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Molina Gutiérrez MÁ, Ventas Maestre R, Rodríguez Sánchez C, Díaz de Terán J. Clinical characterization of pediatric acute confusional migraine: a single-center case series. Acta Neurol Belg 2024:10.1007/s13760-024-02582-1. [PMID: 38755330 DOI: 10.1007/s13760-024-02582-1] [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: 09/07/2023] [Accepted: 05/10/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Acute confusional migraine (ACM) is a rare disorder characteristic of pediatric patients. Our objective was to describe the clinical characteristics of patients diagnosed with ACM who visited our pediatric emergency department (PED). METHODS This study was a retrospective review of children who presented to our PED between January 2012 and December 2022 with a discharge diagnosis of ACM. RESULTS During the study period, 23 patients were enrolled: 11 males (47.8%) and 12 females (52.2%); median age was 10.8 years (IQR: 8.3-13.6). Eight patients reported a history of headache. The median length of stay of PED was 4.7 h. Onset was abrupt (less than 12 h) in 100% of cases. Changes in the level and content of consciousness occurred in 47.8% and 91.3% of patients, respectively; confusion (73.9%) was the most common neurological manifestation. Eighteen patients had urgent brain CT scans, none showing pathological findings. Four patients required benzodiazepines to control their psychomotor agitation. Nine patients were hospitalized, including one in the intensive care unit. Two patients underwent MRI and one patient underwent EEG during hospitalization, with normal results. DISCUSSION ACM is a rare condition in pediatric neurology characterized by acute onset of confusion or altered mental status before, during, or after migraine headache. Clinical features overlap with other neurological disorders, making diagnosis challenging. To improve the diagnosis, treatment, and research of AMC, it is essential to include it in the International Classification of Headache Disorders and establish standardized diagnostic criteria.
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Affiliation(s)
| | - Raquel Ventas Maestre
- Pediatric Emergency Department, Hospital Universitario la Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - César Rodríguez Sánchez
- Pediatric Department, Hospital Universitario del Vinalopó, Carrer Tonico Sansano Mora, 14, 03293, Elx, Alicante, Spain
| | - Javier Díaz de Terán
- Headache Unit, Department of Neurology, Hospital Universitario de la Paz, Madrid, Spain
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Azouz H, Muhammed W, Abd Elmaksoud M. Clinical Characteristics and Appropriateness of Investigations in Children With Headaches at the Emergency Department. Pediatr Neurol 2024; 154:58-65. [PMID: 38531164 DOI: 10.1016/j.pediatrneurol.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/25/2024] [Accepted: 02/23/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Identifying the cause of headaches in pediatric emergency departments (PEDs) can be challenging due to the lack of comprehensive research. This study aims to identify the frequency, characteristics, and unnecessary diagnostic procedures of patients with headaches in the PED setting. METHODS A six-month cross-sectional study was conducted at the PED of Alexandria University Children's Hospital, including all children with headaches. Children were classified as having primary headache (PH), secondary benign headache (SBH), and secondary serious headache (SSH) according to predetermined criteria. Logistic regression was employed to analyze the risk factors associated with SSH. RESULTS A total of 164 visits to the PED were recorded, out of a total of 22,662 visits, accounting for approximately 0.72% of all visits and 1.17% of the total number of children admitted. PH was the most common cause, accounting for 61.0% of cases, followed by SSH with 24.4%, whereas SBH was the least common with 13.4%. Abnormal neurological examination (odds ratio, 53.752 [1.628 to 1774.442], P = 0.026∗) was found to have a strong and statistically significant association with SSH in the multivariate analysis. Regarding the appropriateness of the investigations conducted, it was found that over half (66.5%) of the cases had unnecessary neuroimaging, with 52% of these cases being children with PH. CONCLUSIONS Headaches in children are commonly reported during visits to the PED. PH was the most prevalent, followed by SSH, whereas SBH was the least common. Many of the children received inaccurate first diagnoses and performed unnecessary laboratory tests, neuroimaging, and other tests, mostly electroencephalography.
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Affiliation(s)
- Hanan Azouz
- Neurology Unit, Pediatrics Department, Alexandria University, Alexandria, Egypt
| | - Wafaa Muhammed
- Neurology Unit, Pediatrics Department, Alexandria University, Alexandria, Egypt
| | - Marwa Abd Elmaksoud
- Neurology Unit, Pediatrics Department, Alexandria University, Alexandria, Egypt.
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Tsze DS, Kuppermann N, Casper TC, Barney BJ, Richer LP, Liberman DB, Okada PJ, Morris CR, Myers SR, Soung JK, Mistry RD, Babcock L, Spencer SP, Johnson MD, Klein EJ, Quayle KS, Steele DW, Cruz AT, Rogers AJ, Thomas DG, Grupp-Phelan JM, Johnson TJ, Dayan PS. Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol. BMJ Open 2023; 13:e079040. [PMID: 37993148 PMCID: PMC10668138 DOI: 10.1136/bmjopen-2023-079040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/16/2023] [Indexed: 11/24/2023] Open
Abstract
INTRODUCTION Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.
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Affiliation(s)
- Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, University of California Davis Health, Sacramento, California, USA
| | - T Charles Casper
- Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Bradley J Barney
- Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lawrence P Richer
- Women and Children's Health Research Institute, Edmonton, Alberta, Canada
- Department of Pediatrics, Division of Neurology, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Danica B Liberman
- Departments of Pediatrics and Population and Public Health Sciences, Division of Emergency and Transport Medicine, University of Southern California Keck School of Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Pamela J Okada
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Claudia R Morris
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sage R Myers
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jane K Soung
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rakesh D Mistry
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lynn Babcock
- Department of Pediatrics, Division of Emergency Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sandra P Spencer
- Department of Pediatrics, Division of Emergency Medicine, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michael D Johnson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eileen J Klein
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kimberly S Quayle
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Dale W Steele
- Departments of Emergency Medicine, Pediatrics and Health Services, Policy & Practice, Warren Alpert Medical School and School of Public Health of Brown University, Providence, Rhode Island, USA
| | - Andrea T Cruz
- Department of Pediatrics, Divisions of Emergency Medicine & Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Danny G Thomas
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Tiffani J Johnson
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, University of California Davis Health, Sacramento, California, USA
| | - Peter S Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Cappellari AM, Bruschi G, Beretta GB, Molisso MT, Bertolozzi G. How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department? CHILDREN (BASEL, SWITZERLAND) 2023; 10:1837. [PMID: 38136039 PMCID: PMC10742139 DOI: 10.3390/children10121837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.
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Affiliation(s)
- Alberto M. Cappellari
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gaia Bruschi
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Gisella B. Beretta
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Maria T. Molisso
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Giuseppe Bertolozzi
- Pediatric Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
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Rodriguez NM, Mower WR, Raja AS, Gupta M, Montoy JC, Parry B, Chan V, Wong AHK, Wilcox J, Quiñones A, Rodriguez RM. Accuracy of physician gestalt in prediction of significant abdominal and pelvic injury in adult blunt trauma patients. Acad Emerg Med 2023; 30:1039-1046. [PMID: 37363986 DOI: 10.1111/acem.14768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Focusing on potential missed injury rates and sensitivity of low-risk of injury predictions, we sought to evaluate the accuracy of physician gestalt in predicting clinically significant injury (CSI) in the abdomen and pelvis among blunt trauma patients presenting to the emergency department (ED). METHODS We collected gestalt data on physicians caring for adult blunt trauma patients who received abdominal/pelvic computed tomography (CT) at three Level I and one Level II trauma centers. The primary outcome of CSI was defined as injury on abdominal/pelvic CT requiring hospitalization or intervention. Physicians evaluating trauma patients estimated the likelihood of CSI prior to abdominal/pelvic CT review (response choices: <2%, 2%-10%, 11%-20%, 21%-40%, >40%). We evaluated potential missed injury rates (prevalence of CSI) and sensitivity for prediction categories, as well as calibration and area under the receiver operating characteristic (AUROC) curve for overall physician gestalt. RESULTS Of 2030 patients, 402 (20%) had an injury on abdominal/pelvic CT and 270 (13%) had CSI. The <2% risk of CSI gestalt cutoff had a potential missed injury rate of 5.6% and a sensitivity of 95.2% (95% confidence interval [CI] 91.7%-97.3%). The 0%-10% cutoff of CSI gestalt had a potential missed injury rate of 6.3% (95% CI, 5.0%-7.9%) and a sensitivity of 75.2% (95% CI 69.5%-80.1%). With an overall AUROC of 0.699 (95% CI 0.679-0.719), physician gestalt was moderately accurate and calibrated for the midranges of predicted risk but poorly calibrated at the extremes. CONCLUSIONS Physician gestalt for the prediction of adult abdominal and pelvic CSI is moderately accurate and calibrated. However, the potential missed CSI rate and low sensitivity of the low perceived risk of injury cutoffs indicate that gestalt by itself is insufficient to direct selective abdominal/pelvic CT use in adult blunt trauma patient evaluation.
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Affiliation(s)
| | | | - Ali S Raja
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Malkeet Gupta
- University of California, Los Angeles, California, USA
- Antelope Valley Medical Center, Lancaster, California, USA
| | | | - Blair Parry
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Virginia Chan
- University of California, San Francisco, California, USA
| | | | - James Wilcox
- Antelope Valley Medical Center, Lancaster, California, USA
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Lenglart L, Monteil C, Spreafico E, Moulding T, Titomanlio L. Sudden onset headaches in paediatric emergency departments: diagnosis and management. Ital J Pediatr 2023; 49:122. [PMID: 37710275 PMCID: PMC10503087 DOI: 10.1186/s13052-023-01526-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
Headache is one of the most common pain syndromes in the paediatric population. Headaches are classified as primary (migraine, tension-type headaches, trigeminal autonomic cephalalgia and other primary headaches) or secondary (e.g. post-traumatic). Non-febrile, non-traumatic headaches represent 1% of all paediatric emergency departments (PED) visits. Many patients present with an acute, moderate to severe pain, sometimes with a sudden onset. Sudden onset headache can be the main symptom of life-threatening neurological conditions as well as a sign of primary headaches such as thunderclap or stabbing headaches. This review aims to describe the presentation of sudden primary headaches in children, in order to help the physician to provide effective management in the emergency setting.
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Affiliation(s)
- Léa Lenglart
- Paediatric Emergency Department, APHP - Hopital Robert Debré, 48 Boulevard Serurier, Paris, 75019, France.
| | - Cécile Monteil
- Paediatric Emergency Department, APHP - Hopital Robert Debré, 48 Boulevard Serurier, Paris, 75019, France
| | - Eugenia Spreafico
- Paediatric Department, IRCCS Fondazione Policlinico S. Matteo, University of Pavia, Pavia, Italy
| | - Thomas Moulding
- Paediatric Department, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Luigi Titomanlio
- Paediatric Emergency Department, APHP - Hopital Robert Debré, 48 Boulevard Serurier, Paris, 75019, France
- Paediatric Migraine and Neurovascular Diseases Unit, APHP - Hopital Robert Debré, Paris, France
- Paris University, INSERM U1141, DHU Protect, Paris, France
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Boutin A, Gouin S, Bailey B, Lebel D, Gravel J. Additive Value of Intranasal Fentanyl on Ibuprofen for Pain Management of Children With Moderate to Severe Headaches: A Randomized Controlled Trial. J Emerg Med 2023; 65:e119-e131. [PMID: 37474344 DOI: 10.1016/j.jemermed.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/20/2023] [Accepted: 04/19/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Few studies have evaluated the rapid pain improvement provided by medications for children presenting to an emergency department (ED) with headaches. OBJECTIVE Our aim was to evaluate pain reduction provided by intranasal fentanyl (INF) compared with placebo in addition to ibuprofen. METHODS A single-center, double-blinded, randomized, placebo-controlled clinical trial was conducted in a tertiary care pediatric ED. All children aged 8-17 years presenting with a moderate to severe headache were eligible. Study participants were randomly allocated to receive INF 1.5 µg/kg (maximum dose of 100 µg) or similar placebo solution. Co-administration of oral ibuprofen 10 mg/kg (maximum dose of 600 mg) was also provided. The primary outcome was the mean pain rating reduction at 15 min. RESULTS Among the 62 participants, the median age was 14 years (interquartile range [IQR] 12-16 years in both groups) and the median initial visual analog scale (VAS) score was 64 (IQR 55-72 in the intervention group; IQR 50-81 in the control group). There was no difference in the mean pain score reduction at 15 min between the two groups (mean difference 2 mm; 95% CI -7 to 11 mm). Mean VAS score reductions were also similar at 30 and 60 min. Adverse events were more frequent in the INF group (risk ratio 2.8; 95% CI 1.29 to 6.22), but all events were minor and transient. No significant differences were found in other outcomes. CONCLUSIONS This study did not find a benefit from INF for providing additional pain relief in children presenting to ED with headaches.
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Affiliation(s)
- Ariane Boutin
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada.
| | - Serge Gouin
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Benoit Bailey
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Denis Lebel
- Department of Pharmacy, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
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Banks C, Gangathimmaiah V, Emeto TI, Jones L, Furyk J. Raising the D-dimer threshold for ruling out pulmonary embolism: A single-site, observational study with a historical comparison. Emerg Med Australas 2023; 35:200-204. [PMID: 36117393 DOI: 10.1111/1742-6723.14089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/22/2022] [Accepted: 08/28/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study was to assess the impact of introduction of a new pulmonary embolism (PE) diagnostic guideline with a raised D-dimer threshold. METHODS This is a single-site, observational, cohort study with a historical comparison. The new guideline raised the D-dimer threshold to 1000 ng/mL for most patients with a Wells' score of 4 or less. Patients investigated for PE with a D-dimer level and/or definitive imaging in 6-month periods before and after the introduction of the guideline were eligible. Patients with D-dimers of 500-1000 ng/mL were prospectively followed up at 3 months for missed PE. RESULTS During the pre-intervention period, 688 patients were investigated for PE, 366 (53.2%) received definitive imaging and 39 PE were diagnosed (5.7% overall, 10.7% of those imaged). For the 121 patients with D-dimers ≥500 and <1000 ng/mL, 87 (71.9%) were imaged with 7 (5.8%) having a PE diagnosed. Post intervention there were 930 patients, of which 426 (45.8%) received definitive chest imaging and there were 50 patients with PE diagnosed (5.4% overall, 11.7% of those imaged). For the 185 patients with D-dimers ≥500 and <1000 ng/mL, 60 (32.4%) were imaged with 5 (2.7%) having PE diagnosed. No cases of missed PE were identified at 3 months. CONCLUSION The introduction of the new guideline was associated with a reduction in overall imaging rates without evidence of missed PE. Further evaluation in other settings is recommended.
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Affiliation(s)
- Colin Banks
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Vinay Gangathimmaiah
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Theophilus I Emeto
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
- World Health Organization Collaborating Centre for Vector-borne and Neglected Tropical Diseases, James Cook University, Townsville, Queensland, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Leonie Jones
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Jeremy Furyk
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Emergency Department, University Hospital Geelong, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
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Almuqbil M, Alsayed SA, Almutairi AM, Aladhadh KM, Alghannami AO, Almutairi M. Diagnostic Yield of Neuroimaging for Headache in a Pediatric Emergency Department: A Single Tertiary Centre Experience. Healthcare (Basel) 2023; 11:healthcare11060913. [PMID: 36981570 PMCID: PMC10048237 DOI: 10.3390/healthcare11060913] [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: 02/12/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
OBJECTIVES This study aimed to examine headache neuroimaging findings among the pediatric population visiting the emergency department in Saudi Arabia. METHODS This was a cross-sectional retrospective study of pediatric patients who presented to the emergency department with a headache as their primary complaint. Data were extracted from the electronic medical files of the patients at King Abdullah Specialized Children Hospital (KASCH) between 2015 and 2020. The diagnosis of headache was confirmed using a computerized tomography (CT) scan or magnetic resonance imaging (MRI) upon the patients' presentation. RESULTS A total of 263 patients met the inclusion criteria, and their data were extracted. The CT scans were abnormal in 50% of the patients. The MRI showed abnormal findings for 26% of the patients. CT scans and MRI identified that abnormalities were predominantly among patients with the secondary type of headache. The most common abnormal findings on CT were sinusitis (16%), masses (7%), and hydrocephalus (7%). The most common abnormal findings on MRI were masses (8%), cysts (5%), and hydrocephalus (3%). Of all patients with headaches, 10% had a prior diagnosis of headache, and 12% had a family history of headache. A significantly higher percentage of patients with secondary headache were prescribed NSAID and required admission compared to patients with primary headache (p ≤ 0.05). There was no statistically significant differences in the proportion of patients diagnosed with primary and secondary headache in terms of their neurological examination and headache types (p = 0.43). CONCLUSIONS Neuroimaging is essential for diagnosing headaches in children. Headaches were associated with sinusitis in children. The secondary type was more likely to have abnormal CT and MRI results. Primary type headaches were more common in those with a family history. CT scans and MRIs are needed when a headache is accompanied by an abnormal clinical evaluation. Neuroimaging and mild CT usage may be explored if there are clinical abnormalities or family history.
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Affiliation(s)
- Mohammed Almuqbil
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
- Pediatric Emergency Department, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh 52569, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh 11481, Saudi Arabia
| | - Saud Abdulaziz Alsayed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
| | - Amer Mohammed Almutairi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
| | - Khalid Mohammed Aladhadh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
| | - Abdullah Omar Alghannami
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
| | - Mohammed Almutairi
- Pediatric Emergency Department, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh 52569, Saudi Arabia
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Conti R, Marta G, Wijers L, Barbi E, Poropat F. Red flags Presented in Children Complaining of Headache in Paediatric Emergency Department. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020366. [PMID: 36832495 PMCID: PMC9955876 DOI: 10.3390/children10020366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
This study aimed to determine how common are specific red flags of life-threatening headache (LTH) among children with complaints of headache in the emergency department. A retrospective study was conducted over five years, including all patients aged < 18 years who presented for a headache to a Pediatric Emergency Department. We identified patients with life-threatening headaches and compared the recurrence of the main red flags (occipital location, vomit, nocturnal wake-up, presence of neurological signs, and family history of primary headache) to the remaining sample. Two-thousand-fifty-one children (51% female, 49% male) were included. Seven patients (0.3%) were diagnosed with a life-threatening headache. In the analysis of red flags, only the presence of abnormal neurological evaluation and vomiting was found to be more common in the LTH sample. No statistically significant difference was found for nocturnal awakening or occipital localization of pain. Urgent neuroradiological examinations were performed in 72 patients (3.5% of cases). The most common discharge diagnosis was infection-related headache (42.4%), followed by primary headaches (39.7%). This large retrospective study confirms the most recent literature suggesting that night awakenings and occipital pain are common symptoms also associated with not-LTH. Therefore, if isolated, they should not be considered red flags.
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Affiliation(s)
- Rosaura Conti
- Department of Medicine and Surgery and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Giorgia Marta
- Department of Medicine and Surgery and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Lotte Wijers
- Faculty of Health, Medicine and Life Sciences, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Egidio Barbi
- Department of Medicine and Surgery and Health Sciences, University of Trieste, 34127 Trieste, Italy
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, 34137 Trieste, Italy
| | - Federico Poropat
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, 34137 Trieste, Italy
- Correspondence:
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11
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Shastry S, Manoochehri O, Richardson LD, Manini AF. Cocaethylene cardiotoxicity in emergency department patients with acute drug overdose. Acad Emerg Med 2023; 30:82-88. [PMID: 36000306 PMCID: PMC9918638 DOI: 10.1111/acem.14584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/10/2022] [Accepted: 08/20/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Cocaine use results in over 500,000 emergency department (ED) visits annually across the United States and ethanol co-ingestion is reported in 34% of these. Commingling cocaine with ethanol results in the metabolite cocaethylene (CE), which is metabolically active for longer than cocaine alone. Current literature on the cardiotoxicity of CE compared to cocaine alone is limited and lacks consensus. This study aims to fill this gap in the literature and examine cardiovascular events in cocaine use as confirmed by urine toxicology versus CE exposure. METHODS This was a secondary data analysis of a prospective cohort study of adult patients with acute drug overdose at two urban tertiary care hospital EDs over 4 years. Patients with positive urinary cocaine metabolites were analyzed, and outcomes were compared between patients with overdose and confirmed presence of cocaine on urine toxicology (cocaine group) and patients with cocaine and ethanol use (CE group). The primary outcome was cardiac arrest. Secondary outcomes included myocardial injury and hyperlactatemia. Data were analyzed using multivariable regression models. RESULTS We enrolled a total of 199 patients (150 cocaine, 49 CE). Rates of cardiac arrest were significantly higher in the CE group compared to cocaine (6.1% vs. 0.67%, p = 0.048). Cocaine was significantly associated with myocardial injury compared to CE exposure (mean initial troponin 0.01 ng/ml vs. 0.16 ng/ml, p = 0.021), while hyperlactatemia was associated with CE exposure (mean initial lactate 4.1 mmol/L vs. 2.9 mmol/L, p = 0.038). CONCLUSIONS When compared to cocaine exposure alone, CE exposure in ED patients with acute drug overdose was significantly associated with higher occurrence of cardiac arrest, higher mean lactate concentrations, and lower occurrence of myocardial injury.
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Affiliation(s)
- Siri Shastry
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Omid Manoochehri
- Emergency Medicine Residency, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex F. Manini
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, New York, USA
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12
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The diagnostic values of red flags in pediatric patients with headache. Brain Dev 2022; 44:512-519. [PMID: 35568652 DOI: 10.1016/j.braindev.2022.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/08/2022] [Accepted: 04/17/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Headache is a common complaint in childhood and adolescence. Differentiating benign primary headaches from ominous secondary headaches is often difficult. Clinicians usually seek red flags to determine the need for neuroimaging. We aimed to evaluate the diagnostic values of red flags in pediatric headaches. METHODS We retrospectively reviewed the medical records of 1510 pediatric patients (1470 with primary headache, 40 with secondary headache) presenting with headache and underwent neuroimaging from two centers between March 2010 and December 2019. RESULTS The secondary-headache group exhibited significantly higher frequencies of abnormal neurologic signs/symptoms (40.0% vs 6.8%, p < 0.001), Valsalva maneuver/exercise-induced headache (15.0% vs 4.9%, p = 0.004), headache with vomiting (35.0% vs 17.9%, p = 0.006), and onset under age 6 (25.0% vs 10.3%, p = 0.003) than the primary-headache group, with the following positive likelihood ratio (PLR): 5.88, 3.06, 1.96, and 2.42, respectively. The sensitivity values were as follows: abnormal neurologic signs/symptoms (16/40, 40.0%), headache with vomiting (14/40, 35.0%), onset under age 6 (10/40, 25.0%), and Valsalva maneuver/exercise-induced headache (6/40, 15.0%). The overall sensitivity for ominous secondary headaches requiring surgical treatment was 86.2% (25/29). CONCLUSIONS Certain red flags, including abnormal neurologic signs/symptoms, Valsalva maneuver/exercise-induced headache, headache with vomiting, and onset under age 6, were more prevalent in the secondary-headache group; nonetheless, their sensitivity values and PLR were relatively low. Notwithstanding, considering these red flags' high overall sensitivity for ominous secondary headaches, neuroimaging in patients presenting these red flags should rely on careful follow-up of symptom progression.
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13
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Irwin SL, Greene KA, Pavitt SJ, Ross AC. Headache in the Pediatric Population: Focus on Migraine. Semin Neurol 2022; 42:479-488. [DOI: 10.1055/s-0042-1757927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPediatric headache is a common condition with significant impact on quality of life and ability to function in academic, social, and extracurricular activities. Most pediatric patients seen in primary care and neurology clinics with headache have primary headache disorders. Diagnosis is largely based on clinical history. Imaging is rarely needed in the absence of red flag features. Careful diagnosis is important to guide appropriate treatment. Treatment focuses on a biopsychosocial model integrating lifestyle, pharmacologic and nonpharmacologic treatment modalities. As few therapies are approved in the pediatric population, treatments are often used off-label based on evidence extrapolated from adult studies. Outcomes vary over time but are generally favorable when headache disorders are diagnosed promptly and managed in a multidisciplinary setting.
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Affiliation(s)
- Samantha L. Irwin
- Department of Neurology, University of California, San Francisco (UCSF), California
| | - Kaitlin A. Greene
- Division of Pediatric Neurology, Department of Pediatrics, Oregon Health and Science University (OHSU), Portland, Oregon
| | - Sara J. Pavitt
- Department of Neurology, University of Texas, Austin, Texas
| | - Alexandra C. Ross
- Department of Pediatrics, University of California, San Francisco (UCSF), California
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14
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Güngör A, Göktuğ A, Bodur İ, Öztürk B, Güneylioğlu MM, Yaradilmiş RM, Tekeli A, Karacan CD, Tuygun N. Retrospective Evaluation of Acute Headache in Pediatric Emergency Department: Etiologies, Red Flags, and Neuroimaging. Neurologist 2022; 27:95-99. [PMID: 34855667 DOI: 10.1097/nrl.0000000000000377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aims of this study were to describe the etiologies of acute headache presenting to the pediatric emergency department, determine their clinical characteristics, the prevalence of red flag findings and neuroimaging and identify predictors of headaches because of serious intracranial diseases. MATERIALS AND METHODS Patients from 2 to 18 years of age who visited pediatric emergency department with a chief complaint of headache between January 1, 2016 and August 31, 2020 were retrospectively evaluated. RESULTS The mean age of the 558 patients included in the study was 11.17±3.78 years, and 290 (52%) were female. The most common cause of acute headache was head and neck area infections (except central nervous system infections) in 355 (63.6%) patients. Forty patients (7.2%) had a headache because of serious intracranial diseases. According to binary logistic regression analysis, the findings that predicted a serious intracranial diseases were abnormal neurological physical examination [odds ratio (OR): 187.57; 95% confidence interval (CI): 32.67-1076.64], recent onset or suddenly severe headache (OR: 14.41; 95% CI: 3.14-65.91), and vomiting (OR: 9.42; 95% CI: 1.90-46.63). Neuroimaging was performed in 63 (11.3%) patients, and 7 (1.25%) had a pathology requiring emergency treatment. CONCLUSIONS The majority of acute headaches were evaluated as secondary headache. The most common cause of acute headache was head and neck area infections. Abnormal neurological physical examination, recent onset or suddenly severe headache, and vomiting were the most useful red flags for predicting serious intracranial diseases. The requirement for neuroimaging should be evaluated individually for each patient.
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Affiliation(s)
- Ali Güngör
- Department of Pediatric Emergency Medicine, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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15
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Kelly AM, Chu KH, Kuan WS, Keijzers G, Kinnear FB, Cardozo-Ocampo A. Is headache during pregnancy a higher risk for serious secondary headache cause? A HEAD study report. Emerg Med Australas 2022; 34:629-631. [PMID: 35474635 DOI: 10.1111/1742-6723.14005] [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: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Pregnancy is defined as a 'red flag' in headache assessment. We aimed to describe the prevalence and causes of serious secondary headache in pregnant ED patients. METHODS Unplanned secondary analysis of HEAD Study/HEAD Colombia data. RESULTS 3.2% (117/3643) of ED headache patients aged 18-50 years were pregnant, of whom six (5.1%) had a serious secondary cause identified. The proportion of patients with serious headache causes was not significantly different between pregnant female, non-pregnant female and male patient subgroups (P = 0.89). CONCLUSION Inclusion of pregnancy as a 'red flag' in ED headache assessment is not supported by these data.
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Affiliation(s)
- Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kevin H Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Frances B Kinnear
- Emergency and Children's Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Department of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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16
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Tham D, Davis C, Hopper SM. Infrared thermometers and infants: The device is hot the baby maybe not. J Paediatr Child Health 2022; 58:624-629. [PMID: 34694041 DOI: 10.1111/jpc.15787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/22/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
AIM The risk of serious illness in febrile infants (<60 days old) is high, and so fever often warrants aggressive management. Infrared thermometers are unreliable in young infants despite their ubiquity. We aim to describe the: (i) frequency of infrared thermometer usage; (ii) progression to documented fever in the emergency department (ED) and (iii) rate of serious illness (meningitis, urinary tract infection and bacteremia). METHODS In this single-centre retrospective chart review at The Royal Children's Hospital, Melbourne, we audited medical records of infants (<60 days old) presenting to the ED with pre-hospital fever on history over a 12-month period. We described the type of thermometer used at home (tympanic or forehead, 'infrared' vs. axillary or rectal, 'direct') correlated to peak temperature in ED, investigations, treatment and diagnosis. The primary outcome was subsequent fever in ED. RESULTS Of 159 infants, two of three had infrared temperature measurement at home. Fifty-one (32.1%) developed fever in ED (direct 28/54, 52% vs. infrared 23/105, 22% RR 2.36 (95% CI 1.52-3.69)). Investigations (75%) and admission (60%) were common. Pre-hospital fever alone was less likely to be associated with serious illness, with fever in ED a much stronger predictor. CONCLUSIONS In young infants, infrared thermometer use is common and less likely to predict subsequent fever. Twenty-two percent of infants with fever via infrared measurement had fever in ED. History of fever without confirmation is less likely to signal serious illness. Education to public and health-care providers is required to avoid usage of infrared devices in this population.
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Affiliation(s)
- Doris Tham
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Sunshine Paediatric Emergency Department, Western Health, Melbourne, Victoria, Australia
| | - Conor Davis
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Medical Retrieval and Consultation Centre, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Sandy M Hopper
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
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17
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Lynham R, Boxall S, Warren J, Lynham A. Paediatric trauma imaging in a regional Queensland hospital: Do we need clearer guidance? Emerg Med Australas 2022; 34:704-710. [PMID: 35243766 DOI: 10.1111/1742-6723.13954] [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: 11/03/2021] [Revised: 02/08/2022] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Paediatric trauma is a major cause of morbidity and mortality in those aged 0-14. Anatomical and physiological differences require a specialised approach to paediatric trauma care. Medical imaging, particularly computed tomography (CT) scans, requires specific consideration because of the consequences of radiation exposure in the paediatric population. The present study compares current practice of CT scan ordering in paediatric trauma patients at a regional Australian hospital against consensus guidelines published in the UK. METHODS A retrospective audit of paediatric trauma CT scans referred from the ED from May 2017 to May 2018 was completed. Details relating to CT scan ordering were reviewed and compliance with the Royal College of Radiologists Paediatric trauma protocols, was determined. Descriptive statistics and χ2 tests comparing those that met and did not meet guidelines were performed. RESULTS A total of 71 CT scans were included with an overall compliance rate of 56.3%. Specific regional compliance was lowest with CT neck at 14%. Patients where a trauma call was initiated were more likely to receive a full body (pan) scan rather than region specific imaging. Compliance improved when paediatric team involvement was documented. CONCLUSIONS Evidence-based guidelines for CT imaging in paediatric trauma are essential to reduce unnecessary radiation exposure for children. The present study has demonstrated that current practice has the potential to be improved and that decisions should involve a multidisciplinary team.
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Affiliation(s)
- Rohan Lynham
- Anaesthesia Department, Whangarei Hospital, Whangarei, New Zealand
| | - Sarah Boxall
- Emergency Department, Mackay Hospital and Health Service, Mackay, Queensland, Australia
| | - Jacelle Warren
- Jamieson Trauma Institute, Metro North Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Anthony Lynham
- Jamieson Trauma Institute, Metro North Health, The University of Queensland, Brisbane, Queensland, Australia
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Pediatric Headache in Primary Care and Emergency Departments: Consensus with RAND/UCLA Method. Life (Basel) 2022; 12:life12020142. [PMID: 35207430 PMCID: PMC8877535 DOI: 10.3390/life12020142] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 01/09/2023] Open
Abstract
Headache is the most frequent neurological symptom in childhood and the main reason for admission to pediatric emergency departments. The aim of this consensus document is to define a shared clinical pathway between primary care pediatricians (PCP) and hospitals for the management of children presenting with headache. For the purposes of the study, a group of hospital pediatricians and a group of PCP from the Emilia Romagna’s health districts were selected to achieve consensus using the RAND/UCLA appropriateness method. Thirty-nine clinical scenarios were developed: for each scenario, participants were asked to rank the appropriateness of each option from 1 to 9. Agreement was reached if ≥75% of participants ranked within the same range of appropriateness. The answers, results, and discussion helped to define the appropriateness of procedures with a low level of evidence regarding different steps of the diagnostic-therapeutic process: primary care evaluation, emergency department evaluation, hospital admission, acute therapy, prophylaxis, and follow-up. The RAND proved to be a valid method to value appropriateness of procedures and define a diagnostic-therapeutic pathway suitable to the local reality in the management of pediatric headache. From our results, some useful recommendations were developed for optimizing the healthcare professionals’ network among primary care services and hospitals.
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19
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Kanamori K, Miyama S. Classification of pediatric headache cases referred to a neurology department. Pediatr Int 2022; 64:e15181. [PMID: 35770833 DOI: 10.1111/ped.15181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/08/2022] [Accepted: 02/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Headaches are very common in children. The patients often have mild symptoms, but on occasion may have severe, secondary headaches. The present study aimed to clarify the details of children with headaches seen at the outpatient clinic of a pediatric neurological department. METHODS The present, retrospective observational study was conducted at a tertiary pediatric hospital in Japan and enrolled children referred to the neurology department outpatient clinic for headache between April 2018 and March 2021. RESULTS In total, 113 cases of headache were examined; of these, 99 (87.6%) were primary headaches, one case (0.9%) was a secondary headache, and 13 (11.5%) were unclassified or unspecified. There were 46 cases (40.7%) of tension-type headache (TTH), both confirmed and suspected, 30 cases (26.5%) of migraine, and 23 cases (20.4%) of a combination of the TTH and migraine. One case of secondary headache was attributed to an infection. Arachnoid cysts were found in seven patients (7.8%). Acute drug treatments were administered to 93 patients (82.3%), with acetaminophen being the most common drug, followed by ibuprofen. Prophylactic drug treatments were administered to 39 patients (34.5%), with goreisan (a Chinese herbal medicine containing Alisma orientale, Poria cocos, Polyporus umbellatus, Atractylodes lancea, and Cinnamomum cassia) being the most common (41%). CONCLUSIONS Few cases of secondary headache and none of emergency headache were diagnosed. The prevalence of arachnoid cysts was higher than in the general pediatric population, suggesting that arachnoid cysts might be associated with headache.
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Affiliation(s)
- Keita Kanamori
- Department of Neurology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Sahoko Miyama
- Department of Neurology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
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Klim S, Kelly AM, Krieser D. Epidemiology of Headache in Children in a Community Emergency Department: A Scoping Study. Pediatr Emerg Care 2021; 37:e1270-e1273. [PMID: 31977770 DOI: 10.1097/pec.0000000000002000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to describe the epidemiology of headache in children attending a community mixed adult-pediatric emergency department (ED) in Australia with a view to providing scoping data for future headache-related projects for the pediatric ED research networks. METHODS This is a retrospective cohort study by medical record review. Participants were children aged 2 to 16 years who presented to the ED between January 1, 2016, and December 31, 2016, with a major symptom of headache. Exclusion criteria were a history of recent head trauma, a ventriculoperitoneal shunt in situ, or known intracranial conditions associated with headache. Data collected included demographics, clinical features, investigations, diagnosis, disposition, and outcome. The primary outcomes of interest were the proportion of children with a serious ED diagnosis, the distribution of ED diagnoses, investigation ordering patterns, treatments provided, and clinical outcome. RESULTS A total of 225 children were studied, with a median age of 9 years (interquartile range, 6-13 years). The most common associated symptoms were fever (47%) and vomiting (42%). The most common examination feature was fever (21%). Abnormal neurological findings were very uncommon. Few children underwent advanced neuroimaging (7 patients; 3%), and no intracranial abnormalities were detected. Seven children had a serious diagnosis (7/225 [3%]; 95% confidence interval, 2%-6%). Six of these 7 were viral meningitis, and there was 1 case of bacterial meningitis. CONCLUSIONS In a community teaching hospital cohort of children with headache, intercurrent viral illness is the most common cause. Serious causes were very uncommon. The rate of bacterial meningitis, tumor, or abscess was <1%. This has implications for the planning of research projects.
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Affiliation(s)
- Sharon Klim
- From the Joseph Epstein Centre for Emergency Medicine Research at Western Health, Sunshine Hospital
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21
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Kelly AM, Kuan WS, Chu KH, Kinnear FB, Keijzers G, Karamercan MA, Klim S, Wijeratne T, Kamona S, Graham CA, Body R, Roberts T, Horner D, Laribi S. Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study. Headache 2021; 61:1539-1552. [PMID: 34726783 DOI: 10.1111/head.14230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/06/2021] [Accepted: 07/23/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). BACKGROUND Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. METHODS An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. RESULTS We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526). CONCLUSION Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.
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Affiliation(s)
- Anne Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research @ Western Health, Sunshine, Victoria, Australia.,Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kevin H Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Frances B Kinnear
- Emergency & Children's Services, The Prince Charles Hospital, Chermside, Queensland, Australia.,Department of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Mehmet A Karamercan
- Department of Emergency Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research @ Western Health, Sunshine, Victoria, Australia.,Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Health, St Albans, Victoria, Australia.,Public Health School, La Trobe University, Bundoora, Victoria, Australia
| | - Sinan Kamona
- School of Medicine, University of Auckland, Auckland, New Zealand.,Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Colin A Graham
- Emergency Medicine, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Emergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Tom Roberts
- Trainee Emergency Research Network (TERN), Bristol, UK.,North Bristol NHS Trust, Bristol, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Said Laribi
- Emergency Medicine Department, Tours University Hospital, Tours, France
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Ward B, Kollios J, Smith F, Klim S, Senz A, Kelly AM. Characteristics and outcome of patients transported by police to emergency departments under section 351 of the Mental Health Act 2014 (Vic). Emerg Med Australas 2021; 34:263-270. [PMID: 34643031 DOI: 10.1111/1742-6723.13879] [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: 06/02/2021] [Revised: 09/06/2021] [Accepted: 09/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine characteristics, precipitating circumstances, clinical care, outcome and disposition of patients brought to the ED under section 351 (s351, police detention and transport) powers of the Mental Health Act 2014 (Vic) (MHAV). METHODS This is an observational cohort study conducted in two metropolitan teaching hospitals in Victoria. Participants were adult patients brought to ED under s351 of the MHAV. Data collected included demographics, event circumstances, pre-hospital and ED interventions and outcome. Analyses are descriptive. RESULTS The present study included 438 patient encounters. Median age was 34 years. In 84% of encounters (368/438) patients were co-transported with ambulance. The most common primary reason for detainment was suicide risk/intent (296/438, 67.6%) followed by abnormal behaviour without threat to self or others (92/438, 21%). In ED, parenteral sedation was administered in 11% (48/438). Physical restraint was applied in 17.6% (77/438). Psychiatric admission was required in 23.5% (103/438). In 63 cases, psychiatric admission was involuntary (14.4%). Most patients (297/438, 67.8%) were discharged home. A subset of patients had recurrent s351 presentations. Eighteen (5.6%) patients accounted for 22% (96/438) of all events. CONCLUSION Most patients brought to ED under s351 of the MHAV had expressed intention to self-harm, did not require medical intervention and were discharged home. It could be questioned whether the current application of s351 is consistent with the least restrictive principles of the MHAV, especially as there is no apparent monitoring or reporting of the use of these powers. There were a concerning number of patients with multiple s351 events over a short period.
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Affiliation(s)
- Beth Ward
- Department of Emergency Medicine, Western Health, Melbourne, Victoria, Australia
| | - Jason Kollios
- Department of Emergency Medicine, Western Health, Melbourne, Victoria, Australia
| | - Fiona Smith
- Department of Emergency Medicine, Western Health, Melbourne, Victoria, Australia
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, Victoria, Australia
| | - Ainslie Senz
- Emergency Department, Footscray Hospital, Melbourne, Victoria, Australia
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, Victoria, Australia.,Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
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23
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Ibrahim LF, Tham D, Chong V, Corden M, Craig S, Buntine P, Jani S, Zhang M, George S, Kochar A, O'Brien S, Robins-Browne K, Tosif S, Daley A, McNab S, Crawford NW, Wilson C, Babl FE. The characteristics of SARS-CoV-2-positive children who presented to Australian hospitals during 2020: a PREDICT network study. Med J Aust 2021; 215:217-221. [PMID: 34389995 PMCID: PMC8447363 DOI: 10.5694/mja2.51207] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/28/2021] [Accepted: 06/03/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To examine the epidemiological and clinical characteristics of SARS-CoV-2-positive children in Australia during 2020. DESIGN, SETTING Multicentre retrospective study in 16 hospitals of the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network; eleven in Victoria, five in four other Australian states. PARTICIPANTS Children aged 0-17 years who presented to hospital-based COVID-19 testing clinics, hospital wards, or emergency departments during 1 February - 30 September 2020 and who were positive for SARS-CoV-2. MAIN OUTCOME MEASURES Epidemiological and clinical characteristics of children positive for SARS-CoV-2. RESULTS A total of 393 SARS-CoV-2-positive children (181 girls, 46%) presented to the participating hospitals (426 presentations, including 131 to emergency departments [31%]), the first on 3 February 2020. Thirty-three children presented more than once (8%), including two who were transferred to participating tertiary centres (0.5%). The median age of the children was 5.3 years (IQR, 1.9-12.0 years; range, 10 days to 17.9 years). Hospital admissions followed 51 of 426 presentations (12%; 44 children), including 17 patients who were managed remotely by hospital in the home. Only 16 of the 426 presentations led to hospital medical interventions (4%). Two children (0.5%) were diagnosed with the paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). CONCLUSION The clinical course for most SARS-CoV-2-positive children who presented to Australian hospitals was mild, and did not require medical intervention.
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Affiliation(s)
- Laila F Ibrahim
- Murdoch Children's Research Institute, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Doris Tham
- Murdoch Children's Research Institute, Melbourne, VIC.,Western Health, Melbourne, VIC
| | | | | | - Simon Craig
- Monash Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | - Paul Buntine
- Eastern Health, Melbourne, VIC.,Box Hill Hospital, Melbourne, VIC
| | - Shefali Jani
- The Children's Hospital at Westmead, Sydney, NSW.,The University of Sydney, Sydney, NSW
| | | | - Shane George
- Gold Coast University Hospital, Gold Coast, QLD.,The University of Queensland Child Health Research Centre, Brisbane, QLD
| | - Amit Kochar
- Women's and Children's Hospital, Adelaide, SA
| | - Sharon O'Brien
- Perth Children's Hospital, Perth, WA.,Curtin University, Perth, WA
| | | | - Shidan Tosif
- Murdoch Children's Research Institute, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Andrew Daley
- Murdoch Children's Research Institute, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Sarah McNab
- Murdoch Children's Research Institute, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Nigel W Crawford
- Murdoch Children's Research Institute, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | | | - Franz E Babl
- Murdoch Children's Research Institute, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
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24
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Kumar G, Payne AM, Maag LM, MacDonald S. Efficacy of a pediatric headache infusion center: A single-center experience. Headache 2021; 61:1086-1091. [PMID: 34325484 DOI: 10.1111/head.14173] [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: 02/22/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy of a pediatric headache infusion center (HIC) in alleviating the symptoms and preventing future visits to the emergency department (ED). BACKGROUND Headache is a common reason for visits to the pediatric ED. ED visits are associated with inordinate costs of care and are conceived by parents to be avoidable if adequate alternatives are available. An infusion center for acute treatment of intractable headache in children with chronic migraine may be an effective alternative to an ED visit. METHODS This was a retrospective analysis of data from a single-center cohort of patients with a known history of chronic migraine, presenting to Dayton Children's HIC with an acute migraine from June 1, 2017 to June 1, 2020. Patients were treated according to established protocols divided into two pathways. Patient demographics, clinical characteristics, pre- and postinfusion pain scores, ED visits and inpatient admissions within 2 weeks of HIC visit, and ED visits 1 year prior and 1 year after the HIC visit were noted. RESULTS A total of 297 HIC visits were analyzed from 201 patients. The HIC was effective in controlling symptoms with a significant reduction in pain score (median [interquartile range; IQR] 7.0 [2.0] preinfusion vs. 1.0 [2.0] postinfusion, p < 0.001). Only 25/297 (8.4%) patients came to the ED within 2 weeks of the HIC visit, and an even smaller number of patients (20/297, 6.7%) were admitted as inpatients within 2 weeks of the HIC visit. The number of ED visits was significantly reduced in the year after the HIC visit compared with the year prior (median [IQR] 1.0 [2.0] before vs. 0.0 [1.0] after, p < 0.001). CONCLUSION A pediatric HIC is effective in alleviating the symptoms and preventing ED visits. These centers should be considered as standard of care at children's hospitals.
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Affiliation(s)
- Gogi Kumar
- Division of Child Neurology, Dayton Children's Hospital, Dayton, OH, USA.,Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Asia M Payne
- Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Logan Mark Maag
- Internal Medicine, Ohio Health Riverside Methodist Hospital, Columbus, OH, USA
| | - Sarah MacDonald
- Division of Child Neurology, Dayton Children's Hospital, Dayton, OH, USA
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25
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Personnic J, Titomanlio L, Auvin S, Dozières-Puyravel B. Neurological disorders encountered in a pediatric emergency department. Eur J Paediatr Neurol 2021; 32:86-92. [PMID: 33862442 DOI: 10.1016/j.ejpn.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 03/03/2021] [Accepted: 03/29/2021] [Indexed: 11/19/2022]
Abstract
AIM Neurological disorders are one of the reasons for admission in pediatric emergency departments (PEDs). We aimed to evaluate the frequency of neurological disorders seen in a large tertiary PED. METHODS We conducted a one-year retrospective study that included 1471 medical records. Inclusion was based on the main complaint recorded by nurses at triage. We also retrieved the final diagnoses and the investigations performed in the PED. RESULTS About 3.4% of the yearly admissions was based on a neurologic complaint on arrival. The final diagnosis was of a neurologic disorder in 1237 children, 2% of which were admitted to the pediatric intensive care unit. An opinion from a child neurologist was requested for 33% of the children. Seizures were the most frequent reason for admission, followed by headaches. A previous visit to the PED in the past six months was a frequent finding (40%), and about one third of the patients with a neurologic diagnosis (except headaches) was already being followed by a child neurologist. INTERPRETATION Neurological disorders are frequent in our PED and are mainly represented by seizures and headaches. Appropriate training in epileptology might be helpful for healthcare professional working in PEDs.
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Affiliation(s)
- Johan Personnic
- Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Boulevard Serrurier, 75019, Paris, France
| | - Luigi Titomanlio
- Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Boulevard Serrurier, 75019, Paris, France
| | - Stéphane Auvin
- Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Boulevard Serrurier, 75019, Paris, France
| | - Blandine Dozières-Puyravel
- Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Boulevard Serrurier, 75019, Paris, France.
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26
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Ramgopal S, Zhou AZ, Hickey RW, Marin JR. Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache. J Child Neurol 2021; 36:475-481. [PMID: 33356803 DOI: 10.1177/0883073820979137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate rates of presentation, neuroimaging, therapies, and serious neurologic disorders (SNDs) among children and young adults presenting to the emergency department with headache. METHODS We performed a cross-sectional study of a nationally representative sample survey of visits to US emergency departments between 2002 and 2017. We identified encounters of patients ≤25 years old with chief complaint of headache. We report the rates of presentation, imaging, and treatments and report proportions having concomitant diagnoses of serious neurologic disorders. RESULTS Among encounters ≤25 years, 2.0% had a chief complaint of headache, with no change in the yearly rates of encounters (P = .98). Overall, 20.8% had a head computed tomography (CT), with a reduction in performance between 2007 and 2016 (P < .01). One-quarter (25.2%, 95% confidence interval [CI] 22.2%-28.3%) were given narcotics and 2.5% (95% CI 1.7%-3.2%) had serious neurologic disorders. CONCLUSION Overall, 2.0% of emergency department encounters among patients ≤25 years were for headache, with low rates of serious neurologic disorders. CT use appeared to be declining.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy Z Zhou
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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27
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Clement WA, Sooby P, Doherty C, Qayyum N, Irwin G. Acute isolated sphenoid sinusitis in children: A case series and systematic review of the literature. Int J Pediatr Otorhinolaryngol 2021; 140:110492. [PMID: 33234332 DOI: 10.1016/j.ijporl.2020.110492] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study aims to present a case series and systematic review of acute isolated sphenoid sinusitis (AISS) in children in order to better characterize clinical presentation, diagnosis, treatment, and outcomes of this condition. DATA SOURCES Ovid MEDLINE, Pubmed, Embase, Cochrane Library, and Google Scholar. STUDY SELECTION Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text, peer-reviewed journal publications from 1994 to 2020 in English; focus on acute sphenoid sinusitis; pediatric patients (<18 years of age); series with two or more children. Studies were assessed for data including demographics, presenting symptoms and signs, radiological investigations, treatment, outcomes and complications. RESULTS Ten studies identifying 71 patients were included. Average age at presentation was 12.0 years (range 5-17 years). M:F ratio 1:1. The most common presenting symptoms were headache (98.6%), fever (50.7%), nasal symptoms (22.5%) ocular symptoms (19.7%) and decreased level of consciousness (12.7%). Twenty patients (28.1%) had neurological signs. Twenty-three patients (32.4%) presented with headache in isolation. Unsuspected diagnosis at presentation was noted in 54.0%. Average time to initial presentation was 14.0 days (median = 5.5 days, range 1-90 days). The majority of children were treated with antibiotics (98.6%) with 31.0%, 2.8% and 2.8% also undergoing sinus surgery, revision sinus surgery and neurosurgery, respectively. Intracranial complications occurred in 16.9% of patients. Significant long term sequelae occurred in 2 children (2.8%) and one death (1.4%) was also reported. LIMITATIONS All studies were retrospective case note reviews. CONCLUSIONS Acute sphenoid sinusitis is a rare and difficult condition to diagnose in children. The majority of patients make a full recovery with appropriate treatment. If treatment is delayed however consequences can be life-threatening.
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Affiliation(s)
- W A Clement
- Department of Paediatric Otolaryngology, Royal Hospital for Children, Glasgow, United Kingdom.
| | - P Sooby
- Department of Paediatric Otolaryngology, Royal Hospital for Children, Glasgow, United Kingdom
| | - C Doherty
- Department of Paediatric Infectious Diseases Immunology and Allergy, Royal Hospital for Children, Glasgow, United Kingdom
| | - N Qayyum
- Department of Paediatrics, Royal Hospital for Children, Glasgow, United Kingdom
| | - G Irwin
- Department of Paediatric Radiology, Royal Hospital for Children, Glasgow, United Kingdom
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28
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Neuenschwander J, Le T, Parekh A, Hiestand B, Cordial P, Le H, Hammil E, Kojasoy T, Peacock WF. Utilization of a Read-only Pacemaker and Defibrillator Interrogator in the Emergency Department and Hospital. Acad Emerg Med 2020; 27:1344-1347. [PMID: 32124500 DOI: 10.1111/acem.13950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 02/08/2020] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
Affiliation(s)
- James Neuenschwander
- From the, Emergency Department, Genesis Healthcare Systems, The Ohio State University, Zanesville, OH
| | - Tinh Le
- the, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Ankur Parekh
- the, College of Engineering, The Ohio State University, Columbus, OH
| | - Brian Hiestand
- the, School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Parker Cordial
- College of Medicine, The Ohio State University, Columbus, OH
| | - Hana Le
- and the, Center for Life Sciences Education, The Ohio State University, Columbus, OH
| | | | | | - W Frank Peacock
- and the, Ben Taub General Hospital, Baylor College of Medicine, Houston, TX
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29
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Abstract
OBJECTIVES The aims of the study were (1) to analyze the etiology and clinical management of headaches in children in the emergency department and (2) to analyze the treatment used in children diagnosed with headaches and with migraines. METHODS Retrospective study of all the patients who were admitted to the pediatric emergency department of Hospital Professor Doutor Fernando Fonseca, Lisbon, in 2014, with a chief complaint of headaches or the primary discharge diagnosis was headache/migraine. RESULTS Headache related cases represented 3.8% of all the visits, a total of 2354 subjects. The median age was 10 years and 52.6% were female. The most frequent diagnoses were as follow: headaches (21.3%), upper respiratory infections (18.4%), and migraines (6.1%). There were 4 cases of meningitis, 6,5% of all patients underwent computed tomography which was mostly requested in school-age children and adolescents. The average time from the first medical observation until discharge was 85 minutes. Fifty-five percent did not take any pain relief medication, 17.2% took acetaminophen, and 11.1% took ibuprofen. Patients who received ondansetron had less revisits (P = 0.000). Subjects with mild-moderate pain treated with acetaminophen or no medication had more revisits (P = 0.000). CONCLUSIONS Secondary benign headaches were the most common and very rarely headache as a symptom was associated with life-threatening situations. Antiemetics seem to be efficient ally in the treatment of primary headaches, but it is important to consider alternative pharmacological regimes in patients who present with higher pain scores.
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30
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Padrão EMH, Valente FS, Besen BAMP, Rahhal H, Mesquita PS, Alencar JCG, Costa MGP, Wanderley APB, Emerenciano DL, Bortoleto FM, Fortes JCL, Marques B, Souza SFB, Marchini JFM, Neto RAB, Souza HP. Awake Prone Positioning in COVID-19 Hypoxemic Respiratory Failure: Exploratory Findings in a Single-center Retrospective Cohort Study. Acad Emerg Med 2020; 27:1249-1259. [PMID: 33107664 DOI: 10.1111/acem.14160] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Awake prone positioning has been widely used in patients with COVID-19 respiratory failure to avoid intubation despite limited evidence. Our objective was to evaluate if prone positioning is associated with a reduced intubation rate when compared to usual care. METHODS This was a retrospective cohort study in the emergency department of a large quaternary hospital in Sao Paulo. We retrieved data from all admitted patients in need of oxygen supplementation (>3 L/min) and tachypnea (>24 ipm) from March 1 to April 30, 2020, excluding those who had any contraindication to the prone position or who had an immediate need for intubation. The primary endpoint was endotracheal intubation up to 15 days. Secondary outcomes included a 6-point clinical outcome ordinal scale, mechanical ventilation-free days, admission to the intensive care unit, and need of hemodialysis and of vasoactive drugs, all assessed at or up to 15 days. We analyzed unadjusted and adjusted effect estimates with Cox proportional hazards models, logistic regression, quantile regression, and sensitivity analyses using propensity score models. RESULTS Of 925 suspected COVID-19 patients admitted off mechanical ventilation, 166 patients fulfilled inclusion and exclusion criteria: 57 were exposed to prone positioning and 109 to usual care. In the intervention group, 33 (58%) were intubated versus 53 (49%) in the control group. We observed no difference in intubation rates in the univariate analysis (hazard ratio = 1.21, 95% confidence interval [CI] = 0.78 to 1.88, p = 0.39) nor in the adjusted analysis (hazard ratio = 0.90, 95% CI = 0.55 to 1.49, p = 0.69). Results were robust to the sensitivity analyses. Secondary outcomes did not differ between groups. CONCLUSIONS Awake prone positioning was not associated with lower intubation rates. Caution is necessary before widespread adoption of this technique, pending results of clinical trials.
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Affiliation(s)
- Eduardo M. H. Padrão
- From the Department of Internal Medicine University of Connecticut Farmington CTUSA
| | - Fernando S. Valente
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Bruno A. M. P. Besen
- and the Medical ICU, Disciplina de Emergências Clínicas, Departmento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina Universidade de São Paulo São PauloSPBrazil
| | - Hassan Rahhal
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Paula S. Mesquita
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Julio C. G. Alencar
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Millena G. P. Costa
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Annelise P. B. Wanderley
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Debora L. Emerenciano
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Felipe M. Bortoleto
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Julio C. L. Fortes
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Bruno Marques
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Stefany F. B. Souza
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Júlio F. M. Marchini
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Rodrigo A. B. Neto
- and the Emergency Department Medical Emergencies Discipline Internal Medicine Department Faculdade de Medicina Hospital das Clínicas HCFMUSP São Paulo SPBrazil
| | - Heraldo P. Souza
- and the Faculdade de Medicina FMUSP Universidade de São Paulo São Paulo SP Brazil
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31
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Zhou AZ, Marin JR, Hickey RW, Ramgopal S. Serious Diagnoses for Headaches After ED Discharge. Pediatrics 2020; 146:peds.2020-1647. [PMID: 33008843 DOI: 10.1542/peds.2020-1647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Headache is a common complaint among children presenting to the emergency department (ED) and can be due to serious neurologic and nonneurologic diagnoses (SNNDs). We sought to characterize the children discharged from the ED with headache found to have SNNDs at revisits. METHODS We performed a multicenter retrospective cohort study using data from 45 pediatric hospitals from October 1, 2015, to March 31, 2019. We included pediatric patients (≤18 years) discharged from the ED with a principal diagnosis of headache, excluding patients with concurrent or previous SNNDs or neurosurgeries. We identified rates and types of SNNDs diagnosed within 30 days of initial visit and compared these rates with those of control groups defined as patients with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints. RESULTS Of 121 621 included patients (57% female, median age 12.4 years, interquartile range: 8.8-15.4), 608 (0.5%, 95% confidence interval: 0.5%-0.5%) were diagnosed with SNNDs within 30 days. Most were diagnosed at the first revisit (80.8%); 37.5% were diagnosed within 7 days. The most common SNNDs were benign intracranial hypertension, cerebral edema and compression, and seizures. A greater proportion of patients with SNNDs underwent neuroimaging, blood, and cerebrospinal fluid testing compared with those without SNNDs (P < .001 for each). The proportion of SNNDs among patients diagnosed with headache (0.5%) was higher than for control cohorts (0.0%-0.1%) (P < .001 for each). CONCLUSIONS A total 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SNND within 30 days. Further efforts to identify at-risk patients remain a challenge.
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Affiliation(s)
- Amy Z Zhou
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois;
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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32
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Mori T, Takei H, Sasaoka Y, Nomura O, Ihara T. Semi-automatic intraosseous device (EZ-IO) in a paediatric emergency department. J Paediatr Child Health 2020; 56:1376-1381. [PMID: 32479669 DOI: 10.1111/jpc.14940] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 11/28/2022]
Abstract
AIM Intraosseous access is an alternative to conventional intravenous access. A number of studies have demonstrated the utility and safety of EZ-IO, a recently introduced semi-automatic intraosseous device. However, few studies have investigated the use of EZ-IO in the paediatric emergency setting. The aim of this study was to describe the epidemiological characteristics EZ-IO use including complications among paediatric patients in a paediatric emergency department. METHODS We conducted a retrospective descriptive study enrolling children younger than 16 years who visited our emergency department between January 2013 and August 2018. Data on age, gender, diagnosis, insertion success rate and complications were collected and analysed. RESULTS Seventy-two patients were enrolled; of these 38 (52.8%) were male. The median age was 9 months (interquartile range: 3-34.5 months). Of the total, 22 (30.6%) received more than one IO insertion. Ninety-seven consecutive IO insertions were identified. The rate of successful insertions was achieved at 92.7% (90 insertions). There were 21 complications (21.6%), including 17 extravasations (17.5%) of fluid and four dermal abrasions (4.1%). We found no cases of complications that may have compromised patient safety. CONCLUSIONS The success rate of the EZ-IO insertion was high in paediatric patients. However, we found a higher incidence of dermal abrasions, which might be a complication specific to children.
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Affiliation(s)
- Takaaki Mori
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hirokazu Takei
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuta Sasaoka
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Nomura
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Emergency and Disaster Medicine, Hirosaki University, Aomori, Japan
| | - Takateru Ihara
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Friedman AB, Berning AW, Marill KA. Confidence at 100%: Characteristics of Likelihood Ratio Confidence Intervals in the Emergency Medicine Diagnostics Literature. Acad Emerg Med 2020; 27:897-904. [PMID: 32011039 DOI: 10.1111/acem.13930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/19/2019] [Accepted: 01/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We hypothesized that "perfect" 100% sample sensitivity or specificity (PSSS) is common in the emergency medicine (EM) literature. When results yield PSSS, calculating the likelihood ratio (LR) 95% confidence interval (CI) has been challenging. Consequently, we also hypothesized that studies with PSSS would be less likely to report the LR and associated CI, and those that did would use imperfect methods. METHODS We searched PubMed or Scopus for all articles reporting diagnostic test results in the 20 top EM journals from 2011 to 2016 and randomly sampled 124 articles. Trained researchers coded the articles as having PSSS or not ("controls"). We separately sampled 100 articles with PSSS and compared them to 100 controls in terms of their reporting of diagnostic tests and associated CIs. RESULTS Of the 124 articles, 19.4% (95% CI = 13% to 27.6%) feature a diagnostic test with PSSS. The LR is reported significantly less often in PSSS studies versus control studies: 18 of 100 articles (18% [95% CI = 11.3% to 27.2%]) versus 34 of 100 articles (34% [95% CI = 25% to 44.2%]), with an odds ratio (OR) of 0.43 (95% CI = 0.21 to 0.86). The LR 95% CI is also reported less often in PSSS versus control studies: five of 100 articles (5% [95% CI = 1.9% to 11.8%]) versus 27 of 100 articles (27% [95% CI = 18.8% to 37%]), with an OR of 0.11 (95% CI = 0.02 to 0.44). Five articles with perfect sample sensitivity reported their negative LR CI. The bootstrap method resulted in CIs that were 42.7% smaller on average (range = 16.6% to 63.6%). CONCLUSION This analysis provides systematic evidence of diagnostic test reporting in the EM literature. Sample sensitivity or specificity of 100% is common. LRs and their associated 95% CIs are infrequently reported, particularly for PSSS samples. When the LR CI is reported in this scenario, it is overly wide. Improved reporting and methods can enhance the utility and confidence in diagnostic tests in EM.
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Affiliation(s)
- Ari B Friedman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Aric W Berning
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Keith A Marill
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
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34
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Morgenstern J, Heitz C, Bond C, Milne WK. Hot Off the Press: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Acad Emerg Med 2020; 27:917-920. [PMID: 32027434 DOI: 10.1111/acem.13933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 11/27/2022]
Affiliation(s)
| | - Corey Heitz
- Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Chris Bond
- University of Calgary, Calgary, Alberta, Canada
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35
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Ibrahim LF, Tosif S, McNab S, Hall S, Lee HJ, Lewena S, Daley AJ, Crawford NW, Steer AC, Bryant PA, Babl FE. SARS-CoV-2 testing and outcomes in the first 30 days after the first case of COVID-19 at an Australian children's hospital. Emerg Med Australas 2020; 32:801-808. [PMID: 32390285 PMCID: PMC7273066 DOI: 10.1111/1742-6723.13550] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 12/24/2022]
Abstract
Objective International studies describing COVID‐19 in children have shown low proportions of paediatric cases and generally a mild clinical course. We aimed to present early data on children tested for SARS‐CoV‐2 at a large Australian tertiary children's hospital according to the state health department guidelines, which varied over time. Methods We conducted a retrospective cohort study at The Royal Children's Hospital, Melbourne, Australia. It included all paediatric patients (aged 0–18 years) who presented to the ED or the Respiratory Infection Clinic (RIC) and were tested for SARS‐CoV‐2. The 30‐day study period commenced after the first confirmed positive case was detected at the hospital on 21 March 2020, until 19 April 2020. We recorded epidemiological and clinical data. Results There were 433 patients in whom SARS‐CoV‐2 testing was performed in ED (331 [76%]) or RIC (102 [24%]). There were four (0.9%) who had positive SARS‐CoV‐2 detected, none of whom were admitted to hospital or developed severe disease. Of these SARS‐CoV‐2 positive patients, 1/4 (25%) had a comorbidity, which was asthma. Of the SARS‐CoV‐2 negative patients, 196/429 (46%) had comorbidities. Risk factors for COVID‐19 were identified in 4/4 SARS‐CoV‐2 positive patients and 47/429 (11%) SARS‐CoV‐2 negative patients. Conclusion Our study identified a very low rate of SARS‐CoV‐2 positive cases in children presenting to a tertiary ED or RIC, none of whom were admitted to hospital. A high proportion of patients who were SARS‐CoV‐2 negative had comorbidities.
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Affiliation(s)
- Laila F Ibrahim
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Hospital-In-The-Home Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Shidan Tosif
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Sarah McNab
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Samantha Hall
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Hyun Jung Lee
- Emergency Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Stuart Lewena
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Andrew J Daley
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Microbiology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nigel W Crawford
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Andrew C Steer
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Hospital-In-The-Home Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
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Altman DE, Sun BC, Lin B, Baecker A, Samuels-Kalow M, Park S, Shen E, Wu YL, Sharp A. Impact of Physician-Patient Language Concordance on Patient Outcomes and Adherence to Clinical Chest Pain Recommendations. Acad Emerg Med 2020; 27:487-491. [PMID: 32056327 PMCID: PMC7293585 DOI: 10.1111/acem.13940] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/20/2020] [Accepted: 02/05/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to evaluate if there is an association between patient-physician language concordance and adverse patient outcomes or physician adherence to clinical recommendations for emergency department (ED) patients with chest pain. METHODS We conducted a retrospective observational study of adult ED chest pain encounters with a troponin order from May 2016 to September 2017 across 15 community EDs. Outcomes were 30-day acute myocardial infarction or all-cause mortality, hospital admission/observation, or noninvasive cardiac testing. To assess patient outcomes, we used the overall cohort. To assess adherence to clinical recommendations, we used a subgroup of patients with a low-risk HEART score. A mixed-effects logistic regression model was used to compare the odds of the outcomes between language concordant and discordant patient-physician pairs, controlling for patient characteristics. RESULTS Overall, 52,014 ED encounters were included (10,791 low-risk HEART encounters). Of those 6,452 (12.4%) encounters were language discordant and 1.7% in each group had an adverse outcome. Adjusted models demonstrated no increased risk for language discordant ED encounters when comparing adverse outcomes (odds ratio [OR] = 0.96, 95% confidence interval [CI] = 0.6 to 1.5) for all patients or recommended care (OR = 1.02, 95% CI = 0.87 to 1.2) for low-risk patients. CONCLUSIONS No associations were found between patient-physician language concordance and outcomes or physician adherence to clinical recommendations for ED patients with chest pain. Accessible and effective interpretation services, combined with a decision support tool with standard clinical recommendations, may have contributed to equitable care.
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Affiliation(s)
| | - Benjamin C Sun
- the, Department of Emergency Medicine, Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Bryan Lin
- From, Kaiser Permanente Southern California, Pasadena, CA
| | - Aileen Baecker
- From, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Stacy Park
- From, Kaiser Permanente Southern California, Pasadena, CA
| | - Ernest Shen
- From, Kaiser Permanente Southern California, Pasadena, CA
| | - Yi-Lin Wu
- From, Kaiser Permanente Southern California, Pasadena, CA
| | - Adam Sharp
- From, Kaiser Permanente Southern California, Pasadena, CA
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37
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Tsze DS, Cruz AT, Mistry RD, Gonzalez AE, Ochs JB, Richer L, Kuppermann N, Dayan PS. Interobserver Agreement in the Assessment of Clinical Findings in Children with Headaches. J Pediatr 2020; 221:207-214. [PMID: 32446483 PMCID: PMC7251971 DOI: 10.1016/j.jpeds.2020.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/10/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the interobserver agreement of history and physical examination findings in children undergoing evaluation in the emergency department (ED) for headaches. STUDY DESIGN We conducted a prospective, cross-sectional study of children aged 2-17 years evaluated at 3 tertiary-care pediatric EDs for non-traumatic headaches. Two clinicians independently completed a standardized assessment of each child and documented the presence or absence of history and physical examination variables. Unweighted κ statistics were determined for 68 history and 24 physical examination variables. RESULTS We analyzed 191 paired observations; median age was 12 years, with 19 (9.9%) children younger than 7 years. Interrater reliability was at least moderate (κ ≥ 0.41) for 41 (60.3%) patient history variables. Eleven (61.1%) of 18 physical examination variables for which κ statistics could be calculated had a κ that was at least moderate. CONCLUSIONS A substantial number of history and physical examination findings demonstrated at least moderate κ statistic values when assessed in children with headaches in the ED. These variables may be generalizable across different types of clinicians for evaluation of children with headaches. If also found to predict the presence or absence of emergent intracranial abnormalities, the more reliable clinical findings may be helpful in the development of clinical prediction rules or risk stratification models that could be used across settings for children with headaches.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine. Houston, TX
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine. Aurora, CO
| | - Ariana E. Gonzalez
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Julie B. Ochs
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta. Edmonton, Alberta, Canada
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine. Sacramento, CA
| | - Peter S. Dayan
- Department of Emergency Medicine. Division of Pediatric Emergency Medicine. Columbia University College of Physicians and Surgeons. New York, NY
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38
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Family Perspectives on Visiting the Pediatric Emergency Department for Migraine: A Qualitative Study. Pediatr Emerg Care 2020; 36:e310-e317. [PMID: 28926506 DOI: 10.1097/pec.0000000000001285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The aim of this study was to explore the perspectives of families regarding their expectations and experience of visiting the emergency department (ED) for migraine. METHODS This was a qualitative study involving the families of 25 patients aged 10 to 18 years receiving ED care for acute migraine. Following their visit, independent semistructured telephone interviews were conducted with both the patient and parent or guardian. Questions were designed to explore factors pertaining to the family's perspective regarding their visit to the ED and expectations for the ED visit. RESULTS Families reported a variety of reasons for visiting the ED. The majority of participants reported that they were worried about their headaches. Families more commonly had expectations for treatment than they did for investigations. As compared with patients, parents more commonly reported specific expectations for investigations and less commonly expressed concerns about intravenous treatments. Expectations for treatment efficacy varied: whereas some parents expected complete pain relief, for others, lesser degrees of relief were considered satisfactory. The experience of treatment efficacy was related to willingness to receive the same treatment again. CONCLUSIONS Given that a high frequency of families endorsed that they were worried about the headache when presenting to the ED, clinicians should strive to make a diagnosis of migraine in the ED setting and to educate families about this diagnosis. Because of divergent parent and patient perspectives, health care providers should inquire about family expectations, especially in relation to expectations for investigations and concerns surrounding intravenous interventions, and ensure that both the patient's and parent's perspectives are considered when developing a management plan for pediatric migraine.
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Lampart A, Kuster T, Nickel CH, Bingisser R, Pedersen V. Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low-Energy Falls. J Am Geriatr Soc 2020; 68:977-982. [PMID: 32142155 DOI: 10.1111/jgs.16400] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND/OBJECTIVES To determine the prevalence and severity of traumatic intracranial hemorrhage (tICH) in a large cohort of older adults presenting with low-energy falls and the association with anticoagulation or antiplatelet medication. DESIGN Bicentric retrospective cohort analysis. SETTING Two level 1 trauma centers in Switzerland and Germany. PARTICIPANTS Consecutive sample of older adults (aged ≥65 y) presenting to the emergency department (ED) over a 1-year period with low-energy falls who received cranial computed tomography (cCT) within 48 hours of ED presentation. MEASUREMENTS The prevalence and severity of tICHs was assessed and the outcomes (in-hospital mortality, admission to intensive care unit [ICU], or neurosurgical intervention) were specified. We used multivariate regression models to measure the association between anticoagulation/antiplatelet therapy and the risk for tICH after adjustment for known predictors. RESULTS The overall prevalence for tICH detected by cCT was 176 of 2567 (6.9%). Neurosurgical intervention was performed in 15 of 176 (8.5%) patients with tICH, 28 of 176 (15.9%) patients were admitted to the ICU, and 14 of 176 (8.0%) died in the hospital. CT-detected skull fracture and signs of injury above the clavicles were the strongest predictors for the presence of tICH (odds ratio [OR] = 4.28; 95% confidence interval [CI] = 2.79-6.51; OR = 1.88; 95% CI = 1.3-2.73, respectively). Among 2567 included patients, 1424 (55%) were on anticoagulation/antiplatelet therapy. Multivariate regression models showed no differences for the risk of tICH (OR = 1.05; 95% CI = .76-1.47; P = .76) or association with the head-specific Injury Severity Scale (incident rate ratio = 1.08; 95% CI = .97-1.19; P = .15) with or without anticoagulation/antiplatelet therapy. CONCLUSION Medication with anticoagulants or antiplatelet agents was not associated with higher prevalence and severity of tICH in older patients with low-energy falls undergoing cCT examination. In addition to cCT-detected skull fractures, visible injuries above the clavicles were the strongest clinical predictors for tICH. Our findings merit prospective validation. J Am Geriatr Soc 68:977-982, 2020.
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Affiliation(s)
- Alina Lampart
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Tobias Kuster
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Roland Bingisser
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Vera Pedersen
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland.,Department for General, Trauma and Reconstructive Surgery, Ludwig Maximilian University Munich, Munich, Germany
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40
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Green L, Selleck L, Gibbons M, Klim S, Ritchie P, Patel R, Pham CCHP, Kelly AM. Does the evidence justify routine transfer of residents of aged care facilities for CT scan after minor head trauma? Intern Med J 2020; 50:1048-1052. [PMID: 32092229 DOI: 10.1111/imj.14808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND In 2014, the South Australian coroner recommended that residents of residential aged care facilities (RACF) who had sustained a head injury should be transported to emergency departments (ED) for assessment and a head CT scan, with the view to preventing mortality. The evidence base for the recommendation is unclear. AIMS To determine the rate of emergent intervention (neurosurgery, transfusion of blood products or reversal of anti-coagulation) in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. METHODS This was a retrospective cohort study by medical records review at two university-affiliated community ED. Participants were patients from RACF attending ED who had suffered minor head trauma and had their usual cognitive function. Exclusions were altered conscious state, new neurological findings or associated orthopaedic injury requiring hospital admission. The primary outcome was rate of emergent intervention in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. RESULTS A total of 366 patients was studied; median age 86 years, 45% taking anti-coagulant/anti-platelet medication. Eighty per cent underwent head CT. Six per cent had intracranial haemorrhage (ICH; 95% CI 4-8.9%). No patient underwent neurosurgery. One had emergent intervention, reversal of anti-coagulation (0.3%, 95% CI 0.05-1.5%). CONCLUSION The rate of emergent intervention for ICH in patients from RACF who sustained a minor head trauma but had their normal cognitive function was <1%. None underwent neurosurgical intervention. The low rate of intervention seriously challenges the appropriateness of routine transfer and CT for this patient group.
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Affiliation(s)
- Lorne Green
- Department of Emergency Medicine, Western Health, Victoria, Australia
| | - Lucy Selleck
- Department of Emergency Medicine, Western Health, Victoria, Australia
| | - Michael Gibbons
- Department of Emergency Medicine, Western Health, Victoria, Australia
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research at Western Health, St Albans, Victoria, Australia
| | - Peter Ritchie
- Department of Emergency Medicine, Western Health, Victoria, Australia
| | - Rajesh Patel
- Joseph Epstein Centre for Emergency Medicine Research at Western Health, St Albans, Victoria, Australia
| | | | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research at Western Health, St Albans, Victoria, Australia.,Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia
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Daverio M, Da Dalt L, Panozzo M, Frigo AC, Bressan S. A two-tiered high-flow nasal cannula approach to bronchiolitis was associated with low admission rate to intensive care and no adverse outcomes. Acta Paediatr 2019; 108:2056-2062. [PMID: 31102551 DOI: 10.1111/apa.14869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 11/29/2022]
Abstract
AIM We aimed to describe the characteristics and outcomes of infants with bronchiolitis who received high-flow nasal cannula oxygen (HFNC) following a two-tiered approach. METHODS This retrospective study included 211 infants below 12 months of age needing oxygen therapy for bronchiolitis, between 2012 and 2017, on the general paediatric ward of the tertiary Paediatric Hospital of Padova, Italy. HFNC was used as first-line therapy for moderate to severe disease and as rescue therapy for deterioration on low-flow oxygen. RESULTS Median age was 61 days (IQR 31-126), and 57.3% were males. HFNC was used as first-line therapy in 35/211 (16.6%) infants and as rescue in 73/176 (41.5%) patients on low-flow oxygen. Overall 9/211 patients (4.3%) were admitted to intensive care, representing a HFNC failure of 9/108 (8.3%). Intensive care admissions did not significantly differ between initial low-flow oxygen therapy and HFNC (8/176, 4.5% versus 1/35, 2.8%, proportion difference 1.7%, 95%CI -10.2 to 6.7), or between initial and rescue HFNC (1/35, 2.8% versus 8/73, 10.9%; proportion difference 8.1%, 95%CI -4.5 to 18). Only two patients developed air leak and were treated conservatively. CONCLUSION A two-tiered approach to HFNC use in bronchiolitis was associated with low intensive care admissions and no adverse outcomes.
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Affiliation(s)
- Marco Daverio
- Paediatric Intensive Care Unit Department of Women's and Children's Health University Hospital of Padova Padova Italy
| | - Liviana Da Dalt
- Paediatric Emergency Unit Department of Women's and Children's Health University Hospital of Padova Padova Italy
| | - Matteo Panozzo
- Paediatric Emergency Unit Department of Women's and Children's Health University Hospital of Padova Padova Italy
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit Department of Cardiac Thoracic and Vascular Sciences University of Padova Padova Italy
| | - Silvia Bressan
- Paediatric Emergency Unit Department of Women's and Children's Health University Hospital of Padova Padova Italy
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Raucci U, Della Vecchia N, Ossella C, Paolino MC, Villa MP, Reale A, Parisi P. Management of Childhood Headache in the Emergency Department. Review of the Literature. Front Neurol 2019; 10:886. [PMID: 31507509 PMCID: PMC6716213 DOI: 10.3389/fneur.2019.00886] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 07/30/2019] [Indexed: 12/16/2022] Open
Abstract
Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.
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Affiliation(s)
- Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicoletta Della Vecchia
- Department of Pediatrics, University of "Studi della Campania Luigi Vanvitelli", Naples, Italy
| | - Chiara Ossella
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Chiara Paolino
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Maria Pia Villa
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Antonino Reale
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasquale Parisi
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
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Glatstein M, Voliovitch Y, Orbach R, Carmi A, Amarilyo G, Carbell G, Rimon A. Outpatient Management of Headache after Pediatric Emergency Department Visit: Are we Missing Anything? Headache 2019; 59:1530-1536. [PMID: 31348526 DOI: 10.1111/head.13607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Headache is a common complaint in children at a pediatric emergency department (PED). The primary objective of this analysis is to describe the outcome of patients presenting with headache to the PED and discharged with neurology follow up. The secondary objective is to describe the diagnostic evaluation children with headache underwent in the PED and to evaluate headache characteristics which are more likely associated with serious, life-threatening conditions. METHODS A retrospective chart review of children who were discharged from the PED after evaluation for headache, with a scheduled urgent neurology outpatient clinic follow up at the same institution, over a 3.5-year period. RESULTS During the study period, we identified 300 children whose admitting diagnosis was headache and they were discharged from the PED with a scheduled follow up. None of these patients had papilledema on fundoscopy performed by an ophthalmologist during the PED visit. Following neurology outpatient clinic visit, 62 (21%) were referred to perform brain magnetic resonance imaging. None of the patients had a diagnosis of brain tumor or any anatomic abnormality that could increase intracranial pressure. CONCLUSIONS No immediate life-threatening cases presented to the follow up neurology clinic for evaluation. A scheduled urgent neurology outpatient clinic follow up in any child with headache who is discharged from the PED, offers a safety net, even when the physical examination including fundoscopy is normal.
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Affiliation(s)
- Miguel Glatstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sourasky Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Clinical Pharmacology and Toxicology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yair Voliovitch
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sourasky Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rotem Orbach
- Sourasky Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Neurology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Amit Carmi
- Sourasky Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Amarilyo
- Sourasky Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Gary Carbell
- Sourasky Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ayelet Rimon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sourasky Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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44
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Klim S, Krieser D, Kelly AM. Sub-optimal treatment of paediatric migraine in an emergency department: An observational study. Emerg Med Australas 2019; 31:879-881. [PMID: 31343101 DOI: 10.1111/1742-6723.13355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 05/26/2019] [Accepted: 06/19/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe treatment of children presenting to an Australian ED with a final ED diagnosis of migraine. METHODS Planned substudy of a retrospective cohort study of the epidemiology of headache in children was done. Primary outcome of interest was treatment administered in the ED. RESULTS Thirty-five children were studied. The most commonly used medications were non-steroidal anti-inflammatory drugs, paracetamol and ondansetron. Specific antimigraine therapy was used uncommonly. Fourteen percent of children received an opiate. CONCLUSION Treatment of migraine in children was not consistent with the available evidence regarding agents' relative effectiveness. The use of opiates is concerningly high.
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Affiliation(s)
- Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, Victoria, Australia
| | - David Krieser
- Department of Emergency Medicine, Sunshine Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia
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45
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Hopper SM, McKenna S, Williams A, Phillips N, Babl FE. Clinical clearance and imaging for possible cervical spine injury in children in the emergency department: A retrospective cohort study. Emerg Med Australas 2019; 32:93-99. [PMID: 31317676 DOI: 10.1111/1742-6723.13351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES While cervical spine injuries (CSIs) are rare in the paediatric population, presentations to EDs with possible neck injuries are common. Based on a lack of Australian data we set out to determine how many possible injuries are clinically cleared, what imaging is used on the remainder and the incidence and characteristics of confirmed paediatric CSIs. METHODS We undertook a retrospective electronic medical record review of children <18 years with potential CSIs at a large tertiary paediatric trauma centre in Victoria, Australia over a 12 month period (annual census 87 000). For possible injuries we extracted key epidemiologic, imaging and short-term outcome data. RESULTS During the study period, a total of 617 patients with potential neck injuries were seen in the ED (617/87 000, 0.7%). The median age was 11 years. The most common mechanisms of injury were falls (41%), motor vehicle injuries (28%) and sports-related injuries (24%). Four hundred and fourteen of 617 (67%) underwent neck imaging (345/414, 83% plain radiograph; 100/414, 24% computed tomography; 7/414, 1.6% magnetic resonance imaging). Twenty-three of 617 (4.1%) had radiologically documented CSIs. Two required operative interventions for their neck injuries. CONCLUSION While two-thirds of children with potential CSIs undergo radiological evaluation, actual injuries are rare (<4%). These data suggest that there is a potential for improved targeting of cervical spine imaging for trauma. The development of a clinical decision tool may help reduce neck radiography.
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Affiliation(s)
- Sandy M Hopper
- Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stewart McKenna
- Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Amanda Williams
- Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Natalie Phillips
- Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Franz E Babl
- Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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46
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Tsze DS, Ochs JB, Gonzalez AE, Dayan PS. Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging. Cephalalgia 2019; 39:185-196. [PMID: 29874930 PMCID: PMC10693908 DOI: 10.1177/0333102418781814] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND Clinicians appear to obtain emergent neuroimaging for children with headaches based on the presence of red flag findings. However, little data exists regarding the prevalence of these findings in emergency department populations, and whether the identification of red flag findings is associated with potentially unnecessary emergency department neuroimaging. OBJECTIVES We aimed to determine the prevalence of red flag findings and their association with neuroimaging in otherwise healthy children presenting with headaches to the emergency department. Our secondary aim was to determine the prevalence of emergent intracranial abnormalities in this population. METHODS A prospective cohort study of otherwise healthy children 2-17 years of age presenting to an urban pediatric emergency department with non-traumatic headaches was undertaken. Emergency department physicians completed a standardized form to document headache descriptors and characteristics, associated symptoms, and physical and neurological exam findings. Children who did not receive emergency department neuroimaging received 4-month telephone follow-up. Outcomes included emergency department neuroimaging and the presence of emergent intracranial abnormalities. RESULTS We enrolled 224 patients; 197 (87.9%) had at least one red flag finding on history. Several red flag findings were reported by more than a third of children, including: Headache waking from sleep (34.8%); headache present with or soon after waking (39.7%); or headaches increasing in frequency, duration and severity (40%, 33.1%, and 46.3%). Thirty-three percent of children received emergency department neuroimaging. The prevalence of emergent intracranial abnormalities was 1% (95% CI 0.1, 3.6). Abnormal neurological exam, extreme pain intensity of presenting headache, vomiting, and positional symptoms were independently associated with emergency department neuroimaging. CONCLUSIONS Red flag findings are common in children presenting with headaches to the emergency department. The presence of red flag findings is associated with emergency department neuroimaging, although the risk of emergent intracranial abnormalities is low. Many children with headaches may be receiving unnecessary neuroimaging due to the high prevalence of non-specific red flag findings.
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Affiliation(s)
- Daniel S Tsze
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Julie B Ochs
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Ariana E Gonzalez
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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47
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Bauman JL, Jackevicius C, Zillich AJ, Parker RB, Phillips BB. On the methodology of retrospective chart reviews. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jerry L. Bauman
- Pharmacotherapy Publications Inc; University of Illinois at Chicago College of Pharmacy; Chicago Illinois
| | | | - Alan J. Zillich
- Purdue University College of Pharmacy; West Lafayette Indiana
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48
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Perry MC, Yaeger SK, Toto RL, Suresh S, Hickey RW. A Modern Epidemic: Increasing Pediatric Emergency Department Visits and Admissions for Headache. Pediatr Neurol 2018; 89:19-25. [PMID: 30343832 PMCID: PMC8485652 DOI: 10.1016/j.pediatrneurol.2018.07.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/28/2018] [Accepted: 07/28/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Headaches represent 0.9% to 2.6% of visits to a pediatric emergency department (PED). We noted a trend of increasing visits for headache in our tertiary care PED and sought to further characterize this trend. METHODS We identified PED visits with International Classification of Disease, Ninth Revision, Clinical Modification diagnoses for headache at 25 hospitals in Pediatric Health Information System between 2003 and 2013. To further characterize demographics and treatment trends over time we used the electronic health record in our emergency department to identify children ages four to 18 between January 2007 and December 2014 with International Classification of Disease, Ninth Revision codes for headache: a random sample of 50 visits per year were chosen for chart review. RESULTS Pediatric Health Information System visits for headache increased by 166% (18,041 in 2003 and 48,020 in 2013); by comparison, total PED visits increased by 57.6%. The percent admission increased by 300% (2020 admissions in 2003 and 8087 admissions in 2013). At our hospital, headache visits increased 111% from 896 visits in 2007 to 1887 visits in 2014; total PED visits increased 30.2%. The admission percentage for headache increased 187% with 156 admissions in 2007 and 448 in 2014. Management over time differed in the frequency of head computed tomography which decreased 3.7% per year (r = -0.93, 95% CI -0.99, -0.64) from 34% in 2007 to 18% in 2014. CONCLUSION Pediatric emergency department visits for headache are increasing and a growing proportion of these patients are admitted. This finding identifies a potential patient population to target for interventions to improve outpatient management and reduce pediatric emergency department utilization.
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Affiliation(s)
- Michelle C Perry
- A Children's Hospital of Pittsburgh of UPMC, Department of Pediatrics, Pittsburgh, Pennsylvania.
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49
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Orr SL, Richer L, Barrowman N, Zemek R. Oral dexamethasone for the prevention of acute migraine recurrence in pediatric patients presenting to the emergency department with migraine. CEPHALALGIA REPORTS 2018. [DOI: 10.1177/2515816318804158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objective: To assess the feasibility of a randomized controlled trial protocol that aims to determine the efficacy and safety of oral dexamethasone compared to placebo for the prevention of migraine recurrence in children and adolescents visiting the pediatric emergency department (ED) with migraine. Methods: This study was a two-arm, parallel-group, randomized, placebo-controlled, double-blind pilot trial of patients presenting to the pediatric ED with migraine. Eligible participants were randomized at 1:1 ratio to receive either oral dexamethasone 0.6 mg/kg (maximum 15 mg) or matched placebo as a single dose. Efficacy and safety outcomes were assessed at discharge, 48 h and 7 days after discharge. The primary outcome of the trial was feasibility and was assessed through participant recruitment rate, follow-up completion rates, participant satisfaction ratings and comparison of enrolled versus non-enrolled participants. Efficacy and safety outcomes were not analyzed given that this was a pilot study. Results: Twelve participants were enrolled over the 6-month recruitment period. This represents 60% of the planned sample size and a 10.5% recruitment rate. No other feasibility issues were identified and patients expressed high satisfaction rates with their treatment: 90.9% were satisfied with their treatment at discharge and at 48-h follow-up and 81.8% were satisfied with their treatment at 7-day follow-up (81.8%). There were no significant differences observed when comparing enrolled participants to those not enrolled. Conclusion: This pilot randomized controlled trial is the first to assess dexamethasone in the pediatric ED for the prevention of migraine recurrence. The protocol is feasible but recruitment in a single center was lower than expected. Future pediatric ED migraine studies may use innovative or pragmatic trial designs to maximize feasibility from a recruitment standpoint.
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Affiliation(s)
- Serena L Orr
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Women and Children’s Health Research Institute, Edmonton, Alberta, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Roger Zemek
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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50
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Ehrman RR, Favot MJ, Malik AN. Dissecting the Evidence on Aortic Catastrophe. Acad Emerg Med 2018; 25:1184-1185. [PMID: 29904982 DOI: 10.1111/acem.13501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center/Sinai-Grace Hospital, Detroit, MI
| | - Mark J Favot
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center/Sinai-Grace Hospital, Detroit, MI
| | - Adrienne N Malik
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center/Sinai-Grace Hospital, Detroit, MI
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