Pediatric emergency care in New York City during the COVID-19 pandemic shutdown and reopening periods.

OBJECTIVE: New York City (NYC) is home to the largest public healthcare system in the United States and was an early epicenter of coronavirus disease 2019 (COVID-19) infections. This system serves as the safety net for underserved and marginalized communities disproportionately affected by the pandemic. Prior studies reported substantial declines in pediatric emergency department (ED) volume during the initial pandemic surge, but few describe the ongoing impact of COVID-19 throughout the year. We evaluated the characteristics of pediatric ED visits to NYC public hospitals during the pandemic lockdown and reopening periods of 2020 compared to the prior year. METHODS: Retrospective cross-sectional analysis of pediatric ED visits from 11 NYC public hospitals from January 2019-December 2020. Visit demographics, throughput times, and diagnosis information during the early (3/7/20-6/7/20) and late (6/8/20-12/31/20) pandemic periods coinciding with the New York State of emergency declaration (3/7/20) and the first reopening date (6/7/20) were compared to similar time periods in 2019. Findings were correlated with key pandemic shutdown and reopening events. RESULTS: There was a 47% decrease in ED volume in 2020 compared to 2019 (125,649 versus 238,024 visits). After reopening orders began in June 2020, volumes increased but peaked at <60% of 2019 volumes. Admission rates, triage acuity, and risk of presenting with a serious medical illness were significantly higher in 2020 versus 2019 (P < 0.001). Time-to-provider times decreased however provider-to-disposition times increased during the pandemic (P < 0.001). Infectious and asthma diagnoses declined >70% during the pandemic in contrast to the year prior. After reopening periods began, penetrating traumatic injuries significantly increased compared to 2019 [+34%, Relative Risk: 3.2 (2.6, 3.8)]. CONCLUSIONS: NYC public hospitals experienced a sharp decrease in pediatric volume but an increase in patient acuity during both the initial pandemic surge and through the reopening periods. As COVID-19 variants emerge, the threat of the current pandemic expanding remains. Understanding its influence on pediatric ED utilization can optimize resource allocation and ensure equitable care for future surge events.

A Comparison of Temperature Thresholds to Begin Laboratory Evaluation of Well-Appearing Febrile Infants.

OBJECTIVE: Young infants who develop fever are at an increased risk for serious infection. It is unclear, however, what temperature cutoff would be optimal to begin evaluating these infants because some criteria use different thresholds. We sought to determine the percentage of infants presenting to the Emergency Department (ED) with a temperature less than 38.2°C who develop serious infection compared with those with higher temperatures. METHODS: We used a publicly available dataset from the Pediatric Emergency Care Applied Research Network. Patients were included if they were aged 60 days or younger, had a documented rectal temperature of 38.0°C or higher in the ED or a history of fever within 24 hours before presentation to the ED, and were being evaluated for serious infection. We used the same exclusion criteria as the original Pediatric Emergency Care Applied Research Network study but further excluded those who were ill-appearing (Yale Observation Score > 10). Serious infections included any of the following: urinary tract infection, bacteremia, bacterial or herpes meningitis, bacterial pneumonia, or bacterial enteritis. Data were described using frequencies (percentages) and compared between groups using χ 2 test. RESULTS: Of the 4619 eligible infants, 1311 (28.4%) had a temperature lower than 38.2°C. Infants with temperatures lower than 38.2°C were significantly less likely to have a serious infection compared with those with higher temperatures (97 [7.5%] vs 365 [11.2%], P < 0.001). Of the infants with temperatures lower than 38.2°C who were tested, 67 (5.8%) had a urinary tract infection, 10 (0.8%) had bacteremia, 3 (0.4%) had bacterial meningitis, 3 (2.9%) had herpes meningitis, 17 (4.5%) had bacterial pneumonia, and 2 (4.8%) had bacterial enteritis. CONCLUSIONS: In this study, we found that infants with temperatures lower than 38.2°C were significantly less likely to have a serious infection than those with higher temperatures. Using an evaluation cutoff of 38.2°C, however, would likely miss a clinically important number of well-appearing infants with serious infections.

Predicting Adverse Outcomes for Shiga Toxin-Producing Escherichia coli Infections in Emergency Departments.

OBJECTIVE: To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting. STUDY DESIGN: We reviewed medical records of children <18 years old infected with STEC and treated in 1 of 38 participating emergency departments in North America between 2011 and 2015. The HUS severity score (hemoglobin [g/dL] plus 2-times serum creatinine [mg/dL]) was calculated using first available laboratory results. Children with scores >13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness. RESULTS: A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children <5 years old (area under the curve 0.77, 95% CI 0.68-0.87). For children <5 years, greatest net benefit was achieved for a threshold probability >26%. CONCLUSIONS: The HUS severity score was able to discriminate between high- and low-risk children <5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.

Association of thoracic cage fractures and pericardial effusion in blunt trauma.

BACKGROUND: Several case reports suggest that penetrating thoracic cage fractures are an important cause for hemopericardium and cardiac tamponade following blunt trauma. However, the prevalence of this mechanism of injury is not fully known, and considering this association may provide a better understanding of the utility of cardiac component of the FAST (Focused Assessment with Sonography for Trauma). OBJECTIVE: To determine the association of thoracic cage fractures and pericardial effusion in patients with blunt trauma. METHODS: We performed a retrospective, multicenter cohort study using the Trauma Quality Improvement Program (TQIP) database (2015-2017) of adults ≥18 years of age whose mechanism of injury was either a fall or motor vehicle accident. Thoracic cage fractures were defined as any rib or sternum fracture. The primary outcome was the presence of pericardial effusion. Confounding variables were accounted for using multivariable logistic regression. RESULTS: We included 1,673,704 patients in the study; 226,896 (14%) patients had at least one thoracic cage fracture. A pericardial effusion was present in 4923 (0.3%) patients. When a thoracic cage fracture was present, the odds of having a pericardial effusion was significantly higher (adjusted Odds Ratio [aOR] 6.5 [95% CI: 6.1-7.0]). Patients with left and right-sided rib fractures had similar odds of a pericardial effusion (aOR 1.2 [95% CI 1.04-1.4]). Sternal fractures carried the highest odds of having a pericardial effusion (aOR 11.1 [9.9-12.3]). CONCLUSION: Thoracic cage fractures secondary to blunt trauma represent a significant independent risk factor for the development of a pericardial effusion. Our findings lend support for the mechanism of bony injuries causing penetrating cardiac trauma. Given these findings, and the fact that many thoracic cage fractures are detected after the initial evaluation, we support maintaining the cardiac view in the FAST examination for all blunt trauma patients.

Effect of focused protocol on reducing radiation dose for children who require computed tomography for suspected appendicitis.

BACKGROUND: Despite efforts to incorporate ultrasound into the evaluation of children for appendicitis, computed tomography (CT) is often used to aid in its diagnosis. CT scans, however, expose children to a considerable amount of radiation. In 2017, our institution began using a height-based Focused CT protocol for children with suspected appendicitis in need of CT. OBJECTIVE: To compare the radiation dose received by children with suspected appendicitis who underwent a Standard CT of the abdomen and pelvis (CTAP) with that of a Focused CT. METHODS: We conducted a retrospective study of children <18 years who underwent a CT scan for suspected appendicitis (2014-2020). We included all patients whose indication for CT was "appendicitis" or "right lower quadrant pain" and excluded those whose CT scan record lacked a radiation dose report. The effective radiation dose delivered was calculated using the dose-length product from the dose report. We compared the effective dose of those who received a Standard CTAP to those who received a Focused CT. To account for differences in radiation dose over time and by CT scanner, analyses were adjusted for CT dose index volume (CTDIvol) and size-specific dose estimate (SSDE) using quantile regression. RESULTS: A total of 474 patients who underwent CT were included. Prior to CT, 362(76%) had received an ultrasound. In total, 309(65%) patients underwent a Standard CTAP and 165(35%) underwent a Focused CT. The appendix was identified in 259(84%) Standard CTAPs compared to 151(92%) Focused CTs (p = 0.02). Compared to the Standard CTAP, children who received a Focused CT were exposed to a significantly lower effective dose (relative difference: CTDI-adjusted -13%[95% CI:-21,-5]; SSDE-adjusted -14%[95% CI:-24,-3]). CONCLUSIONS: Our height-based Focused CT protocol reduces radiation for children undergoing CT evaluation for suspected appendicitis without sacrificing diagnostic accuracy. Further study is needed to validate these findings at other institutions.

Current Practices in Pediatric Emergency Medicine Fellowship Trauma Training.

OBJECTIVE: The management of injured children is a required element of pediatric emergency medicine (PEM) fellowship training. Given the relatively infrequent exposure of trainees to major trauma, it is important to understand how programs train fellows and assess their competency in pediatric trauma. METHODS: An online survey was sent to 84 PEM fellowship program directors (PDs). Program directors were asked to describe their program's characteristics, the degree of fellow independence, educational techniques used to train fellows in trauma, and their expectation of fellows' competency in 14 core trauma-related skills upon graduation. Program directors were classified as having high expectations if they anticipated that graduating fellows could perform 12 trauma skills or more independently. RESULTS: Fifty-nine programs (70%) responded. Although most programs (55, 93%) identified as pediatric trauma centers, fellows at the majority of programs (41, 69%) spent some or all of their trauma experience at an outside hospital. Only a minority of programs (17, 29%) allowed fellows to lead pediatric trauma resuscitations as independent attendings without precepting. Programs used over a dozen different educational methods to varying degrees. Less than half of programs (28, 47%) used a formal trauma curriculum. Whereas 33 PDs (56%) had high expectations, only 9 (15%) expected fellows to be able to perform all 14 skills. CONCLUSIONS: There is considerable variability in how PEM fellows are trained to care for injured children. Most PDs do not realistically expect fellows to be able to perform all recommended trauma skills after graduation. Our findings highlight the need for further research and efforts to standardize the training of PEM fellows in pediatric trauma.

Utility of Point-of-Care Ultrasound for the Diagnosis of Hill-Sachs Deformity in the Pediatric Emergency Department.

ABSTRACT: We report a case of a 20-year-old man presenting to our pediatric emergency department with an anterior shoulder dislocation. Point-of-care ultrasound demonstrated a Hill-Sachs deformity. The potential role of ultrasound and the clinical importance of identifying patients with Hill-Sachs deformities are discussed.

Internationally Acquired Severe Systemic Infections in Febrile Pediatric Travelers Presenting to the Emergency Department.

OBJECTIVES: Most children in the United States who visit the emergency department (ED) with fever have minor illnesses not requiring treatment or hospitalization. However, when a child has recently immigrated or traveled abroad, internationally acquired severe systemic infections (ISSIs) must be considered. We sought to describe children who have traveled internationally and present to the ED with a complaint of fever and to determine risk factors associated with ISSIs in these patients. METHODS: We conducted a retrospective study of children younger than 18 years who presented to 2 pediatric EDs in Bronx, NY (June 2007 to May 2017). Patients were included if they had both fever within 24 hours and international travel within 30 days. We compared groups using bivariate analyses and created a prediction model for ISSIs using multivariable logistic regression. RESULTS: Of the 353 children included, 44 (12%) had ISSI: 25 (57%), malaria; 6 (14%), dengue; and 13 (30%), bacteremia. Eight (18%) of those with ISSI presented with fever to another medical provider in the week prior but did not receive bloodwork. Four variables were independently associated with ISSIs: headache (odds ratio [OR], 21.7; 95% confidence interval [CI], 6.8-69.3), travel to Africa or Asia (OR, 18.8; 95% CI, 4.8-73.2), platelets of 150,000/µL or less (OR, 15.1; 95% CI, 4.7-48.6), and alanine aminotransferase level of 30 IU/L or greater (OR, 8.9; 95% CI, 3.1-25.3). CONCLUSIONS: Children who travel internationally and present with fever upon return are at substantial risk for developing ISSIs. The diagnosis of ISSIs is often overlooked, but certain risk factors have the potential to aid clinicians.

Association of Delay in Appendectomy With Perforation in Children With Appendicitis.

OBJECTIVE: The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation. METHODS: We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression. RESULTS: Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9-15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8-15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00-1.04). CONCLUSIONS: Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.

Focused CT using a height-adjusted metric and the umbilicus as a landmark for children undergoing evaluation for appendicitis.

BACKGROUND: Confirmation of appendicitis in children often requires CT. A focused CT scan that is limited to the lower abdomen/pelvis might help to reduce radiation exposure. OBJECTIVE: To determine the position of the appendix relative to the umbilicus and derive a height-adjusted threshold for a focused CT that would identify most appendices. MATERIALS AND METHODS: We conducted a retrospective study of children younger than 18 years who underwent a CT scan for suspected appendicitis. A pediatric radiologist determined the distance from the most cephalad portion of the appendix to the center of the umbilicus. This distance was divided by the child's height to create a ratio for each child. We then assessed the largest of these distance/height ratios ("height constants") as potential height-adjusted thresholds that, when multiplied by any patient's height, would yield the superior threshold for the focused CT scan. Radiation reduction was calculated as percentage decrease in scan length compared to a complete abdominopelvic CT. RESULTS: Of 270 patients whose entire appendix was identified on CT, all were identified within 10.5 cm above the umbilicus. A focused CT using a height constant of 0.07 identified 100% of the appendices visualized on the complete CT scan and resulted in an estimated mean percentage radiation reduction of 27% (standard deviation [SD] +/-4.7). If a height constant of 0.03 was used, 97% of appendices were identified and the estimated radiation reduction was 43% (SD +/-4.3). CONCLUSION: A height-adjusted focused abdominopelvic CT scan might reduce radiation exposure without sacrificing the diagnostic accuracy of the complete CT scan.

Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?

BACKGROUND: Despite being an effective analgesic for children with fractures, some clinicians may avoid prescribing ibuprofen due to its potentially harmful effect on bone healing. OBJECTIVE: To determine if exposure to ibuprofen is associated with an increased risk of bone healing complications in children with fractures. METHODS: We performed a retrospective study of children aged 6 months to 17 years who presented to the pediatric emergency department (PED) with a fracture of the tibia, femur, humerus, scaphoid, or fifth metatarsus and who followed up with the orthopedic service. We chose these fractures due to their higher risk for complications. We classified patients as exposed if they received ibuprofen in the PED or during hospitalization or were prescribed ibuprofen at discharge. The main outcome was a bone healing complication as evidenced by nonunion, delayed union, or re-displacement on follow-up radiographs. RESULTS: Of the 808 patients included in the final analysis, 338 (42%) were exposed to ibuprofen. Overall, 27 (3%) patients had a bone healing complication; 8 (1%) developed nonunion, 3 (0.4%) developed delayed union, and 16 (2%) developed re-displacement. Ten (3%) patients who were exposed to ibuprofen, and 17 (4%) who were not, developed a bone healing complication (odds ratio 0.8, 95% confidence interval 0.4-1.8; p = 0.61). There was no significant association between ibuprofen exposure and the development of a bone healing complication despite adjustment for potential confounders. CONCLUSION: Children with extremity fractures who are exposed to ibuprofen do not seem to be at increased risk for clinically important bone healing complications.

Pelvic Fracture Urethral Injuries in Children: A Case Report and Appraisal of Their Emergency Management.

Pelvic fracture urethral injuries are uncommon injuries that are frequently overlooked in the emergency department. We present a case of a 2-year-old girl whose urethral trauma was initially missed and potentially worsened by the placement of a urinary catheter. The clinical and diagnostic features of these rare injuries are discussed along with the controversies surrounding urinary catheter placement and retrograde urethrography.

A Validation Study of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) Tape--A New Weight Estimation Tool.

OBJECTIVE: To evaluate the performance of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) tape, a new weight-estimation tool with a modifier for body habitus, in our increasingly obese population. STUDY DESIGN: A convenience sample of children presenting to the pediatric emergency department of an urban public hospital was enrolled. A nurse or doctor assigned the patient a body habitus score and used the PAWPER tape to estimate the weight. The true weight was then recorded for comparison.The estimated weight was considered accurate if it was within 10% of the true weight. RESULTS: We enrolled 1698 patients; 579 (34%) were overweight or obese. Overall, the estimated weight was accurate for 64% of patients (95% CI 61%-65%). For children with an above-average body habitus, the tape was accurate 50% of the time (95% CI 46%-55%). There was no significant difference in the accuracy of the PAWPER tape for children assessed during medical and trauma resuscitations. CONCLUSION: Although the PAWPER tape may ultimately be useful, its initial performance was not replicated in our population. A simple, accurate method of weight estimation remains elusive.

Internal Hernia as a Cause for Intestinal Obstruction in a Newborn.

BACKGROUND: An internal hernia is a rare cause of intestinal obstruction, which can occur at any age. Children most often develop an internal hernia due to a congenital defect in the mesentery. While some patients are asymptomatic, others present to medical attention with vague abdominal symptoms, an acute abdomen, or in shock. CASE REPORT: We report a case of a 5-day-old previously healthy baby who presented to our pediatric emergency department with bilious vomiting, grossly bloody stool, and abdominal distention. During an exploratory laparotomy, the patient was diagnosed with an internal hernia caused by a congenital mesenteric defect. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although internal hernia is an infrequent cause of intestinal obstruction in a newborn and requires emergent operative repair, it may be mistaken for other more common causes, such as necrotizing entercolitis, which are often managed medically. This case report aims to highlight some of the difficulties in diagnosis and key features that may assist the clinician in identifying these patients.

Surgical stabilization of rib fractures in patients with pulmonary comorbidities.

INTRODUCTION: Prior studies have shown that the surgical stabilization of rib fractures (SSRF) for patients with multiple rib fractures is associated with improved outcomes by restoring chest wall integrity and decreasing time to return to prior functional status. It is unclear if patients with pulmonary comorbidities (PCM) would benefit from this procedure. OBJECTIVE: To compare the difference in morbidity and mortality of patients with multiple rib fractures undergoing SSRF who have underlying PCM to those who do not have PCM. METHODS: We performed a retrospective cohort study of patients with multiple rib fractures using data from the Trauma Quality Improvement Program (January 2015 to December 2018). Patients with penetrating injuries, those who died within the first 24 h, those with substantial head, spine, or abdominopelvic injuries, and those who were pregnant, were excluded. A PCM was defined as chronic lower respiratory disease, active smoking, or morbid obesity. Dichotomous outcomes were adjusted for potential confounders by creating a propensity score for PCM and applying inverse probability weighting. The propensity score accounted for multiple patient-level and hospital level covariates. Continuous outcomes were adjusted for these same covariates using multivariable quantile regression. RESULTS: Of the 4,084 patients who underwent SSRF, 3048 (75%) were males, the median age was 57 years [IQR 47, 66], and 1504 (37%) had at least one PCM. After adjusting for the propensity score, patients with PCM who underwent SSRF had no significant difference in mortality compared to those without PCM (absolute difference, 0.7% [95% CI -0.2, 1.7]). Similarly, there was no significant difference in time on the ventilator (0.6 days [-0.1, 1.4]). Patients with PCM, however, had a statistically significantly longer hospital LOS (0.8 days [0.3, 1.3]) and ICU LOS (0.6 days [0.1, 1.1]), higher risk of tracheostomy (2.7% [0.1, 4.6]) and higher probability of pulmonary complications (2.7% [1.2, 4.2]), compared to those without PCM. CONCLUSION: Among patients with multiple rib fractures who undergo SSRF, having a PCM did not result in a clinically important higher probability of dying or experiencing substantial morbidity. This factor should not exclude patients with PCM from receiving SSRF for multiple rib fractures but the small increased risk in morbidity should be discussed with patients prior to SSRF.

When New York City was the COVID-19 pandemic epicenter: The impact on trauma care.

BACKGROUND: During early spring 2020, New York City (NYC) rapidly became the first US epicenter of the COVID-19 pandemic. With an unparalleled strain on health care resources, we sought to investigate the impact of the pandemic on trauma visits and mortality in the United States' largest municipal hospital system. METHODS: We conducted a retrospective multicenter cohort study of the five level 1 trauma centers in NYC's public health care system, New York City's Health and Hospitals Corporation. Clinical characteristics, mechanism of injury, and mortality of trauma patients presenting during the early pandemic (March 1, 2020, to May 31, 2020) were compared with a similar period in the previous 2 years. To account for important patient and hospital-level confounding variables, we created a propensity score for treatment and applied inverse probability weighting. RESULTS: In March to May 2020, there was a 25% decrease in median number of monthly trauma visits (693 vs. 528; p = 0.02) but a 50% increase (15% vs. 22%; p = <0.001) in patients presenting for penetrating injuries, compared with the same period for 2018 and 2019. Injured patients with COVID were significantly more likely to die compared with those without COVID-19 (10.5% vs. 3.6%; p < 0.001). Overall, there was no significant difference in mortality for non-COVID-injured New Yorkers cared for in 2020 compared with 2018 and 2019. Less severely injured non-COVID patients (Injury Severity Score, <15), however, were significantly more likely to die compared with this same subgroup in 2018 and 2019 (adjusted relative risk, 2.7 [95% confidence interval, 1.5-4.7]). CONCLUSION: Despite a decline in overall trauma visits during the early part of the COVID pandemic in NYC, there was a significant increase in the proportion of penetrating mechanisms. Less-injured non-COVID patients experienced an increase in mortality in the early pandemic, possibly from a depletion of human and hospital resources from the large influx of COVID patients. These data lend support to the safeguarding of trauma system resources in the event of a future pandemic. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Cardiopulmonary resuscitation skill training and retention in teens (CPR START): A randomized control trial in high school students.

AIM: High school students are currently the largest group of individuals in the US receiving CPR training every year. This study examines the effect of adding a real-time visual feedback device to a standard instructor-led CPR course on skill acquisition and retention in high school students. METHODS: All study participants underwent baseline CPR skill testing and received a standard instructor-led compression-only CPR course. We then randomized students to a 'Feedback Group', consisting of 2 min of CPR training using a real-time visual feedback device, or 'Standard Group' that continued to practice on the inflatable manikin. CPR skills for all students were tested afterwards using the feedback device and reported as a compression score (CS) derived from their chest compression depth, rate, hand position, and full chest recoil. We compared the CS at baseline, week-0 (immediately post-intervention), week-10, week-28, and week-52 between groups. RESULTS: A total of 220 students were included in the analyses (Feedback Group = 110, Standard Group = 110). Both groups showed similar CPR performance at baseline. At week-0, the Feedback Group had a significantly higher CS compared to the Standard Group (adjusted difference: 20% [95% CI: 11%-29%; p < 0.001]). This difference attenuated over time but remained significant at the week-10 and week-28 follow-up; however, by the week-52 follow-up, there was no significant difference between groups. CONCLUSIONS: Using a real-time visual feedback device during CPR training significantly improves skill acquisition and retention in high school students and should be integrated into the high school CPR curriculum.

Association of Cryoprecipitate Use With Survival After Major Trauma in Children Receiving Massive Transfusion.

Importance: Although most massive transfusion protocols incorporate cryoprecipitate in the treatment of hemorrhaging injured patients, minimal data exist on its use in children, and whether its addition improves their survival is unclear. Objective: To determine whether cryoprecipitate use for injured children who receive massive transfusion is associated with lower mortality. Design, Setting, and Participants: This retrospective cohort study included injured patients examined between January 1, 2014, and December 31, 2017, at one of multiple centers across the US and Canada participating in the Pediatric Trauma Quality Improvement Program. Patients were aged 18 years or younger and had received massive transfusion, which was defined as at least 40 mL/kg of total blood products in the first 4 hours after emergency department arrival. Exclusion criteria included hospital transfer, arrival without signs of life, time of death or hospital discharge not recorded, and isolated head injuries. To adjust for potential confounding, a propensity score for treatment was created and inverse probability weighting was applied. The propensity score accounted for age, sex, race/ethnicity, injury type, payment type, Glasgow Coma Scale score, hypoxia, hypotension, assisted respirations, chest tube status, Injury Severity Score, total volume of blood products received, hemorrhage control procedure, hospital size, academic status, and trauma center designation. Data were analyzed from December 11, 2019, to August 31, 2020. Exposures: Cryoprecipitate use within the first 4 hours of emergency department arrival. Main Outcomes and Measures: In-hospital 24-hour and 7-day mortality. Results: Of the 2387 injured patients who received massive transfusion, 1948 patients were eligible for analysis. The median age was 16 years (interquartile range, 9-17 years), 1382 patients (70.9%) were male, and 807 (41.4%) were White. A total of 541 patients (27.8%) received cryoprecipitate. After propensity score weighting, patients who received cryoprecipitate had a significantly lower 24-hour mortality when compared with those who did not (adjusted difference, -6.9%; 95% CI, -10.6% to -3.2%). Moreover, cryoprecipitate use was associated with a significantly lower 7-day mortality but only in children with penetrating trauma (adjusted difference, -9.2%; 95% CI, -15.4% to -3.0%) and those transfused at least 100 mL/kg of total blood products (adjusted difference, -7.7%; 95% CI, -15.0% to -0.5%). Conclusions and Relevance: In this cohort study, early use of cryoprecipitate was associated with lower 24-hour mortality among injured children who required massive transfusion. The benefit of cryoprecipitate appeared to persist for 7 days only in those with penetrating trauma and in those who received extremely large-volume transfusion.