Pediatric Emergency Department Research Articles

The Role of Soluble Urokinase Plasminogen Activator Receptor (suPAR) as an Early Indicator of Mortality in Pediatric Septic Shock.

Despite advancements in antibiotic therapy and resuscitation protocols, sepsis and septic shock remain major contributors to morbidity and mortality in children. We aimed to investigate the utility of soluble urokinase plasminogen activator receptor (suPAR) for the early detection of septic shock and to evaluate its accuracy in predicting mortality. A prospective study was conducted in a tertiary pediatric emergency department (ED), enrolling patients diagnosed with the sepsis, severe sepsis, or septic shock. In addition to assessing infection biomarkers such as C-reactive protein and procalcitonin, suPAR levels were quantified upon admission using enzyme-linked immunosorbent assay. The primary outcome measure was 30-day mortality. Overall 72 patients and 80 healthy children included. Plasma suPAR levels demonstrated a statistically significant elevation in the sepsis, severe sepsis, and septic shock groups compared with the control group (p < 0.001 for all). The septic shock group exhibited the highest suPAR levels upon admission, surpassing both the sepsis and severe sepsis groups (p = 0.009 and 0.042). ROC analysis underscored the promising potential of suPAR with an AUC of 0.832 for septic shock. Analysis of mortality prediction revealed significantly higher suPAR levels in nonsurvivors than survivors (9.7 ng/mL vs. 4.2 ng/mL; p < 0.001). Employing plasma suPAR levels to discriminate between mortality and survival, a threshold of ≥7.0 ng/mL demonstrated a sensitivity of 90.9% and specificity of 71.0%. Plasma suPAR levels have the potential as a biomarker for predicting mortality in children with septic shock. In pediatric septic shock, the presence of plasma suPAR ≥7 ng/mL along with an underlying disease significantly increases the risk of mortality.

Diastolic/systolic blood pressure ratio for predicting febrile children with sepsis and progress to septic shock in the emergency department

ObjectiveGiven the scarcity of studies analyzing the clinical predictors of pediatric septic cases that would progress to septic shock, this study aimed to determine strong predictors for pediatric emergency department (PED) patients with sepsis at risk for septic shock and mortality.MethodsWe conducted chart reviews of patients with ≥ 2 age-adjusted quick Sequential Organ Failure Assessment score (qSOFA) criteria to recognize patients with an infectious disease in two tertiary PEDs between January 1, 2021, and April 30, 2022. The age range of included patients was 1 month to 18 years. The primary outcome was development of septic shock within 48 h of PED attendance. The secondary outcome was sepsis-related 28-day mortality. Initial important variables in the PED and hemodynamics with the highest and lowest values during the first 24 h of admission were also analyzed.ResultsOverall, 417 patients were admitted because of sepsis and met the eligibility criteria for the study. Forty-nine cases progressed to septic shock within 48 h after admission and 368 were discharged without progression. General demographics, laboratory data, and hemodynamics were analyzed by multivariate analysis. Only the minimum diastolic blood pressure/systolic blood pressure ratio (D/S ratio) during the first 24 h after admission remained as an independent predictor of progression to septic shock and 28-day mortality. The best cutoff values of the D/S ratio for predicting septic shock and 28-day mortality were 0.52 and 0.47, respectively.ConclusionsThe D/S ratio is a practical bedside scoring system in the PED and had good discriminative ability in predicting the progression of septic shock and in-hospital mortality in PED patients. Further validation is essential in other settings.

PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study

The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma. For this prospective validation study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician's discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury). 7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery. The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma. The Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Retrospective study of acute mastoiditis in children in Spain attended in a Pediatric Emergency department

ObjectiveTo analyze the cases of acute mastoiditis, characteristics, management and complications in children attended in the emergency department. MethodsRetrospective study of acute mastoiditis in a Spanish tertiary hospital over a 6-year period (2018–2023). ResultsOne hundred two episodes of acute mastoiditis were analyzed (54% males, median age 1.8 years). Microorganisms were isolated in one third of cases, mainly Streptococcus pyogenes (64% of ear secretion cultures). Complications occurred in 27.5%, primarily subperiosteal abscess. A younger age, absence of vaccination schedule, previous history of otitis, cochlear implant carriers or white blood cell counts and C-reactive protein levels were not associated with complications. Complicated cases had longer hospitalizations. Treatment included antibiotics, corticosteroids, and surgery in 50% of cases. ConclusionsThis study shows an increase of acute mastoiditis during 2023, with a relevant role of S. pyogenes. A younger age, absence of vaccination, personal history of otitis or cochlear implant, blood cell counts and C-reactive protein levels were not associated with complications.

Unrecognized Focal Nonmotor Seizures in Adolescents Presenting to Emergency Departments.

Many adolescents with undiagnosed focal epilepsy seek evaluation in emergency departments (EDs). Accurate history-taking is essential to prompt diagnosis and treatment. In this study, we investigated ED recognition of motor vs nonmotor seizures and its effect on management and treatment of focal epilepsy in adolescents. This was a retrospective analysis of enrollment data from the Human Epilepsy Project (HEP), an international multi-institutional study that collected data from 34 sites between 2012 and 2017. Participants were 12 years or older, neurotypical, and within 4 months of treatment initiation for focal epilepsy. We used HEP enrollment medical records to review participants' initial diagnosis and management. A total of 83 adolescents were enrolled between 12 and 18 years. Fifty-eight (70%) presented to an ED before diagnosis of epilepsy. Although most ED presentations were for motor seizures (n = 52; 90%), many patients had a history of nonmotor seizures (20/52 or 38%). Adolescents with initial nonmotor seizures were less likely to present to EDs (26/44 or 59% vs 32/39 or 82%, p = 0.02), and nonmotor seizures were less likely to be correctly identified (2/6 or 33% vs 42/52 or 81%, p = 0.008). A history of initial nonmotor seizures was not recognized in any adolescent who presented for a first-lifetime motor seizure. As a result, initiation of treatment and admission from the ED was not more likely for these adolescents who met the definition of epilepsy compared with those with no seizure history. This lack of nonmotor seizure history recognition in the ED was greater than that observed in the adult group (0% vs 23%, p = 0.03) and occurred in both pediatric and nonpediatric ED settings. Our study supports growing evidence that nonmotor seizures are often undiagnosed, with many individuals coming to attention only after conversion to motor seizures. We found this treatment gap is exacerbated in the adolescent population. Our study highlights a critical need for physicians to inquire about the symptoms of nonmotor seizures, even when the presenting seizure is motor. Future interventions should focus on improving nonmotor seizure recognition for this population in EDs.

Diagnostic testing for chest pain in a pediatric emergency department and rates of cardiac disease before and during the COVID-19 pandemic: a retrospective study

ObjectivesChest pain is a common chief complaint in pediatric emergency departments (EDs). Coronavirus disease-2019 (COVID-19) has been shown to increase the risk of cardiac disease. It remains unclear how COVID-19 changed how pediatric emergency clinicians approach patients presenting with chest pain. The goal of this study was to characterize the diagnostic testing for chest pain in a pediatric ED before and during the COVID-19 pandemic.MethodsThis was a retrospective study of children between the ages of 2–17 years presenting to a pediatric ED from 1/1/2018–2/29/2020 (Pre-COVID-19) and 3/1/2020–4/30/2022 (COVID-19) with chest pain. We excluded patients with a previous history of cardiac disease.ResultsOf the 10,721 encounters during the study period, 5,692 occurred before and 5,029 during COVID-19. Patient demographics showed minor differences by age, weight, race and ethnicity. ED encounters for chest pain consisted of an average of 18% more imaging studies during COVID-19, including 14% more EKGs and 11% more chest x-rays, with no difference in the number of echocardiograms. Compared to Pre-COVID-19, 100% more diagnostic tests were ordered during COVID-19, including cardiac markers Troponin I (p &amp;lt; 0.001) and BNP (p &amp;lt; 0.001). During COVID-19, 1.1% of patients had a cardiac etiology of chest pain compared with 0.7% before COVID-19 (p = 0.03).ConclusionsDuring COVID-19, pediatric patients with chest pain underwent more diagnostic testing compared to Pre-COVID-19. This may be due to higher patient acuity, emergence of multisystem inflammatory syndrome in children (MIS-C) that necessitated more extensive testing and possible changes in ED clinician behavior during COVID-19.

Salmonella Bacteremia in Spanish Pediatric Emergency Departments: Uncommon But Not Mild.

Salmonella spp. is an uncommon microorganism in bloodstream infections among pediatric patients in our setting, although in developing countries it is the most common causative organism in blood cultures. We describe the children presenting to pediatric emergency departments and diagnosed with Salmonella bacteremia (SB) and identify clinical and laboratory predictors of poor outcome (ie, complications, sequelae and death) by bivariate analysis. We performed an observational study and subanalysis of a multicenter prospective registry, including patients <18 years of age with a positive blood culture obtained at any of the 22 participating Spanish pediatric emergency departments between 2011 and 2016. We considered young age, chronic diseases, immunosuppressive treatment and intestinal flora disruption as risk factors for SB. Of the 55 patients with SB (3.2% of registered bacteremia), 32 (58.2%) had no risk factors for SB, 42 (76.3%) had a normal pediatric assessment triangle and 45 (81.8%) an associated gastrointestinal infection (acute gastroenteritis or enteric fever). Nine (16.4%) had a poor outcome, including 1 death (1.8%). A poor outcome was more common in patients with an abnormal pediatric assessment triangle [odds ratio (OR): 51.6; 95% confidence interval (CI): 9.2-289.5], an altered physical examination (OR: 15.2; 95% CI: 4.4-58.8) and elevated C-reactive protein (OR: 1.01; 95% CI: 1.005-1.03). Most SBs were related to a gastrointestinal infection. One in 6 children had a poor outcome; abnormal pediatric assessment triangle on arrival (25% of patients) was the main risk factor identified.

Interest of toxicological analysis in patients admitted to a pediatric emergency department

Objective: Evaluate the interest of toxicology screening in the management of patients in a pediatric emergency department, by assessing its diagnostic utility. Patients and Methods: This is a retrospective cross-sectional study conducted over two years in the Emergency Department of the Abderrahim Harouchi Mother and Child Hospital, of the Ibn Rochd University Hospital in Casablanca, Morocco. We included all children who underwent qualitative toxicological screening by Gas Chromatography coupled with Mass Spectrometry (GC/MS). A descriptive analysis was conducted on the clinical and toxicological characteristics of the patients. The contingency test allowed us to compare the context of the toxicological screening request and its diagnostic utility. Results: Eighty-seven children were included, with a Male-to Female sex ratio of 1.2. The age of the patients ranged from 1 month to 14 years, with a median of three years. Among the included population, 119 screenings were performed. Drugs were implicated in 27 cases, while 4 pesticide intoxications were found, including carbofuron, chloralose, methomyl and terbucarb, along with 2 cannabis intoxications. A proportion of 88% of screening requests, made in the absence of clinical guidance, turned out to be positive, accounting for 31% (24 cases out of 77) (p&lt;0.001). Conclusion: Toxicological analysis is a valuable tool to assist the clinician in managing intoxications by confirming or excluding the toxic hypothesis. However, toxicological analysis can only be useful and effective, avoiding analytical pitfalls, in the presence of dialogue between the clinician and the analyst.

Evaluation of neuroimaging findings in children who admitted to pediatric emergency clinic with acute neurologic complaints

Aim: Acute neurological complaints are one of the reasons why children present to pediatric emergency departments. Neuro-imaging techniques gain more importance in children since physical examination and anamnesis do not provide sufficient information due to insufficient cooperation. We aimed to determine the distribution of patients who applied to the pediatric emergency department with non-traumatic acute neurological complaints and underwent neu-roimaging, and the clinical benefit of neuroimaging in these patients. Methods: The information and records of the patients who applied to the Konya City Hospital Pediatric Emergency Clinic between January 1 and October 1, 2022, due to acute neurological complaints and underwent neuroimaging were retrieved and analyzed retrospectively. Acute neurological complaints of the patients were classified according to the International Classifi-cation of Diseases-10 diagnostic coding. Results: This study included 180 (50.5% male) patients. The median age of the patients was 120 (interquartile range: 45-180) months. Afebrile convulsion was the most common reason for admission in 69 patients (38.3%). Cranial computed tomography (CCT) was performed in all 180 patients. Of the patients, 68 (37.8%) only underwent CCT scan, while 90 (50%) had diffusion magnetic resonance imaging (MRI), 20 (11.1%) had brain+diffusion MRI, and 2 (1.1%) had brain+diffusion+spinal MRI. Neuroimaging abnormalities were statistically higher in patients with abnormal physical examination findings than in patients with normal physical examination findings (p&lt;0.001). Conclusion: Neuroimaging results are mostly normal even in the presence of symptoms such as seizures, headaches, and impaired consciousness. Therefore, neuroimaging should be planned by considering not only the acute neurological complaint on admission but also the physical examination findings.

Healthcare Team Members’ Views on Social Determinants of Health Screening and Referral Practices in a Pediatric Emergency Department

Healthcare Team Members’ Views on Social Determinants of Health Screening and Referral Practices in a Pediatric Emergency Department

After the Türkiye Earthquake: The Experience of a Pediatric Emergency Department in a University Hospital Distant from the Disaster Area.

Earthquakes rank among the most deadly natural disasters, and children are particularly affected due to their inherent vulnerability. Following an earthquake, there is a substantial increase in visits to emergency services. These visits stem not only from patients seeking care for physical traumas resulting from the earthquake and its subsequent complications, but also from individuals affected by the circumstances created by the disaster. This study aims to determine the characteristics and outcomes of children who presented to the pediatric emergency department (PED) after the earthquake and to evaluate children who had crush injuries at a referral tertiary university hospital away from the earthquake area. The medical records of children who presented to the PED from the earthquake area from February 6 through March 7, 2023 were retrospectively reviewed. Children rescued from under rubble were categorized as Group 1, those affected by earthquake conditions as Group 2, and patients seeking medical attention due to the follow-up of chronic illnesses were considered as Group 3. Patient data, including sociodemographic characteristics, time period under rubble (TPR), laboratory findings, and details of medical and surgical procedures, developing acute kidney injury (AKI), and the requirement for hemodialysis were recorded. A total of 252 children were enrolled in the study, with 52 (20.6%) in Group 1, 180 (71.4%) in Group 2, and 16 (6.0%) in Group 3. The median age was six (IQR = 1.7-12.1) years. In the first group (n = 52), 46 (85.2%) children experienced crush injuries, 25 children (46.3%) developed crush syndrome, and 14 of them (14/25; 56.0%) required dialysis. In the second group, the most common diagnoses were upper respiratory tract infections (n = 69; 37.9%), acute gastroenteritis (n = 23; 12.6%), simple physical trauma (n = 16; 8.8%), and lower respiratory tract infections (n = 13; 7.1%). For children in the third group, pediatric neurology (n = 5; 33.3%), pediatric oncology (n = 4; 25.0%), and pediatric nephrology (n = 3; 18.8%) were the most frequently referred specialties. Crush injuries, crush syndrome, and AKI were the most common problems in the early days following the earthquake. Along with these patients, children who were affected by the environmental conditions caused by the earthquake, as well as children with chronic illnesses, also accounted for a significant portion of visits to the PED, even if they were distant from the disaster area.

Decreased incidence of urinary tract infections in febrile infants aged ≤60 days during COVID-19 pandemic.

To investigate the incidence rate of urinary tract infections (UTIs) among febrile infants aged ≤60 days before, during, and after the COVID-19 pandemic. We conducted a retrospective study in 2 Swedish paediatric emergency departments between 2014 and 2022. We included full-term infants aged ≤60 days with fever without source. We calculated the annual incidence rate of UTI per 1000 births. We included 1589 full-term infants with fever without source. In 2020, 89 infants were evaluated in the emergency department versus 203-259 in 2017-2019. In 2020, the incidence rate of UTI was 1.43 per 1000 births/year versus 2.18-2.37 in 2017-2019. The median age, sex, fever duration, and urine testing were similar between the years 2017 and 2020. The number of febrile infants who presented to the paediatric emergency department and the incidence rate of UTIs decreased in 2020. This decrease might imply a systematic misdiagnosis of UTIs in infants with febrile viral infections. A more selective urine testing approach for febrile, previously healthy, infants should be considered to mitigate UTI misdiagnosis and its potential harmful effects.

Bias between capnometry and venous carbon dioxide during initial assessment of pediatric emergency department patients: A video-based study.

The bias of capnometry (ETCO2) and venous carbon dioxide (vpCO2) among pediatric emergency department (PED) patients triaged to critical care areas is unknown. We aimed to explore correlations and bias between ETCO2 and vpCO2¸and identify predictors of bias. This was an observational, video-based, retrospective study comparing ETCO2 and vpCO2. Pediatric patients with simultaneous ETCO2 and vpCO2 data were included. Our primary aim utilized linear regressions to determine correlations and Bland-Altman analysis to assess bias. Our secondary aim utilized multiple regression to identify clinical covariates contributing to bias. Covariates included age, respiratory rate, heart rate, mean arterial blood pressure, capnometry interface, PED diagnosis, and PED disposition. A total of 200 PED patients with ETCO2 and vpCO2 data were included. The median (interquartile range [IQR]) ETCO2, vpCO2, and ΔCO2 in mmHg were 38 (32, 46), 49 (41, 61), and 11 (4, 20), respectively. ETCO2 (r=0.76) and ΔCO2 (r=0.71) were highly correlated with vpCO2. The mean bias between ETCO2 and vpCO2 was -14.1mmHg (95% confidence interval [CI], -41.9 -13.7). The bias between ETCO2 and vpCO2 increased at higher values of each measure. ETCO2 sampling interface was the only independent predictor of vpCO2 in our multivariate analysis. Patients requiring bag-valve mask (BVM) ventilation had the highest median bias between ETCO2 and vpCO2 (29mmHg, IQR 15, 37). ETCO2 and vpCO2 were highly correlated. However, bias increased at higher levels of both ETCO2 and vpCO2. Among PED patients, ETCO2's ability to approximate vpCO2 diminishes with worsening hypercarbic respiratory failure.

Accuracy of Influenza ICD-10 Diagnosis Codes in Identifying Influenza Illness in Children

Studies of influenza in children commonly rely on coded diagnoses, yet the ability of International Classification of Diseases, Ninth Revision codes to identify influenza in the emergency department (ED) and hospital is highly variable. The accuracy of newer International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes to identify influenza in children is unknown. To determine the accuracy of ICD-10 influenza discharge diagnosis codes in the pediatric ED and inpatient settings. Children younger than 18 years presenting to the ED or inpatient settings with fever and/or respiratory symptoms at 7 US pediatric medical centers affiliated with the Centers for Disease Control and Prevention-sponsored New Vaccine Surveillance Network from December 1, 2016, to March 31, 2020, were included in this cohort study. Nasal and/or throat swabs were collected for research molecular testing for influenza, regardless of clinical testing. Data, including ICD-10 discharge diagnoses and clinical testing for influenza, were obtained through medical record review. Data analysis was performed in August 2023. The accuracy of ICD-10-coded discharge diagnoses was characterized using molecular clinical or research laboratory test results as reference. Measures included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Estimates were stratified by setting (ED vs inpatient) and age (0-1, 2-4, and 5-17 years). A total of 16 867 children in the ED (median [IQR] age, 2.0 [0.0-4.0] years; 9304 boys [55.2%]) and 17 060 inpatients (median [IQR] age, 1.0 [0.0-4.0] years; 9798 boys [57.4%]) were included. In the ED, ICD-10 influenza diagnoses were highly specific (98.0%; 95% CI, 97.8%-98.3%), with high PPV (88.6%; 95% CI, 88.0%-89.2%) and high NPV (85.9%; 95% CI, 85.3%-86.6%), but sensitivity was lower (48.6%; 95% CI, 47.6%-49.5%). Among inpatients, specificity was 98.2% (95% CI, 98.0%-98.5%), PPV was 82.8% (95% CI, 82.1%-83.5%), sensitivity was 70.7% (95% CI, 69.8%-71.5%), and NPV was 96.5% (95% CI, 96.2%-96.9%). Accuracy of ICD-10 diagnoses varied by patient age, influenza season definition, time between disease onset and testing, and clinical setting. In this large cohort study, influenza ICD-10 discharge diagnoses were highly specific but moderately sensitive in identifying laboratory-confirmed influenza; the accuracy of influenza diagnoses varied by clinical and epidemiological factors. In the ED and inpatient settings, an ICD-10 diagnosis likely represents a true-positive influenza case.

Face-off Droop: A Case Report of Pediatric Stroke

Introduction: Cerebrovascular accidents rarely occur in children; the incidence of ischemic stroke in patients &amp;lt;16 years of age is between 0.6&amp;ndash;7.9/100,000. However, they are the fourth most common cause of acute neurological deficits in the pediatric population, and possible cases should be evaluated with a high index of suspicion to ensure timely intervention. Case Report: We describe a previously healthy 17-year-old male who presented to the pediatric emergency department with a left facial droop and hemiparesis consistent with a stroke. The patient&amp;rsquo;s age and lack of comorbidities made this an extremely uncommon presentation. Our patient&amp;rsquo;s neurologic symptoms were believed to have been caused by a recent traumatic clavicular injury sustained two weeks prior, which subsequently led to vascular insult. Conclusion: Cerebrovascular accidents are an important cause of morbidity and mortality in pediatric patients. Cerebrovascular accidents in children are most often secondary to congenital causes; however, care should be taken to assess for acquired causes, such as trauma to major blood vessels. While rarely implicated in traumatic injuries, arterial structures posterior to the medial clavicle can result in severe complications.

Bedside critical care training: A quasi-experimental study in the paediatric emergency department of a referral hospital in Nigeria

Background. There is a need for critical care services outside intensive care units (ICUs), especially in emergency departments (EDs). However, there is a paucity of skilled manpower for ED critical care or emergency critical care (ECC) in resource-limited settings. Objective. To evaluate the impact of bedside training on emergency critical care practices of clinical staff. Methods. This was a quasi-experimental study using a pretest - post-test design in a paediatric ED. The intervention was a six-week structured bedside training on bubble continuous positive airway pressure (CPAP) high-flow nasal cannula (HFNC) and mechanical ventilation. Participants’ actual ECC practices pre and post training were evaluated, including their perceived proficiency on an uncalibrated 100 mm visual analogue scale (VAS). Descriptive and inferential analyses were done; p&lt;0.05 was considered significant. Results. A total of 35 clinical staff participated in the training, comprising 9 (24.3%) paediatric registrars, 12 (32.5%) senior registrars, 10 (27.0%) nurses, 4 (10.8%) house officers and 2 (5.4%) paediatric consultants. The male:female ratio of the participants was 1:1.6, and their mean (SD) age was 33.24 (6.30 years. Participants’ understanding of testing the CPAP circuit, connecting the patient and weaning significantly improved following training (p=0.004). Their capacity to select appropriate HFNC parameters improved (p=0.013). They performed more endotracheal intubations in the post-training period (p=0.001). Their pretest-post-test proficiency in mechanical ventilation increased on VAS (mean scores 45.26+31.99 v. 63.26+22.26; p=0.038). Also, there was a significant increase in their perceived proficiency in paediatric analgesia/sedation (30.83+29.86 v. 49.83+23.90; p=0.029). Conclusion. Short-term bedside critical care training enhanced the self-reported competency of paediatric ED staff. There is a need for on-the-job ECC training and retraining of clinical staff in our setting.

Point-of-care ultrasound (POCUS) pediatric resident training course: a cross-sectional survey

BackgroundPoint-of-care ultrasound (POCUS) is becoming increasingly crucial in the Pediatric Emergency Department for objective patient examination. However, despite its growing interest and wide-ranging applications, POCUS remains relatively unexplored in general pediatric training and education. Many physicians still find it challenging to comprehend and implement.MethodsA theoretical-practical POCUS course for pediatric residents was conducted at the University of Catania, Italy. The course’s effectiveness and practical impact on residents was assessed through a pre-post training survey. The first part of the questionnaire focused on the self-perceived time needed to learn how to recognize the following conditions using POCUS: (i) Pleural effusion (ii) Lung consolidation (iii) Pneumothorax (PNX) (iv) Cardiac contractility (v) Pericardial effusion (vi) Perisplenic effusion (vii) Morison’s pouch effusion (viii) Douglas’ pouch effusion (ix) Filling and collapsibility of the inferior vena cava. In the second part, we compared the potential role of POCUS in (i) Reducing the use of ionizing radiation in children (ii) Increasing the sense of security in diagnosis and treatment decisions making and (iii) Increasing the residents’ confidence level with POCUS after the course on a 1-to-10 rating scale.ResultsSeventy-two residents participated in the study. The statistical analysis showed significant pre-post differences in almost all the items considered, except for “cardiac contractility” and “PNX”. Furthermore, the perceived potential role of POCUS in reducing ionizing radiation usage and the sense of security in diagnosis and treatment decisions showed statistically significant differences (p < 0.05) before and after the course. Data analysis also revealed a consistently high confidence level with POCUS after the course.ConclusionsThe results highlight the importance of including a POCUS track course in pediatric post-graduate programs due to its simplicity, rapid learning time, and clinical usefulness. Based on these findings, it would be recommended to increase the teaching hours dedicated to the recognition of pneumothorax and cardiology POCUS examination. Emphasizing POCUS training in pediatric education can enhance patient care and diagnostic accuracy while minimizing radiation exposure.

A family-centered approach to social needs awareness in the pediatric emergency department

ObjectiveWe aimed to understand family preferences around reporting and receiving health-related social needs (HRSN) information by assessment modality during pediatric emergency department (PED) visits. MethodsFamilies were randomized into paper (control), cell phone, or tablet modality groups by their child's exam room. Nurses alerted families to complete a single HRSN assessment during routine workflow. We used logistic regression and McNemar's test to assess discordance in modality preference. ResultsForty-seven percent of families disclosed at least one HRSN across a total 611 assessments. Disclosure of HRSN was similar by modality. Twenty-three percent of those assigned tablet preferred cell phone (p < 0.001). Two-thirds of families preferred receiving digitally formatted community resources (email or text). There was no difference in preferred timing of HRSN assessment completion. ConclusionsAssessment modality did not appear to influence family HRSN disclosure. Families were generally satisfied with all HRSN assessment modalities but demonstrated a particular preference in using personal cell phones over tablets. Digitally formatted community referrals also pose numerous advantages over conventional paper handouts. InnovationUse of personal cell phones is a novel, streamlined method of HRSN interventions in the clinical setting, performing similar to more conventional modalities, with a preference among families when compared to tablets.

Trends in pediatric emergency department transfers from Indian Health Service and tribal health systems.

To describe the frequency and observed trends for all Indian Health Service (IHS) and tribal emergency department (ED) transfers to a pediatric referral center from January 1, 2017, to December 31, 2020, with a secondary analysis to describe trends in final dispositions, lengths of stay (LOS), and the most common primary ICD-10 diagnoses. We performed a retrospective chart review of IHS and tribal ED transfers to a pediatric referral center from 2017 to 2020 (n = 2433). The data were summarized using frequencies and percentages and we used generalized estimating equations to analyze patient characteristics over time. IHS and tribal ED transfers accounted for 6.5%-7.1% of all transfers each year between 2017 and 2020 without significant changes over time. Within this group, 60% were admitted and 62% experienced a LOS greater than 24 h. The most common diagnostic code groups for these patients were respiratory conditions, injuries and poisonings, nonspecific abnormal clinical findings and labs, digestive system diseases, and nervous system diseases. This study addresses important knowledge gaps regarding transfers from IHS and tribal EDs, highlights potential high-impact areas for pediatric readiness, and emphasizes the need for more granular data to inform resource allocation and educational interventions. Further studies are needed to delineate potentially avoidable transfers seen within this population.

Heat waves and pediatric emergency department febrile-related visits

BackgroundIn recent decades, we have observed an increase in ambient temperature due to the effects of climate change. ObjectiveIn this study, we aimed to determine whether there is a correlation between environmental temperature and urgent consultations of pediatric patients related to febrile processes. Research design and methodWe conducted an observational, retrospective, single-center study in the pediatric ED of the Hospital Universitario La Paz, Madrid, Spain. We analyzed visits to the ED for febrile processes during the last heat waves in Madrid. ResultsBetween 2018 and 2022, seven heat waves were recorded in Madrid. A total of 3967 patients with fever as the main reason for consultation attended during this period. In two of the seven heat waves analyzed, febrile-related visits were higher during the heat alert. The first occurred between 6/11/2022 and 6/16/2022, with 345 febrile-related ED visits, 25.4% more than the previous days and 19.7% more than the following days. During this heat wave, we observed a positive correlation between the maximum temperature recorded and the number of visits to the ED for febrile processes (Rs=0.552; p = 0.018). During the heat wave between 09/07/2022 and 17/07/2022, 362 febrile-related ED visits were 3.1% more than the previous days and 24.9% more than the following days. ConclusionDuring recent heat waves in our city, we registered an increase in febrile-related visits compared with non-heat alert periods.