Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study.

OBJECTIVE: The lack of evidence-based criteria to guide chest radiograph (CXR) use in young febrile infants results in variation in its use with resultant suboptimal quality of care. We sought to describe the features associated with radiographic pneumonias in young febrile infants. STUDY DESIGN: Secondary analysis of a prospective cohort study in 18 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from 2016 to 2019. Febrile (≥38°C) infants aged ≤60 days who received CXRs were included. CXR reports were categorised as 'no', 'possible' or 'definite' pneumonia. We compared demographics, clinical signs and laboratory tests among infants with and without pneumonias. RESULTS: Of 2612 infants, 568 (21.7%) had CXRs performed; 19 (3.3%) had definite and 34 (6%) had possible pneumonias. Patients with definite (4/19, 21.1%) or possible (11/34, 32.4%) pneumonias more frequently presented with respiratory distress compared with those without (77/515, 15.0%) pneumonias (adjusted OR 2.17; 95% CI 1.04 to 4.51). There were no differences in temperature or HR in infants with and without radiographic pneumonias. The median serum procalcitonin (PCT) level was higher in the definite (0.7 ng/mL (IQR 0.1, 1.5)) vs no pneumonia (0.1 ng/mL (IQR 0.1, 0.3)) groups, as was the median absolute neutrophil count (ANC) (definite, 5.8 K/mcL (IQR 3.9, 6.9) vs no pneumonia, 3.1 K/mcL (IQR 1.9, 5.3)). No infants with pneumonia had bacteraemia. Viral detection was frequent (no pneumonia (309/422, 73.2%), definite pneumonia (11/16, 68.8%), possible pneumonia (25/29, 86.2%)). Respiratory syncytial virus was the predominant pathogen in the pneumonia groups and rhinovirus in infants without pneumonias. CONCLUSIONS: Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors. Although ANC and PCT levels were elevated in infants with definite pneumonias, further work is necessary to evaluate the role of blood biomarkers in infant pneumonias.

The Pediatric Rigid Stylet Improves First-Pass Success Compared With the Standard Malleable Stylet and Tracheal Tube Introducer in a Simulated Pediatric Emergency Intubation.

BACKGROUND: Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI. METHODS: This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct. RESULTS: Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm). CONCLUSIONS: Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children.

Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results.

It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis. OBJECTIVE: To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results. METHODS: Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results. RESULTS: Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count <4 × 103 cells/mm3 and procalcitonin <0.5 ng/mL. CONCLUSIONS: Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.

Intubation During Pediatric Cardiac Arrest in the Emergency Department Is Associated With Reduced First-Pass Success.

BACKGROUND: Airway compromise and respiratory failure are leading causes of pediatric cardiac arrest making advanced airway management central to pediatric resuscitation. Previous literature has demonstrated that achieving first-pass success (FPS) is associated with fewer adverse events. In cardiac arrest for adult patients, increasing number of intubation attempts is associated with lower likelihood of return of spontaneous circulation (ROSC) and favorable neurologic outcome. There is limited evidence regarding advanced airway management for pediatric out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). The purpose of this study was to compare FPS in pediatric OHCA and non-cardiac arrest patients in the ED. METHODS: This is an analysis of pediatric intubations prospectively recorded into a continuous quality improvement database in an academic pediatric ED over a 12-year period. Between July 1, 2007, and June 30, 2019, physicians recorded all intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation in the ED were eligible for inclusion in the study. The primary outcome was FPS for pediatric patients in cardiac arrest compared with those not in cardiac arrest. A logistic regressions analysis was performed to identify characteristics associated with FPS in OHCA patients. RESULTS: Six hundred eight pediatric patients were intubated during the study period. One hundred three pediatric patients had OHCA compared with 459 non-cardiac arrest patients who underwent rapid sequence intubation. In patients with OHCA, 47.6% had FPS (95% confidence interval [CI], 38.2%-57.1%), 33% required 2 attempts (95% CI, 24.7%-42.6%), and 19.4% required 3 or more attempts (95% CI, 12.9%-28.2%). In patients without OHCA, 75.4% had FPS (95% CI, 75.4%-79.1%), 15% required 2 attempts (95% CI, 12.0%-18.6%), and 9.6% required 3 or more attempts (95% CI, 7.2%-12.6%). Cardiac arrest was associated with a reduction in FPS adjusted odds ratio 0.44 (95% CI, 0.26-0.77). CONCLUSIONS: In this study, we found that pediatric OHCA is associated with reduced FPS in the ED. Although additional studies are needed, rescuers should prioritize restoring effective oxygenation and ventilation and optimizing intubation conditions before an advanced airway attempt.

A Roadmap for the Student Pursuing a Career in Pediatric Emergency Medicine.

INTRODUCTION: Three pathways are available to students considering a pediatric emergency medicine (PEM) career: pediatric residency followed by PEM fellowship (Peds-PEM); emergency medicine residency followed by PEM fellowship (EM-PEM); and combined EM and pediatrics residency (EM&Peds). Questions regarding differences between the training pathways are common among medical students. We present a comparative analysis of training pathways highlighting major curricular differences to aid in students' understanding of these training options. METHODS: All currently credentialed training programs for each pathway with curricula published on their websites were included. We analyzed dedicated educational units (EU) core to all three pathways: emergency department (ED), pediatric-only ED, critical care, and research. Minimum requirements for primary residencies were assumed for fellowship trainees. RESULTS: Of the 75 Peds-PEM, 34 EM-PEM, and 4 EM&Peds programs screened, 85% of Peds-PEM and EM-PEM and all EM&Peds program curricula were available for analysis. Average Peds-PEM EUs were 20.4 EM, 20.1 pediatric-only EM, 5.8 critical care, and 9.0 research. Average EM-PEM EUs were 33.2 EM, 18.3 pediatric-only EM, 6.5 critical care, and 3.3 research. Average EM&Peds EUs were 26.1 EM, 8.0 pediatric-only EM, 10.0 critical care, and 0.3 research. CONCLUSION: All three pathways exceed pediatric-focused training required for EM or pediatric residency. Peds-PEM has the most research EUs, EM-PEM the most EM EUs, and EM&Peds the most critical care EUs. All prepare graduates for a pediatric emergency medicine career. Understanding the difference in emphasis between pathways can inform students to select the best pathway for their own careers.

Pediatric Major Head Injury: Not a Minor Problem.

Traumatic brain injury is a highly prevalent and devastating cause of morbidity and mortality in children. A rapid, stepwise approach to the traumatized child should proceed, addressing life-threatening problems first. Management focuses on preventing secondary injury from physiologic extremes such as hypoxemia, hypotension, prolonged hyperventilation, temperature extremes, and rapid changes in cerebral blood flow. Initial Glasgow Coma Score, hyperglycemia, and imaging are often prognostic of outcome. Surgically amenable lesions should be evacuated promptly. Reduction of intracranial pressure through hyperosmolar therapy, decompressive craniotomy, and seizure prophylaxis may be considered after stabilization. Nonaccidental trauma should be considered when evaluating pediatric trauma patients.

Evaluation of child maltreatment in the emergency department setting: an overview for behavioral health providers.

Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.

Emergency department evaluation of child abuse.

Child abuse presents commonly to emergency departments. Emergency providers are confronted with medical, social, and legal dilemmas with each case. A solid understanding of the definitions and risk factors of victims and perpetrators aids in identifying abuse cases. Forensic examination should be performed only after the child is medically stable. Emergency providers are mandatory reporters of a reasonable suspicion of abuse. The role of the emergency provider is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and to provide an ethical testimony if called to court.