Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians

Ultrasound Investigation of the Fifth Intercostal Space Landmark for Chest Tube Thoracostomy Site Selection in Pediatric Patients

OBJECTIVES

Chest tube thoracostomy site selection is typically chosen through landmark identification of the fifth intercostal space (ICS). Using point-of-care ultrasound (POCUS), studies have shown this site to be potentially unsafe in many adults; however, no study has evaluated this in children. The primary aim of this study was to evaluate the safety of the fifth ICS for pediatric chest tube placement, with the secondary aim to identify patient factors that correlate with an unsafe fifth ICS.

METHODS

This was an observational study using POCUS to evaluate the safety of the fifth ICS for chest tube thoracostomy placement using a convenience sample of pediatric emergency department patients. Safety was defined as the absence of the diaphragm appearing within or above the fifth ICS during either tidal or maximal respiration. Univariate and multivariable analyses were used to identify patient factors that correlated with an unsafe fifth ICS.

RESULTS

Among all patients, 10.3% (95% confidence interval [CI] 6.45-16.1) of diaphragm measurements crossed into or above the fifth ICS during tidal respiration and 27.2% (95% CI 19.0-37.3) during maximal respiration. The diaphragm crossed the fifth ICS more frequently on the right when compared with the left, with an overall rate of 45.0% (95% CI 36.1-54.3) of right diaphragms crossing during maximal respiration. In both univariate and multivariate analyses, a 1-kg/m2 increase in body mass index was associated with an increase of 10% or more in the odds of crossing during both tidal and maximal respiration (P = 0.003 or less).

CONCLUSIONS

A significant number of pediatric patients have diaphragms that cross into or above the fifth ICS, suggesting that placement of a chest tube thoracostomy at this site would pose a significant complication risk. POCUS can quickly and accurately identify these unsafe sites, and we recommend it be used before pediatric chest tube thoracostomy.

Epidemiological Analysis of the Emergency Vascular Access in Pediatric Trauma Patients: Single-Center Experience of Intravenous, Intraosseous, Central Venous, and Arterial Line Placements

Vascular access in severely injured pediatric trauma patients is associated with time-critical circumstances and low incidences, whereas only scarce literature on procedure performance is available. The purpose of this study was to analyze the performance of different vascular access procedures from the first contact at the scene until three hours after admission. Intubated pediatric trauma patients admitted from the scene to a single Level I trauma center between 2008 and 2019 were analyzed regarding intravenous (IV) and intraosseous (IO) accesses, central venous catheterization (CVC) and arterial line placement. Sixty-five children with a median age of 14 years and median injury severity score of 29 points were included, of which 62 (96.6%) underwent successful prehospital IV or IO access by emergency medical service (EMS) physicians, while it failed in two children (3.1%). On emergency department (ED) admission, IV cannulas of prehospital EMS had malfunctions or were dislodged in seven of 55 children (12.7%). IO access was performed in 17 children without complications, and was associated with younger age, higher injury severity and higher mortality. Fifty-two CVC placements (58 attempts) and 55 arterial line placements (59 attempts) were performed in 45 and 52 children, respectively. All CVC and arterial line placements were performed in the ED, operating room (OR) and intensive care unit (ICU). Ten mechanical complications related to CVC placement (17.8%) and seven related to arterial line placement (10.2%) were observed, none of which had outcome-relevant consequences. This case series suggests that mechanical issues of vascular access may frequently occur, underlining the need for special preparedness in prehospital, ED, ICU and OR environments.

Projected Saudi Arabian pediatric emergency consultant physician staffing needs for 2021-2030

BACKGROUND

Assess current and future pediatric emergency physician supply and need at 26 pediatric emergency departments (EDs) in 10 administrative regions across Saudi Arabia from 2021 through 2030.

METHODS

For 10 administrative regions across Saudi Arabia, data were obtained on the size of the pediatric population (children <14 years old), the expected number of pediatric ED visits, and the number of pediatric emergency, fellowship-trained consultant physicians for the years 2015 through 2019. Time series linear regression modeling was used to estimate annual pediatric population sizes and pediatric ED visits for 2021-2030, based on 2015-2019 data trends. The projected number of pediatric emergency consultant physicians needed for 2021-2030 based on these trends was calculated according to a consensus method adopted by the Saudi Ministry of Health.

RESULTS

For the 10 Saudi Arabian administrative regions, the pediatric population is estimated to be 8,061,409 (95% confidence interval [CI]: 7,815,767 to 8,307,052) in 2021 and 9,764,591 (95% CI: 9,046,490 to 10,500,000) for 2030, and estimated the number of pediatric ED visits is 3,442,259 (95% CI: 3,013,697 to 3,870,822) for 2021 and 4,610,072 (95% CI: 3,026,986 to 6,193,158) for 2030. The projected number of pediatric emergency consultant physicians needed for 2021 is 1158 (95% CI: 1,002 to 1,314) and for 2030 is 1500 (95% CI: 985 to 2016), whereas deficit in number of pediatric emergency consultant physicians available is 1107 (95% CI: 944 to 1,270) for 2021 and 1405 (95% CI: 869 to 1,941) for 2030.

CONCLUSIONS

The study projections demonstrate a disparity between current and projected supply and demand of pediatric emergency physicians within Saudi Arabia.

The Pediatric Emergency Research Network (PERN): A decade of global research cooperation in paediatric emergency care

OBJECTIVES

The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks.

METHODS

PERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.

RESULTS

Beginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID-19 pandemic.

CONCLUSIONS

Following its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource-restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world.

The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care

OBJECTIVES

The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks.

METHODS

The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.

RESULTS

Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings.

CONCLUSIONS

The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.