Optimising whole body computed tomography doses for paediatric trauma patients: a Swiss retrospective analysis.

We aimed to evaluate the impact of a low-dose whole-body computed tomography (WBCT) protocol on radiation doses in paediatric major trauma patients. Retrospective cohort study of paediatric trauma patients (<16 years) at a national level 1 paediatric trauma centre (PTC) over a 6 year period prior and post introduction of a low-dose WBCT protocol (2014-2019). Demographic data, patient characteristics, CT device, and exposure information including scan range, dose-length product, and volume CT dose index were collected. Effective dose (ED) and exposure parameters were compared before and after protocol introduction. Forty-eight patients underwent WBCT during the study period. Prior to introduction of the low-dose protocol (n= 18), the ED was 20.6 mSv (median 20.1 ± 5.3 mSv [range 12.5-30.7]). After introduction of the low-dose WBCT protocol (n= 30), mean ED was 4.8 mSv (median 2.6 ± 5.0 [range: 0.8-19.1]). This resulted in a reduction of 77% in mean ED (pvalue <0.001). Significant radiation dose reduction of 77% can be achieved with low-dose WBCT protocols in PTCs.

Feasibility and usefulness of rapid 2-channel-EEG-monitoring (point-of-care EEG) for acute CNS disorders in the paediatric emergency department: an observational study.

INTRODUCTION: The aim of this study was to determine the feasibility and clinical utility of point-of-care electroencephalogram (pocEEG) in the paediatric emergency department (ED) for children presenting with acute non-traumatic central nervous system (CNS) disorders. METHODS: Retrospective observational study of prospectively collected data in paediatric patients (0-16 years) with acute non-traumatic CNS-disorders presenting between April 2014 and February 2017 to a single paediatric ED in Switzerland.The 2-channel EEG was applied to all patients presenting with acute seizures or impaired consciousness to the ED. For a pocEEG, scalp surface electrodes are applied in five locations, thus allowing registration of fronto-temporal bilateral cortical activity. Neurology consultants assisted with interpretation of readings. EEG findings and clinical characteristics were collected. Feasibility and usefulness were rated via Likert scale. RESULTS: 36 patients with acute seizures or altered mental status were analysed. Age range was 9 months to 15 years, median age of 34 months. 21 of 36 (58%) patients arrived out of hours. Application of electrodes was rated as 'easy' in 28 (77.8%) patients and rated as 'difficult' in 8 (22.2%). The utility of the EEG was rated by physicians as 'very useful/diagnostic' in 13 cases (36%), 'useful' in 21 cases (58%), 'not useful' in two cases (8%). None were rated 'negative.' CONCLUSION: Uptake of pocEEG introduction has been very encouraging. Provider ratings were overwhelmingly positive. Recognition of non-convulsive status epilepticus was improved and pocEEG facilitated more targeted interventions.

Two case reports of unexpected tracheal agenesis in the neonate: 3 C's beyond algorithms for difficult airway management.

BACKGROUND: Handling neonates with postnatal respiratory failure due to congenital airway malformations implies knowledge about emergency management of unexpected difficult airway. In these stressful situations both technical and communication skills of the caretakers are essential. CASE PRESENTATION: Two cases with prenatally unknown tracheal agenesis are reported. CONCLUSION: In the presented cases, airway malformation and subsequent difficulties upon endotracheal intubation were not adequately communicated between caretakers. We discuss the aspects of culture, communication, and capnography.

Integrating Neuromonitoring in Pediatric Emergency Medicine: Exploring Two Options for Point-of-Care Electroencephalogram (pocEEG) via Patient Monitors-A Technical Note.

Central nervous system (CNS) disorders are among the most frequent presentations in critically ill children. Status epilepticus (SE) is a frequent scenario in the resuscitation bay. In patients with altered mental status, non-convulsive SE (NCSE) is often underrecognized and critically impacts the neurological outcome and duration of hospitalization. An electroencephalogram (EEG) is required to diagnose NCSE. However, standard EEG recordings are time- and staff-intensive, and their availability is limited, especially outside regular working hours. We aimed to improve patient care by developing a simplified EEG recording method, using a reduced lead montage (point-of-care EEG-pocEEG), that is suitable for use in pediatric emergency departments. The objective was to devise a cost-effective unit with low space requirements that fitted the existing technical infrastructure. We present two technical options for clinical pocEEG acquisition using patient monitors (GE Carescape, Philips IntelliVue) that enable data collection for educational and research purposes. A simplified, rapid response EEG like the pocEEG enables neuromonitoring of patients with CNS disorders in pediatric emergency settings, facilitating timely diagnosis and treatment initiation when standard EEG is not readily available.

Vaccine Hesitancy in Central Switzerland: Identifying and Characterizing Undervaccinated Children in a Pediatric Emergency Department.

Vaccinations play an important role in the prevention of potentially fatal diseases. Vaccine hesitancy has become an important problem both in the public discourse and for public health. We aimed to identify and characterize this potentially unvaccinated or incompletely vaccinated group of children presenting to the pediatric emergency department (PED) of the tertiary children's hospital in central Switzerland, a region that has anecdotally been claimed as a hotspot for vaccine hesitancy. All patients presenting to the PED (N = 20,247) between September 2018 and September 2019 were screened for their vaccination status and categorized as incomplete, unvaccinated, or fully vaccinated in a retrospective cohort study. Some 2.6% (n = 526) visits to the PED were not or incompletely vaccinated according to age, or their vaccination status was unknown. Most of the children in the cohort were not critically ill, and the minority had to be hospitalized. Undervaccinated patients were overrepresented in rural areas. Of all cohort visits, 18 (3.4%) patients received opportunistic vaccination in the PED. No cases of vaccine-preventable diseases were observed. In summary, incompletely vaccinated and unvaccinated status was less frequent than initially expected. The PED may play a role in increasing vaccination coverage by providing opportunistic vaccinations.

Pediatric Trauma and Trauma Team Activation in a Swiss Pediatric Emergency Department: An Observational Cohort Study.

BACKGROUND: Trauma is one of the most common causes of death in childhood, but data on severely injured Swiss children are absent from existing national registries. Our aim was to analyze trauma activations and the profiles of critically injured children at a tertiary, non-academic Swiss pediatric emergency department (PED). In the absence of a national pediatric trauma database, this information may help to guide the design of infrastructure, processes within organizations, training, and policies. METHODS: A retrospective analysis of pediatric trauma patients in a prospective resuscitation database over a 2-year period. Critically injured trauma patients under the age of 16 years were included. Patients were described with established triage and injury severity scales. Statistical evaluation included logistic regression analysis. RESULTS: A total of 82 patients matched one or more of the study inclusion criteria. The most frequent age group was 12-15 years, and 27% were female. Trauma team activation (TTA) occurred with 49 patients (59.8%). Falls were the most frequent mechanism of injury, both overall and for major trauma. Road-traffic-related injuries had the highest relative risk of major trauma. In the multivariate analysis, patients receiving medicalized transport were more likely to trigger a TTA, but there was no association between TTA and age, gender, or Injury Severity Score (ISS). Nineteen patients (23.2%) sustained major trauma with an ISS > 15. Injuries of Abbreviated Injury Scale severity 3 or greater were most frequent to the head, followed by abdomen, chest, and extremities. The overall mortality rate in the cohort was 2.4%. Conclusions: Major trauma presentations only comprise a small proportion of the total patient load in the PED, and trauma team activation does not correlate with injury severity. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED. Our findings indicate that high priority should be given to training in the management of severely injured children in the PED. The leading major trauma mechanisms were preventable, which should prompt further efforts in injury prevention.

Critically Ill Children in a Swiss Pediatric Emergency Department With an Interdisciplinary Approach: A Prospective Cohort Study.

Objective: Delivery of prompt and adequate care for critically ill and injured children presenting to the pediatric emergency department (PED) is paramount for optimal outcomes. Knowledge of the local epidemiology, patient profile, and presentation modes are key for organizational planning, staff education strategy, and optimal care in a PED. Our aim was to analyze the profile of critically ill and injured children admitted to a tertiary, non-academic Swiss PED, to investigate potential risk factors associated with admission to the pediatric intensive care unit (PICU), and the outcomes mortality and PICU admission. Methods: Prospective cohort study of critically ill and injured children presenting to the PED over a two-year period (2018-2019). Inclusion criteria were Australasian triage scale category (ATS) 1, trauma team activation (TTA), medical emergency response (MER) activation, additional critical care consult, and transfer to an outside hospital. Results: Of 42,579 visits during the two-year period, 347 presentations matched the inclusion criteria (0.81%). Leading presentations were central nervous system (CNS) disorders (26.2%), trauma (25.1%), and respiratory emergencies (24.2%). 288 out of 347 cases (83%) arrived during the day or evening with an even distribution over the days of the week. 128 out of 347 (37%) arrived unexpectedly as walk-ins. 233 (67.15%) were ATS category 1. 51% of the cohort was admitted to PICU. Australasian triage scale category 1 was significantly more common in this group (p = 0.0001). Infants with respiratory disease had an increased risk of PICU transfer compared to other age groups (OR 4.18 [95%CI 2.46, 7.09] p = 0.0001), and this age group presented mainly as walk-in (p = 0.0001). Pediatric intensive care unit admissions had a longer hospital stay (4 [2, 8] days vs. 2 [1, 4] days, p = 0.0001) compared to other patients. 0.045% of all PED patients had to be transferred out. Three deaths (0.86%) occurred in the PED, 10 patients died in the PICU (2.9%). Conclusions: High acuity presentations in the PED were rare, more likely to be young with CNS disorders, trauma and respiratory diseases. A significant proportion were unexpected walk-in presentations, mainly during day and evening shifts. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED.

Muscular diagnostics and the feasibility of microsystem acupuncture as a potential adjunct in the treatment of painful temporomandibular disorders: results of a retrospective cohort study.

AIMS: To investigate the effect of microsystem acupuncture on painful temporomandibular disorders (TMD). METHODS: We retrospectively analysed 887 treatments in 407 TMD-patients (mean age 45±1.5 years), who received microsystem acupuncture (mouth, scalp or fingers) with a focus on oral acupuncture. All patients systematically underwent palpation of specific muscular tender points and their pain rating was assessed on a four-point Likert scale (no pain to strong pain) before and after treatment. In 42 cases, the pain intensity was determined using a visual analogue scale (0-100 mm). As the data were normally distributed, analysis was performed with unpaired t-tests. RESULTS: The pterygoid muscles were most painful to palpation, with the lateral pterygoid rated moderate to strong by 76% of patients and the medial pterygoid by 48% of patients. The palpation of microsystem acupuncture points revealed the strongest sensitivity (moderate or strong pain) of the oral retromolar points at the upper jaw (83%). After treatment, the pain intensity of all tender points had significantly decreased (P<0.001). The proportion of moderate to strong pain ratings was below 3% at most tender points. Overall pain intensity of the subjects (n=42) before treatment was 55.5±19.7 mm on the VAS scale and was significantly reduced to 29.6±20.9 mm (P<0.001) post-treatment. CONCLUSIONS: This analysis suggests microsystem acupuncture could reduce the pain intensity of TMD in the short term. Considering the increased local muscular tenderness, further investigations regarding the key role of myofascial trigger points in the occurrence of TMDs are warranted and could lead to new comprehensive treatment strategies.

Airway emergencies presenting to the paediatric emergency department requiring advanced management techniques.

BACKGROUND: Airway emergencies presenting to the emergency department (ED) are usually managed with conventional equipment and techniques. The patient group managed urgently in the operating room (OR) has not been described. AIMS: This study aims to describe a case series of children presenting to the ED with airway emergencies managed urgently in the OR, particularly the anaesthetic equipment and techniques used and airway findings. METHODS: A retrospective cohort study undertaken at The Royal Children's Hospital, Melbourne, Australia. All patients presenting to the ED between 1 January 2012 and 30 July 2015 (42 months) with an airway emergency who were subsequently managed in the OR were included. Patient characteristics, anaesthetic equipment and technique and airway findings were recorded. RESULTS: Twenty-two airway emergencies in 21 patients were included over the study period, on average one every 2 months. Median age was 18 months and 43% were male. Inhalational induction was used in 77.3%, combined inhalational and intravenous induction in 9.1%, and intravenous induction alone in 13.6%. The most commonly used inhalational induction agent was sevoflurane, and the most commonly used intravenous induction agents were ketamine and propofol. Ten airway emergencies did not require intubation, seven for removal of inhaled foreign body, two with progressive tracheal stenosis requiring emergent dilatation and one examination under anaesthesia to rule out inhaled foreign body. Of the 12 airway emergencies that required immediate intubation, direct laryngoscopy was used in 9 and fibre-optic intubating bronchoscopy in 3. For intubations performed by direct laryngoscopy, one was difficult (Cormack and Lehane grade 3). First pass success was 83.3%. Adverse events occurred in 3/22 (13.6%) cases. CONCLUSION: Advanced airway techniques, including inhalational induction and intubation via fibre-optic intubating bronchoscope, are rarely but predictably required in the management of patients presenting to the ED. Institutions caring for children should prepare in advance where such patients should be managed, by whom, and provide equipment and training for their care.

Observational study of alternative therapies among paediatric emergency department patients.

OBJECTIVE: While complementary medicine use among ED paediatric patients is common, the use of alternative therapies (ATs; physical or spiritual therapies) is unknown. We aimed to determine the 12 month period prevalence and nature of AT use among paediatric patients and parent perceptions of AT use. METHODS: We undertook a cross-sectional survey of a convenience sample of parents of paediatric patients in three EDs in metropolitan Melbourne, Australia (January-June, 2015). Parents were invited to complete a validated, anonymous, self-administered questionnaire. The main outcomes were AT use by the patient and parent perceptions of ATs. RESULTS: A total of 806 parents were enrolled. In the previous 12 months, 393 (48.8%) patients had received at least one AT. There were no gender or ethnicity differences between AT users and non-users. AT use was more common among older patients (P < 0.05). Patients with chronic illness tended to use more ATs (P = 0.12). A total of 1091 courses of 43 different ATs had been provided. The most common were massage (16% of patients), chiropractic therapy (9.8%), relaxation (7.2%), meditation (6.2%) and aromatherapy (6.1%). ATs were generally used for musculoskeletal problems, health maintenance, stress and anxiety. Parents who arranged the ATs were significantly more likely to report that ATs are safe, prevent and treat illness, assist prescription medicines and offer a more holistic approach to healthcare (P < 0.001). CONCLUSION: AT use is common among paediatric ED patients. Parents who arrange AT have differing perceptions of AT usefulness and safety from those who do not.