highest risk for malpositioning. Due to relevant growth-related differences in tibial anatomy, an age-related and well-reflected approach is crucial to successfully establish intraosseous access.
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Affiliation(s)
- Stéphanie Capobianco
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Thomas Schraner
- Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland.,Department of Diagnostic Imaging, University Children's Hospital, Zurich, Switzerland
| | - Jennifer Stimec
- Division of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kathrin Neuhaus
- Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland.,Division of Plastic and Reconstructive Surgery, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Diego Neuhaus
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
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Gould SW, Harty MP, Givler NE, Christensen TE, Curtin RN, Harcke HT. Pediatric postmortem computed tomography: initial experience at a children's hospital in the United States. Pediatr Radiol 2019; 49:1113-1129. [PMID: 31201439 DOI: 10.1007/s00247-019-04433-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/17/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022]
Abstract
Postmortem CT might provide valuable information in determining the cause of death and understanding disease processes, particularly when combined with traditional autopsy. Pediatric applications of postmortem imaging represent a new and rapidly growing field. We describe our experience in establishing a pediatric postmortem CT program and present a discussion of the distinct challenges in developing this type of program in the United States of America, where forensic practice varies from other countries. We give a brief overview of recent literature along with the common imaging findings on postmortem CT that can simulate antemortem pathology.
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Affiliation(s)
- Sharon W Gould
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA.
| | - M Patricia Harty
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Nicole E Givler
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Theresa E Christensen
- Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Riley N Curtin
- Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Howard T Harcke
- Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA
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Gould SW, Harty MP, Givler N, Christensen T, Harcke HT. Pediatric Postmortem CT: Initial Experience at a Tertiary Care Children’s Hospital. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0250-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Arthurs OJ, Hutchinson JC, Sebire NJ. Current issues in postmortem imaging of perinatal and forensic childhood deaths. Forensic Sci Med Pathol 2017; 13:58-66. [PMID: 28083782 PMCID: PMC5306347 DOI: 10.1007/s12024-016-9821-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 11/27/2022]
Abstract
Perinatal autopsy practice is undergoing a state of change with the introduction of evidence-based cross-sectional imaging, driven primarily by parental choice. In particular, the introduction of post mortem magnetic resonance imaging (PMMR) has helped to advance less-invasive perinatal autopsy in the United Kingdom (UK) and Europe. However, there are limitations to PMMR and other imaging techniques which need to be overcome, particularly with regard to imaging very small fetuses. Imaging is also now increasingly used to investigate particular deaths in childhood, such as suspected non-accidental injury (NAI) and sudden unexpected death in infancy (SUDI). Here we focus on current topical developments the field, with particular emphasis on the application of imaging to perinatal autopsy, and pediatric forensic deaths. Different imaging modalities and their relative advantages and disadvantages are discussed, together with other benefits of more advanced cross-sectional imaging which currently lie in the research domain. Whilst variations in local imaging service provision and need may determine different practice patterns, and access to machines and professionals with appropriate expertise and experience to correctly interpret the findings may limit current practices, we propose that gold standard perinatal and pediatric autopsy services would include complete PMMR imaging prior to autopsy, with PMCT in suspicious childhood deaths. This approach would provide maximal diagnostic yield to the pathologist, forensic investigator and most importantly, the parents.
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Affiliation(s)
- Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
- Institute of Child Health, UCL, London, UK.
| | - John C Hutchinson
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Neil J Sebire
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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