Pediatric Sepsis in General Emergency Departments: Association Between Pediatric Sepsis Case Volume, Care Quality, and Outcome

STUDY OBJECTIVE

To assess whether a general emergency department's (ED) annual pediatric sepsis volume increases the odds of delivering care concordant with Surviving Sepsis pediatric guidelines.

METHODS

A retrospective cohort study of children <18 years with sepsis presenting to 29 general EDs. Emergency department and hospital data were abstracted from the medical records of 2 large health care systems, including all hospitals to which children were transferred. Guideline-concordant care was defined as intravenous antibiotics within 3 hours, intravenous fluid bolus within 3 hours, and lactate measured. The association between annual ED pediatric sepsis encounters and the probability of receiving guideline-concordant care was assessed.

RESULTS

We included 1,527 ED encounters between January 1, 2015, and September 30, 2021. Three hundred and one (19%) occurred in 25 EDs with <10 pediatric sepsis encounters annually, 466 (31%) in 3 EDs with 11 to 100 pediatric sepsis encounters annually, and 760 (50%) in an ED with more than 100 pediatric sepsis encounters annually. Care was concordant in 627 (41.1%) encounters. In multivariable analysis, annual pediatric sepsis volume was minimally associated with the probability of guideline-concordant care (odds ratio 1.002 [95% confidence interval 1.001 to 1.00]). Care concordance increased from 23.1% in 2015 to 52.8% in 2021.

CONCLUSION

Guideline-concordant sepsis care was delivered in 41% of pediatric sepsis cases in general EDs, and annual ED pediatric sepsis encounters had minimal association with the odds of concordant care. Care concordance improved over time. This study suggests that factors other than pediatric sepsis volume are important in driving care quality and identifying drivers of improvement is important for children first treated in general EDs.

Information Seeking and Sensemaking in Emergency Medical Service through Simulation Video Review

Emergency medical services (EMS) providers often face significant challenges in their work, including collecting, integrating, and making sense of a variety of information. Despite their criticality, EMS work is one of the very few medical domains with limited technical support. To design and implement effective decision support, it is essential to examine and gain a holistic understanding of the fine-grained process of sensemaking in the field. To that end, we reviewed 25 video recordings of EMS simulations to understand the nuances of EMS sensemaking work, including 1) the types of information and situation that are collected and made sense of in the field; 2) the work practices and temporal patterns of EMS sensemaking work; and 3) the challenges in EMS sensemaking and decision-making process. Based on the results, we discuss implications for technology opportunities to support rapid information acquisition and sensemaking in time-critical, high-risk medical settings such as EMS.

Frequency, Type, and Degree of Potential Harm of Adverse Safety Events among Pediatric Emergency Medical Services Encounters

BACKGROUND

Only 5-10% of emergency medical services (EMS) patients are children, and most pediatric encounters are low-acuity. EMS chart review has been used to identify adverse safety events (ASEs) in high-acuity and high-risk pediatric encounters. The objective of this work was to evaluate the frequency, type, and potential harm of ASEs in varied acuity pediatric EMS encounters.

METHODS

This cross-sectional study evaluated pediatric (ages 0-18 years) prehospital records from 15 EMS agencies among three states (Colorado, Connecticut, and Rhode Island) between November 2019 and October 2021. Research associates used a previously validated tool to analyze electronic EMS and hospital records. Adverse safety events were recorded in six care categories, grouped into four levels for analysis: assessment/diagnosis/clinical decision-making, procedures, medication administration (including O2), and fluid administration, and defined across five types of ASEs: Unintended injuries or consequences, Near misses, Suboptimal actions, Errors, and Management complications (UNSEMs). Type and frequency of ASEs in each category were rated in three harm severities: Harm Unlikely, Mild/Temporary, or Permanent/Severe. Three physicians verified ASEs determined by research associates. Frequency of ASEs and harm likelihood are reported.

RESULTS

Records for 508 EMS patients were reviewed, with 63 (12.4%) transported using lights and sirens. At least one clinical intervention beyond assessment/diagnosis/clinical decision-making was documented for 183 (36.1%, 95% CI: 31.8, 40.4) patients. A total of 162 ASEs were identified for 112 patients (22.1%, 95% CI: 18.5, 25.7). Suboptimal actions were the most frequent UNSEM (n = 66, 40.7%; 95% CI: 33.1, 48.3). For ASEs, (n = 162), the most frequent associations were with procedures 39.5% (95% CI: 32.0, 47.0) or assessment/diagnosis/clinical decision making, 32.1%, (95% CI: 24.9, 39.3). Among care categories, fluid administration was associated with significantly more UNSEMs (58.1%, 95% CI:53.8, 62.4). Most ASEs were determined to be 'Harm Unlikely' 62.4% (95% CI: 54.4, 70.4), with assessment/diagnosis/clinical decision making having significantly fewer ASEs with documented harm (22.4%, 95% CI: 10.7, 34.1) compared to other care categories.

CONCLUSION

Over 20% of pediatric EMS encounters had an identified ASE, and most were unlikely to cause harm. Most frequent ASEs were likely to be associated with procedures and assessment/diagnosis/clinical decision-making.

Pediatric Trauma Surgery in Iraq and Afghanistan: Mortality, Indicators, and Most Common Operating Room Interventions from 2007-2016

BACKGROUND

The wars in Afghanistan and Iraq produced thousands of pediatric casualties, utilizing substantial military medical resources. We sought to describe characteristics of pediatric casualties that underwent operative intervention in Iraq and Afghanistan.

METHODS

This is a retrospective analysis of pediatric casualties treated by US Forces in the Department of Defense Trauma Registry (DoDTR) with at least one operative intervention during their course. We report descriptive, inferential statistics, and multivariable modeling to assess associations for receiving an operative intervention and survival. We excluded casualties that died on arrival to the emergency department.

RESULTS

During the study period, there were a total of 3439 children in the DoDTR of which 3388 met inclusion criteria. Of those, 2538 (75%) required at least one operative intervention totaling 13,824 (median 4, IQR 2-7, range 1-57). Compared to nonoperative casualties, operative casualties were older, male, and had a higher proportion of explosive and firearm injuries, higher median composite injury severity scores, higher overall blood product administration, and longer intensive care hospitalizations. The most common operative procedures were related to abdominal, musculoskeletal, and neurosurgical trauma, burn management, and head and neck. When adjusting for confounders, older age (unit OR 1.04, 1.02-1.06), receiving a massive transfusion during their initial 24 hours (6.86, 4.43-10.62), explosive injuries (1.43, 1.17-1.81), firearm injuries (1.94, 1.47-2.55), and age-adjusted tachycardia (1.45, 1.20-1.75) were all associated with going to the operating room. Survival to discharge on initial hospitalization was higher in the operative cohort (95% versus 82%, p < 0.001). When adjusting for confounders, operative intervention was associated with improved mortality (OR 7.43, 5.15-10.72).

CONCLUSIONS

Most children treated in US Military/Coalition treatment facilities required at least one operative intervention. Several pre-operative descriptors were associated with casualties' likelihood of operative interventions. Operative management was associated with improved mortality.

LEVEL OF EVIDENCE

Level III, Prognostic/Epidemiological.

Prehospital Management of Pediatric Behavioral Health Emergencies: A Scoping Review

Pediatric behavioral health emergencies (BHE) are increasing in prevalence, yet there are no evidence-based guidelines or protocols for prehospital management. The primary objective of this scoping review is to identify prehospital-specific pediatric BHE research and publicly available emergency medical services (EMS) protocols for pediatric BHE. Secondary objectives include identifying the next priorities for research and EMS protocol considerations for children with neurodevelopmental conditions. This is a scoping review comprised of a research literature search for publications from 2012-2022 and an internet search for publicly available EMS protocols from the United States. Included publications contain data on the epidemiology of pediatric BHE or describe prehospital management of pediatric BHE. EMS protocols were included if they had advisements specific to pediatric BHE. A total of 50 research publications and EMS protocols from 43 states were screened. Seven publications and four protocols were included in this study. Research studies indicated an increase in pediatric BHE over the last decade, but few papers discuss current prehospital management (n=4). Two EMS protocols were specific to pediatric BHE or pediatric agitation, and the other two EMS protocols focused on adult populations with integrated pediatric recommendations. All four EMS protocols encouraged nonpharmaceutical interventions prior to the use of pharmacologic restraints. Although there is a substantial rise in pediatric BHE, there is sparse research data and clinical EMS protocols to support best practices for prehospital pediatric BHE management. This scoping review identifies important future research aims to inform best practices for the prehospital management of pediatric BHE.

Smart Glasses for Supporting Distributed Care Work: Systematic Review

BACKGROUND

Over the past 2 decades, various desktop and mobile telemedicine systems have been developed to support communication and care coordination among distributed medical teams. However, in the hands-busy care environment, such technologies could become cumbersome because they require medical professionals to manually operate them. Smart glasses have been gaining momentum because of their advantages in enabling hands-free operation and see-what-I-see video-based consultation. Previous research has tested this novel technology in different health care settings.

OBJECTIVE

The aim of this study was to review how smart glasses were designed, used, and evaluated as a telemedicine tool to support distributed care coordination and communication, as well as highlight the potential benefits and limitations regarding medical professionals' use of smart glasses in practice.

METHODS

We conducted a literature search in 6 databases that cover research within both health care and computer science domains. We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology to review articles. A total of 5865 articles were retrieved and screened by 3 researchers, with 21 (0.36%) articles included for in-depth analysis.

RESULTS

All of the reviewed articles (21/21, 100%) used off-the-shelf smart glass device and videoconferencing software, which had a high level of technology readiness for real-world use and deployment in care settings. The common system features used and evaluated in these studies included video and audio streaming, annotation, augmented reality, and hands-free interactions. These studies focused on evaluating the technical feasibility, effectiveness, and user experience of smart glasses. Although the smart glass technology has demonstrated numerous benefits and high levels of user acceptance, the reviewed studies noted a variety of barriers to successful adoption of this novel technology in actual care settings, including technical limitations, human factors and ergonomics, privacy and security issues, and organizational challenges.

CONCLUSIONS

User-centered system design, improved hardware performance, and software reliability are needed to realize the potential of smart glasses. More research is needed to examine and evaluate medical professionals' needs, preferences, and perceptions, as well as elucidate how smart glasses affect the clinical workflow in complex care environments. Our findings inform the design, implementation, and evaluation of smart glasses that will improve organizational and patient outcomes.

Designing and implementing smart glass technology for emergency medical services: a sociotechnical perspective

Objective

This study aims to investigate key considerations and critical factors that influence the implementation and adoption of smart glasses in fast-paced medical settings such as emergency medical services (EMS).

Materials and Methods

We employed a sociotechnical theoretical framework and conducted a set of participatory design workshops with 15 EMS providers to elicit their opinions and concerns about using smart glasses in real practice.

Results

Smart glasses were recognized as a useful tool to improve EMS workflow given their hands-free nature and capability of processing and capturing various patient data. Out of the 8 dimensions of the sociotechnical model, we found that hardware and software, human-computer interface, workflow, and external rules and regulations were cited as the major factors that could influence the adoption of this novel technology. EMS participants highlighted several key requirements for the successful implementation of smart glasses in the EMS context, such as durable devices, easy-to-use and minimal interface design, seamless integration with existing systems and workflow, and secure data management.

Discussion

Applications of the sociotechnical model allowed us to identify a range of factors, including not only technical aspects, but also social, organizational, and human factors, that impact the implementation and uptake of smart glasses in EMS. Our work informs design implications for smart glass applications to fulfill EMS providers' needs.

Conclusion

The successful implementation of smart glasses in EMS and other dynamic healthcare settings needs careful consideration of sociotechnical issues and close collaboration between different stakeholders.

Predictive accuracy of adding shock index to the American College of Surgeons' minimum criteria for full trauma team activation

BACKGROUND

The American College of Surgeons requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation: hypotension, gunshot wound to the neck or torso, Glasgow Coma Scale (GCS) score < 9, respiratory compromise, transfers receiving blood transfusion, or physician discretion. Our goal was to evaluate the effect of adding varying shock index (SI) thresholds to the ACS-6 in an adult trauma population with the hypothesis that SI would significantly improve sensitivity at the expense of an acceptable decrease in specificity.

METHODS

We performed a secondary analysis of EMS and trauma registry data from an urban Level I trauma center. Consecutive patients > 15 years of age were included from 1993 through 2006. SI at thresholds of ≥0.8, ≥0.85, ≥0.9, and ≥1 were evaluated. Primary outcome was emergency operative (within 1 h of arrival) or procedural (cricothyrotomy or thoracotomy) intervention (EOPI); secondary outcomes were Injury Severity Score (ISS) > 15, ISS > 24, a composite of EOPI or ISS > 15, and urgent operative intervention (within 4 h).

RESULTS

A total of 20,872 patients were included, 27% with an ISS > 15 and 5% who underwent EOPI. Sensitivity and specificity of the ACS-6 alone for EOPI were 86% (95% confidence interval [CI] = 84% to 88%) and 81% (95% CI = 80% to 81%), respectively. Inclusion of SI thresholds of 0.8, 0.85, 0.9, and 1 resulted in sensitivities of 95% (95% CI = 93% to 96%), 93% (CI = 91% to 94%), 92% (95% CI = 90% to 93%), and 90% (95% CI = 88% to 92%), respectively, and specificities of 52% (95% CI = 51% to 52%), 59% (95% CI = 58% to 59%), 64% (95% CI = 64% to 65%), and 72% (95% CI = 71% to 73%), respectively. Similar trends were found for each secondary outcome.

CONCLUSION

The addition of SI to the ACS-6 for trauma team activation increased sensitivity for EOPI with a larger decrease in specificity across all thresholds. Inclusion of a SI threshold of ≥0.9 closely aligns with under- and overtriage benchmarks in this trauma registry cohort using a strict definition of trauma team activation need.

Applications and User Perceptions of Smart Glasses in Emergency Medical Services: Semistructured Interview Study

Background

Smart glasses have been gaining momentum as a novel technology because of their advantages in enabling hands-free operation and see-what-I-see remote consultation. Researchers have primarily evaluated this technology in hospital settings; however, limited research has investigated its application in prehospital operations.

Objective

The aim of this study is to understand the potential of smart glasses to support the work practices of prehospital providers, such as emergency medical services (EMS) personnel.

Methods

We conducted semistructured interviews with 13 EMS providers recruited from 4 hospital-based EMS agencies in an urban area in the east coast region of the United States. The interview questions covered EMS workflow, challenges encountered, technology needs, and users’ perceptions of smart glasses in supporting daily EMS work. During the interviews, we demonstrated a system prototype to elicit more accurate and comprehensive insights regarding smart glasses. Interviews were transcribed verbatim and analyzed using the open coding technique.

Results

We identified four potential application areas for smart glasses in EMS: enhancing teleconsultation between distributed prehospital and hospital providers, semiautomating patient data collection and documentation in real time, supporting decision-making and situation awareness, and augmenting quality assurance and training. Compared with the built-in touch pad, voice commands and hand gestures were indicated as the most preferred and suitable interaction mechanisms. EMS providers expressed positive attitudes toward using smart glasses during prehospital encounters. However, several potential barriers and user concerns need to be considered and addressed before implementing and deploying smart glasses in EMS practice. They are related to hardware limitations, human factors, reliability, workflow, interoperability, and privacy.

Conclusions

Smart glasses can be a suitable technological means for supporting EMS work. We conclude this paper by discussing several design considerations for realizing the full potential of this hands-free technology.

User Needs and Challenges in Information Sharing between Pre-Hospital and Hospital Emergency Care Providers

Effective communication between pre-hospital and hospital providers is a critical first step towards ensuring efficient patient care. Despite many efforts in improving the communication process, inefficiencies persist. It is critical to understand user needs, work practices, and existing barriers to inform technology design for supporting pre-hospital communication. However, existing research examining the ways in which patient information is collected and shared by pre-hospital providers in the field has been limited. We conducted a series of ethnographic studies with both prehospital and hospital care providers to examine 1) the types of information that are commonly collected and shared by the pre-hospital providers in the field; 2) the types of pre-hospital information that are needed by hospital-based teams for ensuring appropriate preparation; and 3) the challenges in the pre-hospital communication process. We conclude by discussing technology opportunities for facilitating real-time information sharing in the field.

Confidential Screening for Sex Trafficking Among Minors in a Pediatric Emergency Department

OBJECTIVES

Child sex trafficking is a global health problem, with a prevalence of 4% to 11% among high-risk adolescents. The objective of this study was to confidentially administer a validated screening tool in a pediatric emergency department by using an electronic tablet to identify minors at risk for sex trafficking. Our hypothesis was that this modality of administration would adequately identify high-risk patients.

METHODS

English- and Spanish-speaking patients from the ages of 12 to 17 years presenting to a large urban pediatric emergency department with high-risk chief complaints were enrolled in a prospective cohort over 13 months. Subjects completed a previously validated 6-item screening tool on an electronic tablet. The screening tool's sensitivity, specificity, and positive and negative predictive values were calculated. Multivariable logistic regression was performed to identify additional risk factors.

RESULTS

A total of 212 subjects were enrolled (72.6% female; median age: 15 years; interquartile range 13-16), of which 26 patients were subjected to child sex trafficking (prevalence: 12.3%). The sensitivity and specificity of the electronic screening tool were 84.6% (95% confidence interval [CI] 70.8%-98.5%) and 53.2% (95% CI 46.1%-60.4%), respectively. The positive predictive value and negative predictive value were 20.2% (95% CI 12.7%-27.7%) and 96.1% (95% CI 92.4%-99.9%), respectively. A previous suicide attempt and history of child abuse increased the odds of trafficking independent of those who screened positive but did not improve sensitivity of the tool.

CONCLUSIONS

A confidentially administered, previously validated, electronic screening tool was used to accurately identify sex trafficking among minors, suggesting that this modality of screening may be useful in busy clinical environments.

Recommended Essential Equipment for Basic Life Support and Advanced Life Support Ground Ambulances 2020: A Joint Position Statement

In continued support of establishing and maintaining a foundation for standards of care, our organizations remain committed to periodic review and revision of this position statement. This latest revision was created based on a structured review of the National Model EMS Clinical Guidelines Version 2.2 in order to identify the equipment items necessary to deliver the care defined by those guidelines. In addition, in order to ensure congruity with national definitions of provider scope of practice, the list is differentiated into BLS and ALS levels of service utilizing the National Scope of Practice-defined levels of Emergency Medical Responder (EMR) and Emergency Medical Technician (EMT) as BLS, and Advanced EMT (AEMT) and Paramedic as ALS. Equipment items listed within each category were cross-checked against recommended scopes of practice for each level in order to ensure they were appropriately dichotomized to BLS or ALS levels of care. Some items may be considered optional at the local level as determined by agency-defined scope of practice and applicable clinical guidelines. In addition to the items included in this position statement our organizations agree that all EMS service programs should carry equipment and supplies in quantities as determined by the medical director and appropriate to the agency's level of care and available certified EMS personnel and as established in the agency's approved protocols.

Simulating Teamwork for Better Decision Making in Pediatric Emergency Medical Services

Emergency Medical Services (EMS) are an essential component of health systems and are critical to the provision of pediatric emergency care. Challenges in this setting include fast pace, need for advanced teamwork, situational awareness and limited resources. The purpose of this study was to identify human factors-related obstacles during care delivery by EMS teams that could lead to inefficiencies and patient safety issues. We examined video recordings of 24 simulations of EMS teams (paramedics and EMTs) who were providing care to pediatric patients. Two reviewers documented a total of 262 efficiency and patient safety issues in 4.25 hours of videos. These issues were grouped into 28 categories. Reviewers also documented 19 decision support opportunities. These issues and decision support opportunities can inform the design of clinical decision support systems that can improve EMS related patient outcomes.

Child Abuse Recognition Training for Prehospital Providers Using Deliberate Practice

BACKGROUND

In most states, prehospital professionals (PHPs) are mandated reporters of suspected abuse but cite a lack of training as a challenge to recognizing and reporting physical abuse. We developed a learning platform for the visual diagnosis of pediatric abusive versus non-abusive burn and bruise injuries and examined the amount and rate of skill acquisition.

METHODS

This was a prospective cross-sectional study of PHPs participating in an online educational intervention containing 114 case vignettes. PHPs indicated whether they believed a case was concerning for abuse and would report a case to child protection services. Participants received feedback after submitting a response, permitting deliberate practice of the cases. We describe learning curves, overall accuracy, sensitivity (diagnosis of abusive injuries) and specificity (diagnosis of non-abusive injuries) to determine the amount of learning. We performed multivariable regression analysis to identify specific demographic and case variables associated with a correct case interpretation. After completing the educational intervention, PHPs completed a self-efficacy survey on perceived gains in their ability to recognize cutaneous signs of abuse and report to social services.

RESULTS

We enrolled 253 PHPs who completed all the cases; 158 (63.6%) emergency medical technicians (EMT), 95 (36.4%) advanced EMT and paramedics. Learning curves demonstrated that, with one exception, there was an increase in learning for participants throughout the educational intervention. Mean diagnostic accuracy increased by 4.9% (95% CI 3.2, 6.7), and the mean final diagnostic accuracy, sensitivity, and specificity were 82.1%, 75.4%, and 85.2%, respectively. There was an increased odds of getting a case correct for bruise versus burn cases (OR = 1.4; 95% CI 1.3, 1.5); if the PHP was an Advanced EMT/Paramedic (OR = 1.3; 95% CI 1.1, 1.4) ; and, if the learner indicated prior training in child abuse (OR = 1.2; 95% CI 1.0, 1.3). Learners indicated increased comfort in knowing which cases should be reported and interpreting exams in children with cutaneous injuries with a median Likert score of 5 out of 6 (IQR 5, 6).

CONCLUSION

An online module utilizing deliberate practice led to measurable skill improvement among PHPs for differentiating abusive from non-abusive burn and bruise injuries.

Modified Delphi Method Derivation of the FAMILY (Family Assessment of Medical Interventions & Liaisons with the Young) EMS Instrument

BACKGROUND

Though family satisfaction with prehospital care is a surrogate for quality and patient outcomes, there are no tools available to measure family satisfaction.

OBJECTIVE

To develop the EMS Family Assessment of Medical Interventions & Liaisons with the Young (FAMILY) instrument.

METHODS

Components of family experiences with pediatric prehospital care were identified with a modified Delphi method. The expert panel included Emergency Medical Technicians, paramedics, family representatives, and EMS leaders from Colorado, Connecticut, and Rhode Island. An online survey was used to assess proposed questions from each of five candidate domains from national guidelines, including Safety, Communication, Family Presence, Cultural Awareness, Children with Special Healthcare Needs and Overall Satisfaction. Round-1 items were scored on a five-point Likert scale. Inclusion in the final instrument required 70% agreement ranking items as "include" or "definitely include." In Round-2, participants assessed proposed refinements. This resulted in FAMILY Version-1, with sections for family members and EMS care providers. EMSC Family Action Network (FAN) representatives evaluated the FAMILY, leading to Version-2. Suggestions from the national FAN about content, clarity, and whether the instrument captured their experiences with pediatric EMS care led to the final FAMILY version. Bilingual speakers translated the instrument into Spanish, while assessing the content for semantic, idiomatic, experiential, and conceptual equivalence between the English and Spanish versions.

RESULTS

There were 22 experts in Round-1, and 20 continued into Round-2 .The Delphi process yielded 12 questions in six domains with 14 recommended modifications. Two questions were excluded. Five domains reached 70% agreement in Round-1. Cultural Awareness reached 75% agreement after Round-2. Six FAN representatives evaluated Version-1, leading to changes for clarity, content and cultural sensitivity. Seventeen FAN representatives evaluated Version-2 leading to additional refinement. The assessment of the equivalence between the English and Spanish survey versions resulted in changes in the Spanish language content for equivalent meaning.

CONCLUSION

A panel of EMS and family stakeholders successfully developed an instrument to assess family satisfaction with pediatric EMS care. Further validation is required in a large respondent population. Assessing family satisfaction with pediatric EMS encounters is an important step toward improving prehospital care.

Documentation of Child Maltreatment by Emergency Medical Services in a National Database

BACKGROUND

Child abuse and neglect (CAN) has an estimated annual incidence of 1.46% among those ≤3 years old. Prehospital providers (PHPs) report difficulties identifying CAN and the frequency in which PHPs document CAN during prehospital encounters of young children is not known.

OBJECTIVE

To report the percentage of CAN documentation by PHPs during encounters among children ≤3 years in a national dataset and describe the characteristics of this population.

METHODS

This is an analysis of concurrent cases in the 2017-18 National Emergency Medical Services Information System database. We identified children ≤3 years old with ICD-10-CM codes specific for CAN including codes for physical and sexual abuse as well as neglect. We examined patient demographics including race, gender, Emergency Medical Services (EMS) primary and secondary impression, associated symptoms, anatomic location of chief complaint, and cause of injury. Our primary outcome is the percentage of CAN reported as an EMS primary or secondary impression; secondary outcomes include proportion of children with each subtype of abuse, the description of patients by demographic information, anatomic location of injury, and associated symptoms.

RESULTS

There were 498,555 for children ≤3 years old, of which 522 had an impression of CAN (0.10%). Within our cohort, 43% were <1 year of age, 51% were male. The most common anatomic location of injury was general/global (29.7%), followed by head (23.5%) and extremity (14%). The most common symptoms reported by PHPs are those associated with injury including codes for injury, burn, fracture, cutaneous findings, hemorrhage, or pain (n = 244, 63%). Pain is the most commonly reported symptom (n = 110, 21%). Few encounters specified vomiting, seizure, or disordered breathing as symptoms (1%, 1%, and 5.4%, respectively). Interestingly, 28.2% (27/124) of cases in our cohort were related to sexual abuse.

CONCLUSIONS

The percentage of PHP documentation of CAN among children ≤3 years of age is very low. Among those with an EMS primary impression of CAN, documentation is primarily associated with findings of injury whereas documentation of nonspecific symptoms such as vomiting and seizure is infrequent. These findings suggest that recognition of abuse primarily occurs in young patients with overt signs of trauma.

Medication Dosing Safety for Pediatric Patients: Recognizing Gaps, Safety Threats, and Best Practices in the Emergency Medical Services Setting. A Position Statement and Resource Document from NAEMSP

BACKGROUND

Millions of patients receive medications in the Emergency Medical Services (EMS) setting annually, and dosing safety is critically important. The need for weight-based dosing in pediatric patients and variability in medication concentrations available in the EMS setting may require EMS providers to perform complex calculations to derive the appropriate dose to deliver. These factors can significantly increase the risk for harm when dose calculations are inaccurate or incorrect.

METHODS

We conducted a scoping review of the EMS, interfacility transport and emergency medicine literature regarding pediatric medication dosing safety. A priori, the authors identified four research topics: (1) what are the greatest safety threats that result in significant dosing errors that potentially result in harm to patients, (2) what practices or technologies are known to enhance dosing safety, (3) can data from other settings be extrapolated to the EMS environment to inform dosing safety, and (4) what impact could standardization of medication formularies have on enhancing dosing safety. To address these topics, 17 PICO (Patient, Intervention, Comparison, Outcome) questions were developed and a literature search was performed.

RESULTS

After applying exclusion criteria, 70 articles were reviewed. The methods for the investigation, findings from these articles and how they inform EMS medication dosing safety are summarized here. This review yielded 11 recommendations to improve safety of medication delivery in the EMS setting.

CONCLUSION

These recommendations are summarized in the National Association of EMS Physicians® position statement: Medication Dosing Safety for Pediatric Patients in Emergency Medical Services.

Pediatric Readiness in Emergency Medical Services Systems

Ill and injured children have unique needs that can be magnified when the child's ailment is serious or life-threatening. This is especially true in the out-of-hospital environment. Providing high-quality out-of-hospital care to children requires an emergency medical services (EMS) system infrastructure designed to support the care of pediatric patients. As in the emergency department setting, it is important that all EMS agencies have the appropriate resources, including physician oversight, trained and competent staff, education, policies, medications, equipment, and supplies, to provide effective emergency care for children. Resource availability across EMS agencies is variable, making it essential that EMS medical directors, administrators, and personnel collaborate with outpatient and hospital-based pediatric experts, especially those in emergency departments, to optimize prehospital emergency care for children. The principles in the policy statement "Pediatric Readiness in Emergency Medical Services Systems" and this accompanying technical report establish a foundation on which to build optimal pediatric care within EMS systems and serve as a resource for clinical and administrative EMS leaders.

Pediatric Readiness in Emergency Medical Services Systems

This is a joint policy statement from the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Services Physicians, and National Association of Emergency Medical Technicians on pediatric readiness in emergency medical services systems.

Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation Than Men in Out-of-Hospital Cardiac Arrest

BACKGROUND

Women who suffer an out-of-hospital cardiac arrest receive bystander cardiopulmonary resuscitation (CPR) less often than men. Understanding public perceptions of why this occurs is a necessary first step toward equitable application of this potentially life-saving intervention.

METHODS

We conducted a national survey of members of the public using Mechanical Turk, Amazon's crowdsourcing platform, to determine reasons why women might receive bystander CPR less often than men. Eligible participants were adults (≥18 years) located in the United States. Responses were excluded if the participant was not able to define CPR correctly. Participants were asked to answer the following free-text question: "Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?" Descriptive statistics were used to define the cohort. The free-text response was coded using open coding, and major themes were identified via classical content analysis.

RESULTS

In total, 548 subjects were surveyed. Mean age was 38.8 years, and 49.8% were female. Participants were geographically distributed as follows: 18.5% West, 9.2% Southwest, 22.0% Midwest, 27.5% Southeast, and 22.9% Northeast. After analysis, 3 major themes were detected for why the public perceives that women receive less bystander CPR. They include the following: (1) sexualization of women's bodies; (2) women are weak and frail and therefore prone to injury; and (3) misperceptions about women in acute medical distress. Overall, 41.9% (227) were trained in CPR while 4.4% reported having provided CPR in a medical emergency.

CONCLUSIONS

Members of the general public perceive fears about inappropriate touching, accusations of sexual assault, and fear of causing injury as inhibiting bystander CPR for women. Educational and policy efforts to address these perceptions may reduce the sex differences in the application of bystander CPR.

Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography

Objective: Needle thoracostomy is a life-saving procedure. Advanced Trauma Life Support guidelines recommend insertion of a 5 cm, 14-gauge needle for pneumothorax decompression. High-risk complications can arise if utilizing an inappropriate needle size. No study exist evaluating appropriate needle length in pediatric patients. Utilizing computed tomography (CT), we determined the needle length required to access the pleural cavity in children matched to Broselow™ Pediatric Emergency Tape color. Methods: Three investigators reviewed chest CTs of children <13 years of age obtained between 2010 and 2015. Patient exclusions included those with a chest wall mass, muscle disease, pectus deformity, anasarca, prior open thoracotomy, inadequate imaging, or missing height documentation. We established 4 groups based upon Broselow™ color as determined by recorded height. Investigators, trained by a pediatric board-certified radiologist, obtained standardized CT measurements of chest wall thickness at 4 points: right/left second intercostal space at the midclavicular line (ICS-MCL) and right/left fourth intercostal space in the anterior axillary line (ICS-AAL). Our outcome was the median chest wall thickness and 95% confidence intervals for each Broselow grouping and anatomic site. Results: A total of 273 chest CTs were reviewed, of which 23 were excluded, for a resultant study population of 250 scans and 498 total measurements. Median patient age was 4 years, 52.8% were male. Children measuring Broselow Gray/Pink (<68 cm), had a median chest wall thickness at the 2nd ICS-MCL of 1.57 cm (95% CI 1.42 cm, 1.72 cm), 4th ICS-AAL 1.67 cm (95% CI 1.48 cm, 1.86 cm). Broselow Red/Purple (68.1-90 cm): 2nd ICS-MCL of 1.96 cm (95% CI 1.84 cm, 2.08 cm), 4th ICS-AAL 1.73 cm (95% CI 1.62 cm, 1.84 cm). Broselow Yellow/White (90.1-115cm): 2nd ICS-MCL of 2.12 cm (95% CI 2.03 cm, 1.22 cm), 4th ICS-AAL 1.91 cm (95% CI 1.8 cm, 2.01 cm). Broselow Blue/Orange/Green (>115.1 cm): 2nd ICS-MCL of 2.45 cm (95% CI 2.3 cm, 2.6 cm), 4th ICS-AAL 2.19cm (95% CI 2.02 cm, 2.36 cm). Conclusion: Median chest wall thickness varies little by height or location in children <13 years of age. The standard 5-cm needle is twice the chest wall thickness of most children. Commercially available 14 g or 16 g standard-length 3.8 cm (1½ inch) needles are of adequate length to access the pleural cavity, regardless of height as measured by Broselow LBT.

Executive Summary: The 2018 Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps

Emergency care providers share a compelling interest in developing an effective patient-centered, outcomes-based research agenda that can decrease variability in pediatric outcomes. The 2018 Academic Emergency Medicine Consensus Conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps (AEMCC)" aimed to fulfill this role. This conference convened major thought leaders and stakeholders to introduce a research, scholarship, and innovation agenda for pediatric emergency care specifically to reduce health outcome gaps. Planning committee and conference participants included emergency physicians, pediatric emergency physicians, pediatricians, and researchers with expertise in research dissemination and translation, as well as comparative effectiveness, in collaboration with patients, patient and family advocates from national advocacy organizations, and trainees. Topics that were explored and deliberated through subcommittee breakout sessions led by content experts included 1) pediatric emergency medical services research, 2) pediatric emergency medicine (PEM) research network collaboration, 3) PEM education for emergency medicine providers, 4) workforce development for PEM, and 5) enhancing collaboration across emergency departments (PEM practice in non-children's hospitals). The work product of this conference is a research agenda that aims to identify areas of future research, innovation, and scholarship in PEM.

A Randomized Double Blind Trial of Needle-free Injected Lidocaine Versus Topical Anesthesia for Infant Lumbar Puncture

OBJECTIVES

Lumbar punctures (LPs) are commonly performed in febrile infants to evaluate for meningitis, and local anesthesia increases the likelihood of LP success. Traditional methods of local anesthesia require injection that may be painful or topical application that is not effective immediately. Recent advances in needle-free jet injection may offer a rapid alternative to these modalities. We compared a needle-free jet-injection system (J-Tip) with 1% buffered lidocaine to topical anesthetic (TA) cream for local anesthesia in infant LPs.

METHODS

This was a single-center randomized double-blind trial of J-Tip versus TA for infant LPs in an urban tertiary care children's hospital emergency department. A computer randomization model was used to allocate patients to either intervention. Patients aged 0 to 4 months were randomized to J-Tip syringe containing 1% lidocaine and a placebo TA cream or J-Tip syringe containing saline and TA. The primary outcome was the difference between the Neonatal Faces Coding Scale (NFCS) before the procedure and during LP needle insertion. Secondary outcomes included changes in heart rate (HR) and NFCS throughout the procedure, difficulty with LP, number of LP attempts, provider impression of pain control, additional use of lidocaine, skin changes at LP site, and LP success.

RESULTS

We enrolled 66 subjects; 32 were randomized to J-Tip with lidocaine and 34 to EMLA. Six participants were excluded from the final analysis due to age greater than 4 months, and the remaining 58 were analyzed in their respective groups (32 J-Tip, 34 TA). There was no difference detected in NFCS between the two treatment groups before the procedure and during needle insertion for the LP (p = 0.58, p = 0.37). Neither HR nor NCFS differed among the groups throughout the procedure. Median perception of pain control by the provider and the need for additional lidocaine were comparable across groups. LPs performed with a J-Tip were twice as likely to be successful compared to those performed using TA (relative risk = 2.0; 95% confidence interval = 1.01-3.93; p = 0.04) with no difference in level of training or number of prior LPs performed by providers.

CONCLUSIONS

In a randomized controlled trial of two modalities for local anesthesia in infant LPs, J-Tip was not superior to TA cream as measured by pain control or physiologic changes. Infant LPs performed with J-Tip were twice as likely to be successful.

Evaluating Clinical Effectiveness and Pharmacokinetic Profile of Atomized Intranasal Midazolam in Children Undergoing Laceration Repair

BACKGROUND

Atomized intranasal midazolam is a common adjunct in pediatrics for procedural anxiolysis. There are no previous studies of validated anxiety scores with pharmacokinetic data to support optimal procedure timing.

OBJECTIVES

We describe the clinical and pharmacokinetic profile of atomized intranasal midazolam in children presenting for laceration repair.

METHODS

Children 11 months to 7 years of age and weighing <26 kg received 0.4 mg/kg of atomized intranasal midazolam for simple laceration repair. Blood samples were obtained at 3 time points in each patient, and the data were fit with a 1-compartment model. Patient anxiety was rated with the Observational Scale of Behavioral Distress. Secondary outcomes included use of adjunctive medications, successful completion of procedure, and adverse events.

RESULTS

Sixty-two subjects were enrolled, with a mean age of 3.3 years. The median time to peak midazolam concentration was 10.1 min (interquartile range 9.7-10.8 min), and the median time to the procedure was 26 min (interquartile range 21-34 min). There was a trend in higher Observational Scale of Behavioral Distress scores during the procedure. We observed a total of 2 adverse events, 1 episode of vomiting (1.6%) and 1 paradoxical reaction (1.6%). Procedural completion was successful in 97% of patients.

CONCLUSIONS

Atomized intranasal midazolam is a safe and effective anxiolytic to facilitate laceration repair. The plasma concentration was >90% of the maximum from 5 to 17 min, suggesting this as an ideal procedural timeframe after intranasal midazolam administration.

Definitions and Assessment Approaches for Emergency Medical Services for Children

Pediatric Life Support (PLS) courses and instructional programs are educational tools developed to teach resuscitation and stabilization of children who are critically ill or injured. A number of PLS courses have been developed by national professional organizations for different health care providers (eg, pediatricians, emergency physicians, other physicians, prehospital professionals, pediatric and emergency advanced practice nurses, physician assistants). PLS courses and programs have attempted to clarify and standardize assessment and treatment approaches for clinical practice in emergency, trauma, and critical care. Although the effectiveness of PLS education has not yet been scientifically validated, the courses and programs have significantly expanded pediatric resuscitation training throughout the United States and internationally. Variability in terminology and in assessment components used in education and training among PLS courses has the potential to create confusion among target groups and in how experts train educators and learners to teach and practice pediatric emergency, trauma, and critical care. It is critical that all educators use standard terminology and patient assessment to address potential or actual conflicts regarding patient evaluation and treatment. This article provides a consensus of several organizations as to the proper order and terminology for pediatric patient assessment. The Supplemental Information provides definitions for terms and nomenclature used in pediatric resuscitation and life support courses.

Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills

OBJECTIVE

Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT).

METHODS

Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK.

RESULTS

The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073).

CONCLUSION

This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.

Relationship of Physician-identified Patient Race and Ethnicity to Use of Computed Tomography in Pediatric Blunt Torso Trauma

OBJECTIVES

The objective was to determine whether a child's race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma.

METHODS

We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007-2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child's risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals.

RESULTS

Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non-Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra-abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1).

CONCLUSIONS

After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non-Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of abdominal CT in children. Further studies should focus on explaining how patient race can affect provider choices regarding ED radiographic imaging.

Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury

BACKGROUND

Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries.

OBJECTIVES

The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries.

METHODS

The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data.

RESULTS

The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR] = 1.89, 95% confidence interval [CI] = 1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent.

CONCLUSIONS

Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

Computed tomography with intravenous contrast alone: the role of intra-abdominal fat on the ability to visualize the normal appendix in children

BACKGROUND

Computed tomography (CT) with enteric contrast is frequently used to evaluate children with suspected appendicitis. The use of CT with intravenous (IV) contrast alone (CT IV) may be sufficient, however, particularly in patients with adequate intra-abdominal fat (IAF).

OBJECTIVES

The authors aimed 1) to determine the ability of radiologists to visualize the normal (nondiseased) appendix with CT IV in children and to assess whether IAF adequacy affects this ability and 2) to assess the association between IAF adequacy and patient characteristics.

METHODS

This was a retrospective 16-center study using a preexisting database of abdominal CT scans. Children 3 to 18 years who had CT IV scan and measured weights and for whom appendectomy history was known from medical record review were included. The sample was chosen based on age to yield a sample with and without adequate IAF. Radiologists at each center reread their site's CT IV scans to assess appendix visualization and IAF adequacy. IAF was categorized as "adequate" if there was any amount of fat completely surrounding the cecum and "inadequate" if otherwise.

RESULTS

A total of 280 patients were included, with mean age of 10.6 years (range = 3.1 to 17.9 years). All 280 had no history of prior appendectomy; therefore, each patient had a presumed normal appendix. A total of 102 patients (36.4%) had adequate IAF. The proportion of normal appendices visualized with CT IV was 72.9% (95% confidence interval [CI] = 67.2% to 78.0%); the proportions were 89% (95% CI = 81.5% to 94.5%) and 63% (95% CI = 56.0% to 70.6%) in those with and without adequate IAF (95% CI for difference of proportions = 16% to 36%). Greater weight and older age were strongly associated with IAF adequacy (p < 0.001), with weight appearing to be a stronger predictor, particularly in females. Although statistically associated, there was noted overlap in the weights and ages of those with and without adequate IAF.

CONCLUSIONS

Protocols using CT with IV contrast alone to visualize the appendix can reasonably include weight, age, or both as considerations for determining when this approach is appropriate. However, although IAF will more frequently be adequate in older, heavier patients, highly accurate prediction of IAF adequacy appears challenging solely based on age and weight.

Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain

OBJECTIVES

The objective was to evaluate the use of a single 2 μg/kg dose of intranasal fentanyl as analgesia for painful orthopedic injuries in children presenting to a pediatric emergency department (ED).

METHODS

This was a prospective, nonblinded interventional trial, in a convenience sample of patients 3 to 18 years of age seen in a tertiary care pediatric ED. All had clinically suspected fractures and were treated between July and November 2006. Eligible patients had moderate to severe pain based on initial pain scores using the Wong Baker Faces Scale (WBS) for patients aged 3-8 years or the Visual Analog Scale (VAS) for patients aged 9-18 years. All enrolled patients received fentanyl via intranasal atomization. Pain scores were obtained at baseline and at 10, 20, and 30 minutes after intranasal fentanyl administration. Satisfaction scores were obtained using a 100-mm VAS. Vital signs and adverse events were recorded.

RESULTS

Eighty-one patients were enrolled, 28 in the VAS group and 53 in the WBS group. The mean patient age was 8 years. Fracture locations included forearm, 38 (47%); supracondylar, 16 (20%); clavicle, 7 (9%); tibia/fibula, 5 (6%); and other, 15 (18%). In the WBS group, the median pain scores decreased from five faces (interquartile range [IQR] = 4-6) at baseline to three faces (IQR = 2-5) at 10 minutes, two faces (IQR = 1-4) at 20 minutes, and two faces (IQR = 1-3) at 30 minutes. The mean pain score in the VAS group at baseline was 70 mm (95% confidence interval [CI] = 63 to 77 mm). In this group, the pain scores decreased by a mean of 21 mm (95% CI = 14 to 28 mm) at 10 minutes, 25 mm (95% CI = 15 to 34 mm) at 20 minutes, and 27 mm (95% CI = 16 to 37 mm) at 30 minutes. Mean satisfaction scores were 79 mm for providers, 74 mm for parents, and 62 mm for patients. No adverse events were recorded.

CONCLUSIONS

  Intranasal fentanyl at a dose of 2 μg/kg provides effective analgesia for pediatric ED patients with painful orthopedic trauma within 10 minutes of administration.

Intranasal midazolam vs rectal diazepam for the home treatment of acute seizures in pediatric patients with epilepsy

OBJECTIVE

To compare intranasal midazolam, using a Mucosal Atomization Device (IN-MMAD), with rectal diazepam (RD) for the home treatment of seizures in children with epilepsy.

DESIGN

Prospective randomized study.

SETTING

Patients' homes and a freestanding children's hospital that serves as a referral center for 5 states.

PATIENTS

A total of 358 pediatric patients who visited a pediatric neurology clinic from July 2006 through September 2008 and were prescribed a home rescue medication for their next seizure.

INTERVENTION

Caretakers were randomized to use either 0.2 mg/kg of IN-MMAD (maximum, 10 mg) or 0.3 to 0.5 mg/kg of RD (maximum, 20 mg) at home for their child's next seizure if it lasted more than 5 minutes.

OUTCOME MEASURES

The primary outcome measure was total seizure time after medication administration. Our secondary outcome measures were total seizure time, time to medication administration, respiratory complications, emergency medical service support, emergency department visits, hospitalizations, and caretakers' ease of administration and satisfaction with the medication.

RESULTS

A total of 92 caretakers gave the study medication during a child's seizure (50 IN-MMAD, 42 RD). The median time from medication administration to seizure cessation for IN-MMAD was 1.3 minutes less than for RD (95% confidence interval, 0.0-3.5 minutes; P=.09). The median time to medication administration was 5.0 minutes for each group. No differences in complications were found between treatment groups. Caretakers were more satisfied with IN-MMAD and report that it was easier to give than RD.

CONCLUSIONS

There was no detectable difference in efficacy between IN-MMAD and RD as a rescue medication for terminating seizures at home in pediatric patients with epilepsy. Ease of administration and overall satisfaction was higher with IN-MMAD compared with RD. Trial Registration clinicaltrials.gov Identifier: NCT00326612.