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Lee MS, Sweetnam-Holmes D, Soffer GP, Harel-Sterling M. Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine. Curr Opin Pediatr 2024; 36:256-265. [PMID: 38411588 DOI: 10.1097/mop.0000000000001340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care. RECENT FINDINGS POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care. SUMMARY POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.
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Affiliation(s)
- Michelle Sin Lee
- Pediatric Emergency Medicine, Hospital for Sick Children, Assistant Professor, University of Toronto, Toronto, ON, Canada
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Weinstein R, Naber CE, Brumme K. Revisiting dexamethasone use in the pediatric emergency department. Curr Opin Pediatr 2024; 36:251-255. [PMID: 38655807 DOI: 10.1097/mop.0000000000001351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Dexamethasone is an essential treatment for common pediatric inflammatory, airway, and respiratory conditions. We aim to provide up-to-date recommendations for treatment of anaphylaxis, croup, coronavirus disease, multisystem inflammatory syndrome in children, and asthma with dexamethasone for use in the pediatric emergency department. RECENT FINDINGS Literature largely continues to support the use of dexamethasone in most of the above conditions, however, recommendations for dosing and duration are evolving. SUMMARY The findings discussed in this review will enable pediatric emergency medicine providers to use dexamethasone effectively as treatment of common pediatric conditions and minimize the occurrence of side-effects caused by gratuitous corticosteroid use.
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Affiliation(s)
- Rebecca Weinstein
- Massachusetts General Hospital, 55 Fruit Street Boston, Massachusetts, USA
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3
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VanDerhoef KF, Bergmann K, Kaila R, Shanley R, Louie JP. A Retrospective Report on Simple Febrile Seizure Management in a Pediatric Emergency Department. Clin Pediatr (Phila) 2024; 63:764-768. [PMID: 37497942 DOI: 10.1177/00099228231188607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To determine whether pediatric emergency medicine physicians are compliant with the 9-year-old simple febrile seizure guideline created by the American Academy of Pediatrics (AAP). METHODS A retrospective chart review of patients, ages 6 to 60 months, who presented to the emergency department between May 2011 and December 2019. Key variables abstracted were urine, blood, nasal viral swab, and radiographic results. RESULTS The retrospective cohort of 285 children met inclusion criteria. Among 285 children, 342 studies were performed with a median of 1.2 studies per patient. There were 77 urine cultures obtained with 6 bacterial pathogens. Nasal viral swabs were performed on 65 children with 9 positive results. Blood cultures were obtained for 28 children and none were positive. Chest radiographs were performed on 37 children with 4 showing pneumonia. CONCLUSION The study results reflect areas of opportunity to update guidelines with a focus to consider obtaining urine studies, viral sampling, and chest x-rays.
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Affiliation(s)
- Katlin F VanDerhoef
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Kelly Bergmann
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Rahul Kaila
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Ryan Shanley
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Jeffrey P Louie
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
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4
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Reppucci ML, Acker SN, Cooper E, Meier M, Stevens J, Phillips R, Moulton SL, Bensard DD. Improved identification of severely injured pediatric trauma patients using reverse shock index multiplied by Glasgow Coma Scale. J Trauma Acute Care Surg 2022; 92:69-73. [PMID: 34932042 DOI: 10.1097/ta.0000000000003432] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients. METHODS Patients (aged 1-18 years) in the 2014 to 2018 Pediatric Trauma Quality Improvement Program database with complete heart rate, systolic blood pressure, and total GCS were included. Optimal cut points of rSIG were calculated for predicting blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. From the optimal thresholds, sensitivity, specificity, and area under the curve were calculated from receiver operating characteristics analyses to predict each outcome and compared with SI and SIPA. RESULTS A total of 604,931 patients with a mean age of 11.1 years old were included. A minority of patients had a penetrating injury mechanism (5.6%) and the mean Injury Severity Score was 7.6. The mean SI and rSIG scores were 0.85 and 18.6, respectively. Reverse shock index multiplied by Glasgow Coma Scale performed better than SI and SIPA at predicting early trauma outcomes for the overall population, regardless of age. CONCLUSION Reverse shock index multiplied by Glasgow Coma Scale outperformed SI and SIPA in the early identification of traumatically injured children at risk for early interventions, such as blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. Reverse shock index multiplied by Glasgow Coma Scale adds neurological status in initial patient assessment and may be used as a bedside triage tool to rapidly identify pediatric patients who will likely require early intervention and higher levels of care. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Marina L Reppucci
- From the Pediatric Surgery (M.L.R., S.N.A., J.S., R.P., S.L.M., D.D.B.), Children's Hospital Colorado, Aurora, Colorado; Division of Pediatric Surgery, Department of Surgery (M.L.R., S.N.A., J.S., R.P., S.L.M., D.D.B.), University of Colorado School of Medicine, Aurora, CO; The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery (E.C., M.M.), University of Colorado School of Medicine, Aurora, CO; and Department of Surgery (D.D.B.), Denver Health Medical Center, Denver, CO
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5
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Osterman J, Buchanan C. Less-lethal law enforcement weapons: clinical management of associated injuries in the emergency department. Pediatr Emerg Med Pract 2021; 18:1-24. [PMID: 34310093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/10/2021] [Indexed: 06/13/2023]
Abstract
Less-lethal weapons and tactics are being increasingly used by law enforcement to minimize the reliance on more-lethal force. While these methods are designated as "less-lethal," they can cause morbidity and mortality when deployed. Knowledge of these weapons and tactics can help direct the workup and management of patients with injuries from these methods and can protect clinicians from secondary exposure and injuries. This issue reviews the most common less-lethal weapons and tactics used by law enforcement, describes their mechanism of action, and discusses associated common injury patterns. Recommendations are provided for the evaluation and management of these patients in the emergency department.
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Affiliation(s)
- Jessica Osterman
- Associate Professor of Clinical Emergency Medicine, Keck School of Medicine; Associate Residency Director, LAC+USC Department of Emergency Medicine, Los Angeles, CA
| | - Cara Buchanan
- Resident Physician, LAC+USC Department of Emergency Medicine, Los Angeles, CA
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6
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Nik-Ahd M, Agrawal AK, Zimel M. Diagnosis and management of pediatric primary bone tumors in the emergency department. Pediatr Emerg Med Pract 2021; 18:1-20. [PMID: 34196516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Musculoskeletal pain is a common chief complaint of children in the emergency department. Although nonspecific and typically benign, musculoskeletal pain should be investigated thoroughly with consideration for an underlying bone tumor, especially when it is a recurrent visit for pain. This issue reviews the specific signs, symptoms, and unique presentations the emergency clinician should know when evaluating a pediatric patient with musculoskeletal pain. Additionally, assessment of relevant radiographic findings to assist in differentiating bone tumors and guide further management are discussed.
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Affiliation(s)
- Mahnoosh Nik-Ahd
- Pediatric Emergency Medicine Fellow, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Anurag K Agrawal
- Associate Professor, Division of Oncology, Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Melissa Zimel
- Assistant Professor, Division of Orthopaedic Surgical Oncology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA
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Stringer S, Wendt WJ, Salavitabar A, Rogers A. Ruptured sinus of Valsalva aneurysm: An uncommon presentation of shock to the pediatric emergency department. Am J Emerg Med 2021; 49:80-82. [PMID: 34089967 DOI: 10.1016/j.ajem.2021.05.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
This case report describes a rare etiology of cardiogenic shock, particularly in the pediatric population. A healthy 17 year old male presents from an outside hospital in undifferentiated shock requiring vasopressor support. Ruptured sinus of Valsalva aneurysm was diagnosed by echocardiogram and the patient went emergently to the operating room for surgical repair. We discuss the anatomy, incidence, and risk factors for sinus of Valsalva aneurysms, along with the range of clinical presentations and Emergency Department management of symptomatic rupture of sinus of Valsalva aneurysms.
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Affiliation(s)
- Samantha Stringer
- University of Michigan Hospital, Emergency Department, Ann Arbor, MI 48109, United States; C.S. Mott Children's Hospital, University of Michigan, Emergency Department, Ann Arbor, MI 48109, United States.
| | - Wendi-Jo Wendt
- C.S. Mott Children's Hospital, University of Michigan, Emergency Department, Ann Arbor, MI 48109, United States; Children's Wisconsin, Medical College of Wisconsin, Emergency Department, Milwaukee, WI 53226, United States
| | - Arash Salavitabar
- C.S. Mott Children's Hospital, University of Michigan, Pediatric Cardiology, Ann Arbor, MI 48109, United States
| | - Alexander Rogers
- C.S. Mott Children's Hospital, University of Michigan, Emergency Department, Ann Arbor, MI 48109, United States
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8
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Joseph M, Paul A. Emergency department assessment and management of pediatric acute mild traumatic brain injury and concussion. Pediatr Emerg Med Pract 2021; 18:1-28. [PMID: 34008934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/10/2021] [Indexed: 06/12/2023]
Abstract
Mild traumatic brain injury (mTBI) and concussion, a subtype of mTBI, commonly present to the emergency department (ED) and may present with symptoms identical to those associated with more severe TBI. The development and use of clinical decision rules, increased awareness of the risk of radiation associated with head computed tomography, and the potential for patient observation has allowed emergency clinicians to make well-informed decisions regarding the need for imaging for patients who present with mTBI. For patients who present to the ED with concussion, appropriate diagnosis, management, and education are critical for optimal recovery. This issue reviews the most recent literature on concussion and mTBI and provides recommendations for the evaluation, diagnosis, and treatment of mTBI and concussion in the acute setting.
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Affiliation(s)
- Madeline Joseph
- Professor of Emergency Medicine and Pediatrics, Associate Dean for Inclusion and Equity, Emergency Medicine Department, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Audrey Paul
- Assistant Professor, Pediatric Emergency Medicine, NYU Long Island School of Medicine, New York, NY
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9
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Miller JP, Ivanics C, Zalewski K, Mody SS, Kannikeswaran N. Rates and clinical impact of discordant X-ray and CT imaging in transfers to a pediatric emergency department. Am J Emerg Med 2021; 49:166-171. [PMID: 34126562 DOI: 10.1016/j.ajem.2021.05.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/13/2021] [Accepted: 05/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Children are often transferred to a Pediatric Emergency Department (PED) for definitive care after completion of diagnostic imaging. There is a paucity of data on the concordance rates of interpretation of imaging studies between referral and PED. Our objective is to describe the rates and clinical impact of discordant interpretation of X-rays and CT in children transferred to a PED. METHODS This was a retrospective cohort study of patients over a 12-month period from 12/1/2017-11/30/2018 with X-ray (XR) and CT performed prior to transfer to our PED. We compared referral radiology interpretations to those of pediatric radiologists to determine concordance. Encounters with discordant imaging interpretations were further evaluated for clinical impact (none, minor or major) based on need for additional laboratory workup, consultation, and changes in management and disposition. RESULTS We analyzed 899 patient encounters. There were high rates of concordance in both XR and CT interpretation (668/743; 89.9%, 95% CI 0.87-0.91 and 205/235; 87.2%, 95% CI 0.82-0.91, respectively). XR discordance resulted in minor clinical impact in 34 patients (45%, 95% CI 0.35-0.57) and a major clinical impact in 28 patients (37%, 95% CI 0.27-0.49). CT discordance resulted in minor clinical impact in 10 patients (33%, 95% CI 0.19-0.51) of patients and major clinical impact in 15 patients (50%, 95% CI 0.33-0.67). The most common discordances with major clinical impact were related to pneumonia on XR chest and appendicitis or inflammatory bowel disease on CT abdomen. CONCLUSIONS In patients transferred to the PED, concordance of XR and CT interpretations was high. A majority of discordant interpretations led to clinical impact meaningful to the patient and emergency medicine (EM) physician. Referring EM physicians might consider the benefit of pediatric radiology consultation upon transfer, especially for imaging diagnoses related to pneumonia, appendicitis, or inflammatory bowel disease.
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Affiliation(s)
- Jason P Miller
- Children's Hospital of Michigan, Division of Emergency Medicine, 3901 Beaubien Blvd, Detroit, MI 48201, United States; Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States; Central Michigan University School of Medicine, 1280 East Campus Dr, Mt Pleasant, MI 48858, United States.
| | - Ciara Ivanics
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States
| | - Kristina Zalewski
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States
| | - Swati S Mody
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States; Children's Hospital of Michigan, Department of Radiology, 3901 Beaubien Blvd, Detroit, MI 48201, United States
| | - Nirupama Kannikeswaran
- Children's Hospital of Michigan, Division of Emergency Medicine, 3901 Beaubien Blvd, Detroit, MI 48201, United States; Central Michigan University School of Medicine, 1280 East Campus Dr, Mt Pleasant, MI 48858, United States
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10
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Morrison SN, Sigman L. Consent, refusal of care, and shared decision-making for pediatric patients in emergency settings. Pediatr Emerg Med Pract 2021; 18:1-20. [PMID: 33885255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/10/2021] [Indexed: 06/12/2023]
Abstract
Involving patients or their surrogate decision-makers in their care is an important element of modern medical practice. General consent, informed consent, treatment refusal, and shared decision-making are concepts that are used regularly but can be more complex in pediatric emergency settings. This issue summarizes these concepts and provides case examples that may be encountered. It explains the essential elements of informed consent, the distinction between the informed consent process and the document, how to approach treatment refusal, and approaches to involving patients and their surrogates in shared decision-making. Special circumstances include treatment for sexual and mental health conditions, emancipated minors, mature minors, and situations when custody is unclear. Implementation of these concepts can increase patient satisfaction, resolve conflict, and reduce risk.
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Affiliation(s)
- Sephora N Morrison
- Associate Division Chief, Emergency Medicine & Trauma Center; Medical Unit Director, Clinical Operations, Director of Experience & Clinical Integration, Children's National Hospital, Washington, DC
| | - Laura Sigman
- Pediatrician, Director of Legal and Policy Coordination for Emergency Medicine, Children's National Hospital; Clinical Associate Professor of Pediatrics, George Washington University, Washington, DC
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11
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Iqbal A, Langhan ML, Rotruck J, Soma G. An evidence-based approach to nontraumatic ocular complaints in children. Pediatr Emerg Med Pract 2021; 18:1-28. [PMID: 33476507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/10/2020] [Indexed: 06/12/2023]
Abstract
Children commonly present to emergency departments with eye complaints in the absence of antecedent trauma. Signs and symptoms of ocular disease are often nonspecific. Red, swollen, or painful eyes may represent benign or vision-threatening processes, making recognition and triage challenging for the emergency clinician. This issue reviews the presentations of common nontraumatic ocular complaints and provides evidence-based recommendations for management in the emergency department.
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Affiliation(s)
- Ammarah Iqbal
- Pediatric Emergency Medicine Fellow, Pediatric Emergency Department, Yale New Haven Hospital, New Haven, CT
| | - Melissa L Langhan
- Associate Professor of Pediatrics and Emergency Medicine; Fellowship Director, Director of Education, Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Jill Rotruck
- Assistant Professor of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, CT
| | - Gauthami Soma
- Pediatric Emergency Medicine Fellow, Pediatric Emergency Department, Yale New Haven Hospital, New Haven, CT
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12
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Tam D, Tainter C. Calculated decisions: Modified Mallampati classification. Pediatr Emerg Med Pract 2020; 17:CD1-CD2. [PMID: 33080129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/10/2020] [Indexed: 06/11/2023]
Abstract
The Modified Mallampati Classification stratifies predicted difficulty of endotracheal intubation based on anatomic features.
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Affiliation(s)
- Derek Tam
- Department of Pediatrics, Rady Children's Hospital, San Diego, CA
| | - Christopher Tainter
- Division of Critical Care and Department of Emergency Medicine, University of California, San Diego, San Diego, CA
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13
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Alerhand S, Tay ET. Point-of-care ultrasound for confirmation of gastrostomy tube replacement in the pediatric emergency department. Intern Emerg Med 2020; 15:1075-1079. [PMID: 32133576 DOI: 10.1007/s11739-020-02294-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/13/2020] [Indexed: 01/01/2023]
Abstract
Gastrostomy tubes (G-tubes) are frequently used in children for feeding and nutrition. Complications related to G-tubes (and G-buttons) in children represent a common presentation to the emergency department (ED). G-tube replacement is usually performed by pediatric emergency medicine physicians. Misplacement may lead to tract disruption, perforation, fistula tract formation, or feeding into the peritoneum. Contrast-enhanced radiographs are traditionally used for confirmation. In addition to a longer length-of-stay, repeat ED visits result in repeated radiation exposure. The use of point-of-care ultrasound (POCUS) instead of radiography avoids this exposure to ionizing radiation. Here, we describe three patients who presented with G-tube complications in whom POCUS alone performed by pediatricians was used for confirmation of the tubes' replacement. Two children presented to the ED with G-tube dislodgement, and one child presented with a ruptured balloon. In all three cases, a new G-tube was replaced at the bedside using POCUS guidance without the need for further radiographic studies. There were no known ED or clinic returns for G-tube complaints over the next 30 days. This is the first report of pediatricians using POCUS to guide and confirm G-tube replacement in children. The success of these cases suggests the technique's feasibility. Future prospective studies are needed to evaluate the learning curves, diagnostic accuracy, ED length-of-stay, and use of confirmatory imaging.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA.
| | - Ee Tein Tay
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, 10016, USA
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14
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Slubowski D, Ruttan T. High-flow nasal cannula and noninvasive ventilation in pediatric emergency medicine. Pediatr Emerg Med Pract 2020; 17:1-24. [PMID: 32678565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/10/2020] [Indexed: 06/11/2023]
Abstract
The use of high-flow nasal cannula and noninvasive ventilation has become increasingly common in emergency medicine as a first-line treatment of pediatric patients with respiratory distress secondary to asthma and bronchiolitis. When implemented in clinical practice, close monitoring of vital signs and ventilation parameters is warranted to identify possible signs of respiratory failure. This issue provides evidence-based recommendations for the appropriate use of noninvasive ventilation modalities in pediatric patients including high-flow nasal cannula, continuous positive airway pressure, and bilevel positive airway pressure in the setting of acute respiratory distress. Contraindications and complications associated with these modalities are also discussed.
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Affiliation(s)
- Daniel Slubowski
- Assistant Professor of Clinical Emergency Medicine and Pediatrics, Indiana University School of Medicine, Department of Emergency Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Timothy Ruttan
- Assistant Professor of Pediatrics, University of Texas at Austin Dell Medical School, Department of Pediatrics, Dell Children's Medical Center of Central Texas, Pediatric Emergency Medicine, Austin, TX
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15
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Doan Q, Wong H, Meckler G, Johnson D, Stang A, Dixon A, Sawyer S, Principi T, Kam AJ, Joubert G, Gravel J, Jabbour M, Guttmann A. The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study. CMAJ 2019; 191:E627-E635. [PMID: 31182457 DOI: 10.1503/cmaj.181426/-/dc1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department. METHODS We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling. RESULTS A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios [ORs] ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06). INTERPRETATION Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.
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Affiliation(s)
- Quynh Doan
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont.
| | - Hubert Wong
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Garth Meckler
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - David Johnson
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Antonia Stang
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Andrew Dixon
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Scott Sawyer
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Tania Principi
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - April J Kam
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Gary Joubert
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Jocelyn Gravel
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Mona Jabbour
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
| | - Astrid Guttmann
- Division of Pediatric Emergency Medicine, Department of Pediatrics (Doan, Meckler), University of British Columbia; School of Population and Public Health (Wong), University of British Columbia; BC Children's Hospital Research Institute (Doan, Meckler), Vancouver, BC; Alberta Children's Hospital Research Institute (Johnson, Stang), University of Calgary, Calgary, Alta; Stollery Children's Hospital, and Women and Children's Health Research Institute (Dixon), University of Alberta, Edmonton, Alta.; Pediatric Emergency Medicine (Sawyer), University of Manitoba; Children's Hospital, Health Sciences Centre Winnipeg (Sawyer), Winnipeg, Man.; Paediatric Emergency Medicine (Principi), University of Toronto; The Hospital for Sick Children (Principi), Toronto, Ont.; Department of Pediatrics (Kam), McMaster University; McMaster Children's Hospital (Kam), Hamilton, Ont.; Paediatric Emergency Medicine (Joubert), Western University; Children's Hospital of Western Ontario (Joubert), London, Ont.; Département de pédiatrie (Gravel), Université de Montréal; CHU Sainte-Justine (Gravel), Montréal, Que.; Department of Pediatrics (Jabbour), University of Ottawa; Children's Hospital of Eastern Ontario (Jabbour), Ottawa, Ont.; ICES (Guttmann); Department of Paediatrics (Guttmann), University of Toronto, Toronto, Ont
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16
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Seelig S, Ryus CR, Harrison RF, Wilson MP, Wong AH. Cryptococcal Meningoencephalitis Presenting as a Psychiatric Emergency. J Emerg Med 2019; 57:203-206. [PMID: 31014972 DOI: 10.1016/j.jemermed.2019.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Organic conditions can often mimic neuropsychiatric disorders, leading to delays in diagnosis and treatment for the most vulnerable populations presenting to the emergency department (ED). CASE REPORT Here we discuss a case of cryptococcal meningoencephalitis seemingly consistent with psychosis on initial evaluation, and present strategies to recognize and treat this condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to the indolent time course of this disease, initial symptoms of altered mental status and personality changes may be attributed to drug use or psychiatric illness before more overt evidence for increased intracranial pressure and neurologic infection develops. It is important for emergency clinicians to maintain a high level of suspicion for this condition in at-risk patients and reassess them frequently during their ED visit.
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Affiliation(s)
- Sandra Seelig
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut
| | - Caitlin R Ryus
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut
| | - Raquel F Harrison
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael P Wilson
- Department of Emergency Medicine, Behavioral Emergencies Research (DEMBER) Lab, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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17
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Hardesty W, Singichetti B, Yi H, Leonard JC, Yang J. Characteristics and Costs of Pediatric Emergency Department Visits for Sports- and Recreation-Related Concussions, 2006-2014. J Emerg Med 2019; 56:571-579. [PMID: 30857833 DOI: 10.1016/j.jemermed.2019.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/19/2018] [Accepted: 01/08/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although concussion-related emergency department (ED) visits increased after the passage of concussion laws, little is known about how the laws may disproportionately impact ED utilization and associated health care costs among children in different demographic groups. OBJECTIVE Our aim was to examine the patient and clinical characteristics of pediatric ED visits and associated health care costs for sports- and recreation-related concussions (SRRCs) before and after concussion law enactment. METHODS We retrospectively analyzed ED visits for SRRCs by children ages 5-18 years between 2006 and 2014 in the Pediatric Health Information System database (n = 123,220). ED visits were categorized as "pre-law," "immediate post-law," and "post-law" according to the respective state concussion law's effective date. Multinomial logistic regression models were used to assess the impact of the law on ED utilization. RESULTS The majority of visits were by males (n = 83,208; 67.6%), children aged 10-14 years (n = 49,863; 40.9%), and privately insured patients (n = 62,376; 50.6%). Female sex, older age, and insured by Medicaid/Medicare were characteristics associated with increased ED visits during the immediate post-law and post-law periods compared to their counterparts. A significant decrease in proportion of imaging use was observed from pre-law to post-law (adjusted odds ratio 0.49; 95% confidence interval 0.47-0.50; p < 0.0001). While annual adjusted costs per ED visits decreased, annual total adjusted costs per hospital for SRRCs increased from pre-law to post-law (p < 0.0001). CONCLUSIONS Concussion laws might have impacted pediatric concussion-related ED utilization, with increased annual total adjusted costs. These results may have important implications for policy interventions and their effects on health care systems.
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Affiliation(s)
- Walter Hardesty
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Bhavna Singichetti
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Honggang Yi
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Julie C Leonard
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Jingzhen Yang
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
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Violano P, Aysseh N, Lucas M, Gawel M, Morrell P, Norway C, Alfano A, Bechtel K. Feasibility of providing child restraint devices after a motor vehicle crash in a pediatric emergency department. Traffic Inj Prev 2019; 19:844-848. [PMID: 30657709 DOI: 10.1080/15389588.2018.1496243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 05/17/2018] [Accepted: 06/28/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Motor vehicle crashes (MVCs) cause disproportionate childhood morbidity and mortality. Ensuring that children are placed in appropriate child restraint devices (CRDs) would significantly reduce injuries and deaths as well as medical costs. The goal of the study is to evaluate the feasibility of providing child restraint devices after an MVC in a pediatric emergency department (PED). METHODS A guideline was developed to assess the need for CRDs for patients discharged from a PED after an MVC. Providers were educated on the use of the guideline. Caregivers were provided a brief educational intervention on legislation, proper installation, and best practices prior to distribution of a CRD. Quality assurance was conducted weekly to monitor for any missed opportunities. RESULTS From August 31, 2015, to August 31, 2016, 291 patients <7 years were evaluated in the PED of a level 1 trauma center following an MVC. Two hundred forty-seven children were correctly identified according to the guidelines (84.9%). Of these, 187 (75.7%) were identified as not requiring a replacement seat and 60 (24.3%) required a CRD replacement based on crash mechanisms and restraint use status and received a CRD replacement. Of the remaining 44 children, 38 (86.4%) whose crash mechanisms were severe enough or who were inappropriately restrained were not provided a CRD and thus missed; 6 (13.6%) received a replacement seat even though criteria were not met. Thus, PED providers correctly identified 61.2% (60/98) of children who required CRD replacement after an MVC. CONCLUSION Caring for children who present for evaluation after an MVC offers an opportunity for ED personnel to provide education to caregivers about the appropriate use of CRDs and state legislation. Establishing guidelines for the provision of a CRD for children who present to an ED following an MVC may help to improve the safety of children being transported in motor vehicles. Having a systematic process and adequate supply of CRDs readily available contributes to the success of children being discharged with the appropriate age- and weight-based CRD after being treated in an ED following an MVC.
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Affiliation(s)
- Pina Violano
- a Injury Prevention, Community Outreach & Research, Yale New Haven Hospital , New Haven , Connecticut
- b Injury Free Coalition for Kids of New Haven, Yale New Haven Children's Hospital , New Haven , Connecticut
| | - Nick Aysseh
- a Injury Prevention, Community Outreach & Research, Yale New Haven Hospital , New Haven , Connecticut
- b Injury Free Coalition for Kids of New Haven, Yale New Haven Children's Hospital , New Haven , Connecticut
| | - Monica Lucas
- a Injury Prevention, Community Outreach & Research, Yale New Haven Hospital , New Haven , Connecticut
- b Injury Free Coalition for Kids of New Haven, Yale New Haven Children's Hospital , New Haven , Connecticut
| | - Marcie Gawel
- a Injury Prevention, Community Outreach & Research, Yale New Haven Hospital , New Haven , Connecticut
- b Injury Free Coalition for Kids of New Haven, Yale New Haven Children's Hospital , New Haven , Connecticut
| | - Patricia Morrell
- c Trauma Department , Yale New Haven Hospital , New Haven , Connecticut
| | - Calvin Norway
- a Injury Prevention, Community Outreach & Research, Yale New Haven Hospital , New Haven , Connecticut
- c Trauma Department , Yale New Haven Hospital , New Haven , Connecticut
| | - April Alfano
- d Emergency Operations Center, Yale New Haven Health System , New Haven , Connecticut
| | - Kirsten Bechtel
- a Injury Prevention, Community Outreach & Research, Yale New Haven Hospital , New Haven , Connecticut
- b Injury Free Coalition for Kids of New Haven, Yale New Haven Children's Hospital , New Haven , Connecticut
- e Department of Pediatrics , Yale School of Medicine , New Haven , Connecticut
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19
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Burns C, Burns R, Sanseau E, Mazor S, Reid J, Stone K, Thomas A. Pediatric Emergency Medicine Simulation Curriculum: Marijuana Ingestion. MedEdPORTAL 2018; 14:10780. [PMID: 30800980 PMCID: PMC6342394 DOI: 10.15766/mep_2374-8265.10780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 10/22/2018] [Indexed: 06/01/2023]
Abstract
Introduction Altered mental status can be a challenging presenting symptom in children due to the wide differential diagnosis, which ranges from the relatively benign to the life threatening. Marijuana ingestion and unintentional intoxication are becoming an increasingly common cause of altered mental status in children as marijuana use and availability of enticing marijuana edibles increase in the United States. Because children present with altered mental status rather than the typical marijuana toxidrome, appropriately managing these patients in emergency settings can be particularly challenging. Methods This simulation-based curriculum involved the evaluation and management of a 6-year-old boy who presented with altered mental status from acute marijuana intoxication unbeknownst to his parents. Participants systematically evaluated a pediatric patient with a broad differential diagnosis of altered mental status and managed the patient with acute marijuana intoxication. This scenario may be modified based on trainee level (medical student vs. resident vs. fellow). Results A total of 20 trainees comprising six emergency medicine fellows and 14 pediatric residents and medical students participated in this simulation curriculum over three iterations. Trainees consistently rated it as an overall positive learning experience for pediatric altered mental status and toxidrome education. Discussion Low-frequency, high-risk illnesses such as altered mental status due to marijuana intoxication require providers to be familiar with their evaluation and management. This curriculum provides instructors with the materials to successfully implement and improve the simulation over time.
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Affiliation(s)
- Carson Burns
- Resident, Department of Pediatrics, Seattle Children's Hospital
- Resident, Department of Pediatrics, University of Washington School of Medicine
| | - Rebekah Burns
- Assistant Professor, Department of Pediatrics, University of Washington School of Medicine
| | | | - Suzan Mazor
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Jennifer Reid
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Kimberly Stone
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Anita Thomas
- Assistant Professor, Department of Pediatrics, University of Washington School of Medicine
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Abstract
Advances in technology are continuously transforming medical care, including pediatric emergency medicine. The increasing adoption of point-of-care ultrasound examination can improve timely diagnoses without radiation and aids the performance of common procedures. The recent dramatic increase in electronic health record adoption offers an opportunity for enhanced clinical decision-making support. Simulation training and advances in technologies can provide continued proficiency training despite decreasing opportunities for pediatric procedures and cardiorespiratory resuscitation performance. This article reviews these and other recent advances in technology that have had the greatest impact on the current practice of pediatric emergency medicine.
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Affiliation(s)
- Marisa C Louie
- Department of Emergency Medicine, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA; Department of Pediatrics, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA.
| | - Todd P Chang
- Pediatric Emergency Medicine, Keck School of Medicine at University of Southern California, Children's Hospital Los Angeles, 4650 Sunset Boulevard Mailstop 113, Los Angeles, CA 90027, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Roberts Center, 2716 South Street, 15th Floor, Philadelphia, PA 19146, USA
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21
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Augenstein JA, Deen J, Thomas A, Moser E, Stone K, Reid J, Burns R. Pediatric Emergency Medicine Simulation Curriculum: Cardiac Tamponade. MedEdPORTAL 2018; 14:10758. [PMID: 30800958 PMCID: PMC6342367 DOI: 10.15766/mep_2374-8265.10758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 09/01/2018] [Indexed: 05/02/2023]
Abstract
Introduction Cardiac tamponade is an uncommon presentation to the pediatric emergency department and requires early recognition and emergent intervention. Methods We developed this patient simulation case to simulate a low-frequency, high-acuity scenario for pediatric emergency medicine fellows and resident physicians in emergency medicine, pediatrics, and family medicine. We ran the case in a pediatric emergency department using a high-fidelity pediatric mannequin and equipment found in the clinical environment, including a bedside ultrasound machine. The case involved a 10-year-old patient with Hodgkin lymphoma who presented with fever, neutropenia, and shock and was found to have a pericardial effusion with tamponade after evaluation. The providers were expected to identify signs and symptoms of shock, as well as cardiac tamponade, and demonstrate appropriate emergent evaluation and management. Required personnel included a simulation technician, instructors, and a nurse. Debriefing tools tailored specifically for this scenario were created to facilitate a formal debriefing and formative learner assessment at the end of the simulation. Results This case has been implemented with 10 pediatric emergency medicine fellows during two 3-year cycles of fellow education. Session feedback reflected a high level of satisfaction with the case and an increased awareness of bedside ultrasound in the identification of cardiac tamponade. Discussion This resource for teaching the critical components for diagnosing and managing unstable cardiac tamponade in the pediatric patient, including use of bedside ultrasound, was well received by pediatric emergency medicine fellows.
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Affiliation(s)
| | - Jason Deen
- Assistant Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Anita Thomas
- Assistant Professor, Department of Pediatrics, University of Washington School of Medicine
| | | | - Kimberly Stone
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Jennifer Reid
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Rebekah Burns
- Assistant Professor, Department of Pediatrics, University of Washington School of Medicine
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Anderson J, Arboleda N, Calleo V. High-Fidelity Simulation Scenario: Pyridoxine-Dependent Epilepsy and Treatment. MedEdPORTAL 2018; 14:10753. [PMID: 30800953 PMCID: PMC6342356 DOI: 10.15766/mep_2374-8265.10753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 08/28/2018] [Indexed: 06/09/2023]
Abstract
Introduction Treatment of seizures in the neonatal patient is urgent and time sensitive. Effective and timely treatment of this life-threatening condition is vital in preventing mortality and long-term morbidity. This simulation-based curriculum involves the identification and management of a seizure in a 4-day-old neonate with pyridoxine-dependent epilepsy. The target audience is emergency medicine and pediatric residents, pediatric emergency medicine fellows, and medical students. Methods The primary objectives for this simulation are to (1) rapidly initiate stabilization techniques for a seizing neonate, (2) recognize the importance of checking a glucose level in a seizing neonate, (3) demonstrate understanding of antiepileptic medications and dosing, and (4) identify status epilepticus and initiate pyridoxine once initial seizure management has failed. The goals of this simulation are for residents to treat a seizing infant in an emergency department setting, identify status epilepticus, develop a differential diagnosis that includes vitamin B6 deficiency, and correctly administer pyridoxine. Requirements of this simulation include a high-fidelity patient simulator, medical supplies, a patient simulator operator, and one actor. Results This simulation case was performed at the simulation lab at the State University of New York Upstate Medical University with emergency medicine and pediatric residents. Feedback evaluations for the case showed that it improved resident education and clinical skills. Discussion This simulation case was well received and helped residents develop a systematic approach to seizure management of a newborn. Residents reported increased confidence in treating a seizing neonate and increased comprehension of pyridoxine-dependent epilepsy.
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Affiliation(s)
- Jacob Anderson
- Pediatric Resident, Department of Pediatrics, State University of New York Upstate Medical University
| | - Nathan Arboleda
- Medical Student, Department of Education, State University of New York Upstate Medical University
| | - Vincent Calleo
- Pediatric Emergency Medicine Fellow, Department of Emergency Medicine, State University of New York Upstate Medical University
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Abstract
Introduction Chronic salicylate toxicity is an uncommon, potentially life-threatening poisoning that requires high clinical suspicion in order to make the diagnosis. We created a simulation case that challenges learners to analyze case information, construct a differential diagnosis of an elevated anion gap metabolic acidosis with respiratory alkalosis, and initiate treatment for this toxicity. Methods The simulation case was designed for emergency medicine residents and pediatric emergency medicine fellows. The activity began with a brief overview of the monitors, equipment, and simulation experience. For interns, a team of two learners comanaged the case; for senior learners, the case was managed solo. The learners had 15 minutes to complete a focused history and physical exam, request and interpret labs and studies, and initiate specific treatments. The simulation was followed by a 15-minute facilitated debrief session that included an overview of key learning points and learner performance based on an evaluation checklist. Results Residents completed a postparticipation questionnaire consisting of six questions rated on a 5-point Likert scale. Overall, residents reported a high degree of satisfaction with the simulation experience. The case and debrief were effective in meeting the educational objectives and proved to be an effective modality to fill this educational gap. Discussion This simulation exercise was effective in showing residents the uncommon presentation of chronic salicylate toxicity. Learners reported increased confidence in recognizing and managing this ingestion. The simulation experience closed an identified education gap and provided an experiential learning opportunity that accomplished the targeted learning objectives.
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Affiliation(s)
- Mary Wittler
- Assistant Professor, Department of Emergency Medicine, Wake Forest Baptist Medical Center
| | - David A. Masneri
- Assistant Professor, Department of Emergency Medicine, Wake Forest Baptist Medical Center
- Emergency Medicine Simulation Director, Wake Forest Baptist Medical Center
| | - Jennifer Hannum
- Assistant Professor, Department of Emergency Medicine, Wake Forest Baptist Medical Center
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Akhavan AR, Burns R, Stone K, Reid J, Mazor S. Pediatric Toxidrome Simulation Curriculum: Liquid Nicotine Overdose. MedEdPORTAL 2018; 14:10735. [PMID: 30800935 PMCID: PMC6342440 DOI: 10.15766/mep_2374-8265.10735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/03/2018] [Indexed: 06/01/2023]
Abstract
Introduction Liquid nicotine exposure is becoming more common in the pediatric population. Toxicity may occur with exposure to small quantities given the high concentrations in solutions available commercially. Effects can include altered mental status, seizure, and death. Methods This simulation-based case involves the identification and management of a toddler presenting with acute liquid nicotine exposure, with emphasis on the general approach to the acutely ill pediatric patient, consideration in toxic exposures, and the presentation of nicotine exposure. Providers should assess airway, breathing, and circulation while concurrently providing supportive care for an actively seizing simulated patient, necessitating appropriate selection of medications and acute airway management. Additionally, providers must maintain a broad differential diagnosis and obtain a focused history to narrow that differential and identify toxic exposure as a cause of the patient's presentation. Preparatory and didactic material is provided to help the instructor prepare the simulation environment, guide learners through the case, and debrief with learners afterward. Results We implemented this curriculum with four pediatric emergency medicine fellows and 15 pediatric residents during two sessions. Feedback was overwhelmingly positive; participants who completed evaluations reported high levels of confidence with knowledge and skills directly related to the educational objectives after participation (mean Likert scores of 4.9 out of 5 in response to effectiveness of the case in teaching evaluation and management of nicotine toxicity). Discussion This comprehensive resource will aid in offering continuing education for providers and specifically in educating learners with regard to acute liquid nicotine exposure in a child.
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Affiliation(s)
| | - Rebekah Burns
- Assistant Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Kimberly Stone
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Jennifer Reid
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Suzan Mazor
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
- Medical Director of Toxicology, Seattle Children's Hospital
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Schumacher DJ, Holmboe ES, van der Vleuten C, Busari JO, Carraccio C. Developing Resident-Sensitive Quality Measures: A Model From Pediatric Emergency Medicine. Acad Med 2018; 93:1071-1078. [PMID: 29215378 DOI: 10.1097/acm.0000000000002093] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE To begin closing the gap with respect to quality measures available for use among residents, the authors sought to identify and develop resident-sensitive quality measures (RSQMs) for use in the pediatric emergency department (PED) setting. METHOD In May 2016, the authors reviewed National Quality Measures Clearinghouse (NQMC) measures to identify resident-sensitive measures. To create additional measures focused on common, acute illnesses (acute asthma exacerbation, bronchiolitis, closed head injury [CHI]) in the PED, the authors used a nominal group technique (NGT) and Delphi process from September to December 2016. To achieve a local focus for developing these measures, all NGT and Delphi participants were from Cincinnati Children's Hospital Medical Center. Delphi participants rated measures developed through the NGT in two areas: importance of measure to quality care and likelihood that measure represents the work of a resident. RESULTS The review of NQMC measures identified 28 of 183 as being potentially resident sensitive. The NGT produced 67 measures for asthma, 46 for bronchiolitis, and 48 for CHI. These were used in the first round of the Delphi process. After two rounds, 18 measures for asthma, 21 for bronchiolitis, and 21 for CHI met automatic inclusion criteria. In round three, participants categorized the potential final measures by their top 10 and next 5. CONCLUSIONS This study describes a template for identifying and developing RSQMs that may promote high-quality care delivery during and following training. Next steps should include implementing and seeking validity evidence for the locally developed measures.
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Affiliation(s)
- Daniel J Schumacher
- D.J. Schumacher is assistant professor, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0001-5507-8452. E.S. Holmboe is senior vice president for milestones development and evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois. C. van der Vleuten is professor of education, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, and scientific director, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands. J.O. Busari is consultant pediatrician and associate professor of medical education, Maastricht University, Maastricht, The Netherlands. C. Carraccio is vice president of competency-based assessment, American Board of Pediatrics, Chapel Hill, North Carolina
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Houston KA, George EC, Maitland K. Implications for paediatric shock management in resource-limited settings: a perspective from the FEAST trial. Crit Care 2018; 22:119. [PMID: 29728116 PMCID: PMC5936024 DOI: 10.1186/s13054-018-1966-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 01/26/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although the African "Fluid Expansion as Supportive therapy" (FEAST) trial showed fluid resuscitation was harmful in children with severe febrile illness managed in resource-limited hospitals, the most recent evidence reviewed World Health Organization (WHO) guidelines continue to recommend fluid boluses in children with shock according to WHO criteria "WHO shock", arguing that the numbers included in the FEAST trial were too small to provide reasonable certainty. METHODS We re-analysed the FEAST trial results for all international definitions for paediatric shock including hypotensive (or decompensated shock) and the WHO criteria. In addition, we examined the clinical relevance of the WHO criteria to published and unpublished observational studies reporting shock in resource-limited settings. RESULTS We established that hypotension was rare in children with severe febrile illness complicating only 29/3170 trial participants (0.9%). We confirmed that fluid boluses were harmful irrespective of the definitions of shock including the very small number with WHO shock (n = 65). In this subgroup 48% of bolus recipients died at 48 h compared to 20% of the non-bolus control group, an increased absolute risk of 28%, but translating to an increased relative risk of 240% (p = 0.07 (two-sided Fisher's exact test)). Examining studies describing the prevalence of the stringent WHO shock criteria in children presenting to hospital we found this was rare (~ 0.1%) and in these children mortality was very high (41.5-100%). CONCLUSIONS The updated WHO guidelines continue to recommend boluses for a very limited number of children presenting at hospital with the strict definition of WHO shock. Nevertheless, the 3% increased mortality from boluses seen across FEAST trial participants would also include this subgroup of children receiving boluses. Recommendations aiming to differentiate WHO shock from other definitions will invariably lead to "slippage" at the bedside, with the potential of exposing a wider group of children to the harm of fluid-bolus therapy.
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Affiliation(s)
- Kirsty Anne Houston
- Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG UK
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, PO Box 230, Kilifi, Kenya
| | - Elizabeth C. George
- Medical Research Council Clinical Trials Unit (MRC CTU) at University College London (UCL), 90 High Holborn, 2nd Floor, London, WC1V 6XX UK
| | - Kathryn Maitland
- Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG UK
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, PO Box 230, Kilifi, Kenya
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Berry J, Stone K, Reid J, Bell A, Burns R. Pediatric Emergency Medicine Simulation Curriculum: Electrical Injury. MedEdPORTAL 2018; 14:10710. [PMID: 30800910 PMCID: PMC6342442 DOI: 10.15766/mep_2374-8265.10710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/21/2017] [Indexed: 06/01/2023]
Abstract
Introduction Electrical injuries are rare but potentially life-threatening medical emergencies that require providers to manage a critically ill patient while recognizing and treating the unique sequelae associated with the diagnosis. This simulation case is designed to give pediatric and emergency medicine residents, fellows, attendings, and nurses the opportunity to practice these skills in a realistic setting. Methods This simulation-based curriculum was designed for a high-fidelity mannequin in an emergency department resuscitation room but can be adapted to fit a variety of learning environments. The case featured a 16-year-old boy presenting to the emergency department after arresting in the field after sustaining an electrical injury. He developed ventricular tachycardia during the simulation and had significant hyperkalemia, requiring emergent management. The included debriefing tools assisted instructors in providing formative feedback to learners. Results A total of 40 residents, medical students, and fellows participated in this scenario and provided overwhelmingly positive feedback about the learning experience. Mean Likert scores for participant confidence related to learning objectives after the simulation were 4 or greater on a 5-point scale. Discussion This case was developed to help learners at various levels of training recognize and manage a low-frequency, high-acuity scenario in a standardized environment. Participants specifically had the opportunity to perform airway management, cardiopulmonary resuscitation, defibrillation, and management of hyperkalemia, which may present in real life from a multitude of etiologies. The included materials helped prepare and assist facilitators with debriefing, supplemental education, and bidirectional feedback.
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Affiliation(s)
- Jonathan Berry
- Pediatric Resident, University of Washington School of Medicine
| | - Kimberly Stone
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Jennifer Reid
- Associate Professor, Department of Pediatrics, University of Washington School of Medicine
| | - Alicia Bell
- Lead Simulation Technician, Seattle Children's Hospital Learning and Simulation Center
| | - Rebekah Burns
- Assistant Professor, Department of Pediatrics, University of Washington School of Medicine
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Abstract
Advances in medical imaging are invaluable in the care of pediatric patients in the emergent setting. The diagnostic accuracy offered by studies using ionizing radiation, such as plain radiography, computed tomography, and fluoroscopy, are not without inherent risks. This article reviews the evidence supporting the risk of ionizing radiation from medical imaging as well as discusses clinical scenarios in which clinicians play an important role in supporting the judicious use of imaging studies.
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Affiliation(s)
- Amy L Puchalski
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Christyn Magill
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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Abstract
An inborn error of metabolism should be considered in any neonate who presents to the emergency department in extremis and in any young child who presents with altered mental status and vomiting. In children with unknown diagnoses, it is crucial to draw the appropriate laboratory studies before the institution of therapy, although treatment needs rapid institution to mitigate neurologic damage and avoid worsening metabolic crisis. Although there are hundreds of individual genetic disorders, they are roughly placed into groups that present similarly. This article reviews the approach to the patient with unknown metabolic diagnosis and up-to-date management pearls for children with known disorders.
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Affiliation(s)
- Emily C MacNeill
- Emergency Medicine, Carolinas HealthCare System, 1000 Blythe Boulevard, 3rd Floor MEB, Charlotte, NC 28203, USA.
| | - Chantel P Walker
- Pediatric Emergence Medicine, Carolinas HealthCare System, 1000 Blythe Boulevard, 3rd Floor MEB, Charlotte, NC 28203, USA
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Drucker NA, McDuffie L, Groh E, Hackworth J, Bell TM, Markel TA. Physical Examination is the Best Predictor of the Need for Abdominal Surgery in Children Following Motor Vehicle Collision. J Emerg Med 2017; 54:1-7. [PMID: 29107481 DOI: 10.1016/j.jemermed.2017.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/28/2017] [Accepted: 08/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Exploratory laparotomy in children after motor vehicle collision (MVC) is rare. In the absence of definitive hemorrhage or free abdominal air on radiographic imaging, predictors for operative exploration are conflicting. OBJECTIVE The purpose of this study was to explore objective findings that may aid in determining which children require operative abdominal exploration after MVC. METHODS Data from 2010-2014 at an American College of Surgeons-certified level 1 pediatric trauma center were retrospectively reviewed. Demographics, vital signs, laboratory data, radiologic studies, operative records, associated injuries, and outcomes were analyzed and p < 0.05 was considered statistically significant. RESULTS Eight hundred sixty-two patients 0-18 years of age presented to the hospital after an MVC during the study period. Seventeen patients (2.0%) required abdominal exploration and all were found to have intraabdominal injuries. Respiratory rate was the only vital sign that was significantly altered (p = 0.04) in those who required abdominal surgery compared with those who did not. Physical examination findings, such as the seat belt sign, abdominal bruising, abdominal wound, and abdominal tenderness, were present significantly more frequently in those requiring abdominal surgery (p < 0.0001). Each finding had a negative predictive value for the need for operative exploration of at least 0.98. There were no significant differences in trauma laboratory values or radiographic findings between the 2 groups. CONCLUSION Data from this study solidify the relationship between specific physical examination findings and the need for abdominal exploration after MVC in children. In addition, these data suggest that a lack of the seat belt sign, abdominal bruising, abdominal wounds, or abdominal tenderness are individually predictive of patients who will not require surgical intervention.
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Affiliation(s)
- Natalie A Drucker
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Lucas McDuffie
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Eric Groh
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Jodi Hackworth
- Riley Hospital for Children, Indiana University Health, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Teresa M Bell
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana
| | - Troy A Markel
- Indiana University School of Medicine, Section of Pediatric Surgery, Indianapolis, Indiana; Riley Hospital for Children, Indiana University Health, Section of Pediatric Surgery, Indianapolis, Indiana; Department of Surgery, Section of Pediatric Surgery, Indianapolis, Indiana
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Alzayedi AS, Azizalrahman AA, AlMadi HA, Althekair AM, Blaivas M, Karakitsos D. Use and Education of Point-of-Care Ultrasound in Pediatric Emergency Medicine in Saudi Arabia. J Ultrasound Med 2017; 36:2219-2225. [PMID: 28569379 DOI: 10.1002/jum.14254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 01/18/2017] [Accepted: 02/02/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Point-of-care ultrasound (US) is an emerging tool used by pediatric emergency physicians in the last decade. Currently in the Middle East, point-of-care US use and education are at an early stage, with no designed curriculum or guidelines for its implementation in pediatric emergency medicine (EM). The objective of this article is to describe the clinical and educational uses of point-of-care US among certified pediatric EM physicians. METHODS A 19-question survey was sent to all certified pediatric emergency physicians and fellows in pediatric emergency fellowships in Saudi Arabia in February 2016. Reminders were sent weekly for 4 weeks. RESULTS The response rate was 84 of 88 (95%). Fifty-one of 84 (61%) reported using point-of-care US. Focused assessment with sonography for trauma was the most frequent use of point-of-care US (37%), followed by procedures (19%). The most common barrier for not using point-of-care US was limited training (86%). The most preferred tool for point-of-care US teaching was courses by EM physicians. Currently, there is no specific curriculum designed for pediatric EM in the Middle East. CONCLUSIONS Despite the multiple applications of point-of-care US in pediatric EM, its use is still limited. Formal point-of-care US training with bedside sessions and courses was the mort preferred method of education. A designed curriculum needs to be implemented in pediatric emergency fellowships in Saudi Arabia.
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Affiliation(s)
- Abdullah Saad Alzayedi
- King Saud Medical City, Children's Hospital, Riyadh, Saudi Arabia
- King Fahad Medical City, Children's Hospital, Riyadh, Saudi Arabia
| | | | - Hamad A AlMadi
- King Saud Medical City, Children's Hospital, Riyadh, Saudi Arabia
| | | | - Michael Blaivas
- University of South Carolina school of Medicine, Colombia, South Carolina, USA
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Thomas A, Sanseau E, Uspal N, Burns R, Auerbach M, Caglar D, Stone K, Reid J. Pediatric Emergency Medicine Simulation Curriculum: Submersion Injury With Hypothermia and Ventricular Fibrillation. MedEdPORTAL 2017; 13:10643. [PMID: 30800844 PMCID: PMC6338133 DOI: 10.15766/mep_2374-8265.10643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 09/26/2017] [Indexed: 05/14/2023]
Abstract
Introduction Submersion injury or drowning is a leading preventable cause of pediatric mortality and morbidity. Submersion injuries are often accompanied by hypothermia and asphyxia that can lead to inadequate oxygen delivery to tissues and subsequent cardiac arrhythmias. Methods This simulation-based curriculum involves the identification and management of a submersion injury in a 4-year-old boy who was rescued from a cold-water submersion. The simulated patient is apneic, pulseless, bradycardic, and hypothermic; he is being bag-mask ventilated on arrival without intravenous access. He ultimately develops ventricular fibrillation. Providers must recognize the degree of submersion injury, initiate early airway protection, adequately address circulation, and be alert to developing hypothermia and cardiac arrhythmias to prevent further decompensation. This scenario can be modified based on trainee level (pediatric residents vs. pediatric emergency medicine fellows). Results A total of 22 trainees (PGY 1-PGY 6 pediatric residents and pediatric emergency medicine fellows) participated in this simulation curriculum on separate occasions and rated it as an overall positive learning experience. The curriculum's goal is to provide learners with an opportunity to manage life-threatening pediatric submersion injuries, where the correct steps need to be taken in a limited period of time. Discussion We have provided preparatory materials to help instructors set up, run, and debrief the scenario in a standardized fashion. The debriefing tools allow for adaptation depending on learners' needs and individual experiences during the simulated scenario. Also included are supporting educational materials and a learner feedback form that can be used to evaluate the session.
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Affiliation(s)
- Anita Thomas
- Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine
- Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, Seattle Children's Hospital
| | - Elizabeth Sanseau
- Pediatric Resident, Seattle Children's Hospital
- Pediatric Resident, University of Washington School of Medicine
| | - Neil Uspal
- Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine
- Associate Professor of Pediatric Emergency Medicine and Emergency Medicine, Department of Pediatrics, Yale School of Medicine
| | - Rebekah Burns
- Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine
- Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, Seattle Children's Hospital
| | - Marc Auerbach
- Associate Professor of Pediatric Emergency Medicine and Emergency Medicine, Department of Pediatrics, Yale School of Medicine
- Associate Professor of Pediatric Emergency Medicine and Emergency Medicine, Department of Pediatrics, Yale-New Haven Children's Hospital
| | - Derya Caglar
- Associate Professor, Department of Pediatrics, Division of Emergency Medicine, Seattle Children's Hospital
- Co-Director of Pediatric Emergency Medicine Simulation, Seattle Children's Hospital
| | - Kimberly Stone
- Associate Professor, Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine
- Associate Professor, Department of Pediatrics, Division of Emergency Medicine, Seattle Children's Hospital
- Co-Director of Pediatric Emergency Medicine Simulation, Seattle Children's Hospital
| | - Jennifer Reid
- Associate Professor, Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine
- Associate Professor, Department of Pediatrics, Division of Emergency Medicine, Seattle Children's Hospital
- Co-Director of Pediatric Emergency Medicine Simulation, Seattle Children's Hospital
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Thomas AA, Uspal NG, Oron AP, Klein EJ. Perceptions on the Impact of a Just-in-Time Room on Trainees and Supervising Physicians in a Pediatric Emergency Department. J Grad Med Educ 2016; 8:754-758. [PMID: 28018542 PMCID: PMC5180532 DOI: 10.4300/jgme-d-15-00730.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Just-in-time (JIT) training refers to education occurring immediately prior to clinical encounters. An in situ JIT room in a pediatric emergency department (ED) was created for procedural education. OBJECTIVE We examined trainee self-reported JIT room use, its impact on trainee self-perception of procedural competence/confidence, and the effect its usage has on the need for intervention by supervising physicians during procedures. METHODS Cross-sectional survey study of a convenience sample of residents rotating through the ED and supervising pediatric emergency medicine physicians. Outcomes included JIT room use, trainee procedural confidence, and frequency of supervisor intervention during procedures. RESULTS Thirty-one of 32 supervising physicians (97%) and 122 of 186 residents (66%) completed the survey, with 71% of trainees reporting improved confidence, and 68% reporting improved procedural skills (P < .05, +1.4-point average skills improvement on a 5-point Likert scale). Trainees perceived no difference among supervising physicians intervening in procedures with or without JIT room use (P = .30, paired difference -0.0 points). Nearly all supervisors reported improved trainee procedural confidence, and 77% reported improved trainee procedural skills after JIT room use (P < .05, paired difference +1.8 points); 58% of supervisors stated they intervene in procedures without trainee JIT room use, compared with 42% with JIT room use (P < .05, paired difference -0.4 points). CONCLUSIONS Use of the JIT room led to improved trainee confidence and supervisor reports of less procedural intervention. Although it carries financial and time costs, an in situ JIT room may be important for convenient JIT training.
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Affiliation(s)
- Anita A. Thomas
- Corresponding author: Anita A. Thomas, MD, MPH, Seattle Children's Hospital, Department of Emergency Medicine, Mailstop MB.7.520, 4800 Sand Point Way NE, Seattle, WA 98145, 206.987.2599, fax 206.729.3070,
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Ehrler F, Siebert J, Haddad K, Sahin A, Schrurs P, Diener R, Gervaix A, Manzano S, Lovis C. Adapting Guidelines for Google Glass: the Case of Pediatric CPR. Stud Health Technol Inform 2016; 224:141-145. [PMID: 27225569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Early recognition and management of patients at risk and more aggressive implementation of evidence-based resuscitation guidelines play a role to the reduction of patients' mortality. If, in paediatric emergency department, the proper adherence to the paediatric cardiac arrest guidelines is critical to increase the chance of survival, this adherence is unfortunately often suboptimal. Connected glasses, such as the Google Glass, offer an interesting support to provide guidelines at the point of care. However, existing guidelines format is not adapted to be used directly on the small screen of connected glasses. Their transformation to be displayed on the Google Glass is not a simple task. Problems such as the navigation and the formalization of the guidelines must be solved. In this article, we present the transformation process of the paediatric cardiac arrest algorithm from its paper version to its implementation on the Google Glass.
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Affiliation(s)
- Frederic Ehrler
- Division of Medical Information Science, University Hospital of Geneva
| | - Johan Siebert
- Pediatric Emergency Division, Children's Hospital, University Hospitals of Geneva
| | - Kevin Haddad
- Pediatric Emergency Division, Children's Hospital, University Hospitals of Geneva
| | | | | | - Raphael Diener
- Division of Medical Information Science, University Hospital of Geneva
| | - Alain Gervaix
- Pediatric Emergency Division, Children's Hospital, University Hospitals of Geneva
| | - Sergio Manzano
- Pediatric Emergency Division, Children's Hospital, University Hospitals of Geneva
| | - Christian Lovis
- Division of Medical Information Science, University Hospital of Geneva
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