The Toddler's Fracture.

OBJECTIVE: The tibial toddler's fracture is an important diagnosis in both emergency and urgent care, presenting as acute onset lower extremity pain or limping in a young child. Diagnosis and management may be challenging because of an extensive differential diagnosis. The objectives of this study were to provide an overview of the toddler's fracture and to guide clinicians by summarizing up to date literature for both diagnosis and management this common condition. METHODS: This study analyzed literature from the PubMed database from the years of 1964 to 2018. The main focus was on the diagnosis and management of the toddler's fracture. RESULTS: This review demonstrates that diagnosis is primarily made through history and physical examination, as radiographs are often negative at initial presentation. Treatment involves a short period of immobilization, which can be facilitated through the use of a cast, a splint, or no external support. Successful healing and a full return to normal activities and development are near universal. CONCLUSIONS: Although a stable fracture with an excellent prognosis, opportunities exist to improve toddler's fractures diagnosis and treatment protocols, to optimize clinical management.

Point of care lung ultrasound of children with acute asthma exacerbations in the pediatric ED.

OBJECTIVES: Primary objective was to characterize lung ultrasound findings in children with asthma presenting with respiratory distress to the emergency department (ED). Secondary objectives included correlating these findings with patients' clinical course in the ED. METHODS: Eligible patients 2-17years of age, underwent a lung ultrasound by the study sonographer between November 2014 to December 2015. Positive lung ultrasound was defined as the presence of ≥1 of the following findings: ≥3 B-lines per intercostal space, consolidation and/or pleural abnormalities. The treating physician remained blinded to ultrasound findings; clinical course was extracted from the medical chart. RESULTS: A total of sixty patients were enrolled in this study. Lung ultrasound was positive in 45% (27/60) of patients: B-line pattern in 38%, consolidation in 30% and pleural line abnormalities in 12%. A positive lung ultrasound correlated with increased utilization of antibiotics (26% vs 0%, p=0.03), prolonged ED length of stay (30% vs. 9%, p=0.04) and admission rate (30% vs 0%, p=0.03). Inter-rater agreement between novice and expert sonographers was excellent with a kappa of 0.92 (95% CI: 0.84-1.00). CONCLUSIONS: This study characterized lung ultrasound findings in pediatric patients presenting with acute asthma exacerbations; nearly half of whom had a positive lung ultrasound. Positive lung ultrasounds were associated with increased ED and hospital resource utilization. Future prospective studies are needed to determine the utility and reliability of this tool in clinical practice.

The effect of simulator fidelity on acquiring non-technical skills: a randomized non-inferiority trial.

INTRODUCTION: As simulator fidelity (i.e., realism) increases from low to high, the simulator more closely resembles the real environment, but it also becomes more expensive. It is generally assumed that the use of high-fidelity simulators results in better learning; however, the effect of fidelity on learning non-technical skills (NTS) is unknown. This was a non-inferiority trial comparing the efficacy of high- vs low-fidelity simulators on learning NTS. METHODS: Thirty-six postgraduate medical trainees were recruited for the trial. During the pre-test phase, the trainees were randomly assigned to manage a scenario using either a high-fidelity simulator (HFS) or a low-fidelity simulator (LFS), followed by expert debriefing. All trainees then underwent a video recorded post-test scenario on a HFS, and the NTS were assessed between the two groups. The primary outcome was the overall post-test Ottawa Global Rating Scale (OGRS), while controlling for overall pre-test OGRS scores. Non-inferiority between the LFS and HFS was based on a non-inferiority margin of greater than 1. RESULTS: For our primary outcome, the mean (SD) post-test overall OGRS score was not significantly different between the HFS and LFS groups after controlling for pre-test overall OGRS scores [3.8 (0.9) vs 4.0 (0.9), respectively; mean difference, 0.2; 95% confidence interval, -0.4 to 0.8; P = 0.48]. For our secondary outcomes, the post-test total OGRS score was not significantly different between the HFS and LFS groups after controlling for pre-test total OGRS scores (P = 0.33). There were significant improvements in mean overall (P = 0.01) and total (P = 0.003) OGRS scores from pre-test to post-test. There were no significant associations between postgraduate year (P = 0.82) and specialty (P = 0.67) on overall OGRS performance. CONCLUSION: This study suggests that low-fidelity simulators are non-inferior to the more costly high-fidelity simulators for teaching NTS to postgraduate medical trainees.

Emergency Point-of-Care Ultrasound Diagnosis of Retained Soft Tissue Foreign Bodies in the Pediatric Emergency Department.

The presence of a foreign body (FB), its depth and size, is often indeterminate by clinical examination. Conventional imaging such as a radiograph can fail to visualize soft tissue FBs. We present 2 cases where point-of-care ultrasound was used to detect previously unidentified FBs.

Point-of-care lung ultrasound in young children with respiratory tract infections and wheeze.

OBJECTIVE: Characterise lung ultrasound (LUS) findings, diagnostic accuracy and agreement between novice and expert interpretations in young children with respiratory tract infections and wheeze. METHODS: Prospective cross-sectional study in a paediatric ED. Patients ≤2 years with a respiratory tract infection and wheeze at triage were recruited unless in severe respiratory distress. Prior to clinical management, a novice sonologist performed the LUS using a six-zone scanning protocol. The treating physician remained blinded to ultrasound findings; final diagnoses were extracted from the medical record. An expert sonologist, blinded to all clinical information, assessed the ultrasound video clips at study completion. Positive LUS was defined as the presence of ≥1 of the following findings: ≥3 B-lines per intercostal space, consolidation and/or pleural abnormalities. RESULTS: Ninety-four patients were enrolled (median age 11.1 months). LUS was positive in 42% (39/94) of patients (multiple B-lines in 80%, consolidation in 64%, pleural abnormalities in 23%). The proportion of positive LUS, along with their diagnostic accuracy (sensitivity (95% CI), specificity (95% CI)), were as follows for children with bronchiolitis, asthma, pneumonia and asthma/pneumonia: 46% (45.8% (34.0% to 58.0%), 72.7% (49.8% to 89.3%)), 0% (0% (0.0% to 23.3%), 51.3% (39.8% to 62.6%)), 100% (100% (39.8% to 100.0%), 61.1% (50.3% to 71.2%)), 50% (50% (6.8% to 93.2%), 58.9% (48.0% to 69.2%)), respectively. There was good agreement between the novice and expert sonographers for a positive LUS (kappa 0.68 (95% CI 0.54 to 0.82)). CONCLUSIONS: Among children with respiratory tract infections and wheeze, a positive LUS seems to distinguish between clinical syndromes by ruling in pneumonia and ruling out asthma. If confirmed in future studies, LUS may emerge as a point-of-care tool to guide diagnosis and disposition in young children with wheeze.

Household transmission of SARS-CoV-2 from unvaccinated asymptomatic and symptomatic household members with confirmed SARS-CoV-2 infection: an antibody-surveillance study.

BACKGROUND: Household transmission contributes to SARS-CoV-2 spread, but the role of children in transmission is unclear. We conducted a study that included symptomatic and asymptomatic children and adults exposed to SARS-CoV-2 in their households with the objective of determining how SARS-CoV-2 is transmitted within households. METHODS: In this case-ascertained antibody-surveillance study, we enrolled households in Ottawa, Ontario, in which at least 1 household member had tested positive for SARS-CoV-2 on reverse transcription polymerase chain reaction testing. The enrolment period was September 2020 to March 2021. Potentially eligible participants were identified if they had tested positive for SARS-CoV-2 at an academic emergency department or affiliated testing centre; people who learned about the study through the media could also self-identify for participation. At least 2 participants were required for a household to be eligible for study participation, and at least 1 enrolled participant per household had to be a child (age < 18 yr). Enzyme-linked immunosorbent assays were used to evaluate SARS-CoV-2-specific IgA, IgM and IgG against the spike-trimer and nucleocapsid protein. The primary outcome was household secondary attack rate, defined as the proportion of household contacts positive for SARS-CoV-2 antibody among the total number of household contacts participating in the study. We performed descriptive statistics at both the individual and household levels. To estimate and compare outcomes between patient subgroups, and to examine predictors of household transmission, we fitted a series of multivariable logistic regression with robust standard errors to account for clustering of individuals within households. RESULTS: We enrolled 695 participants from 180 households: 180 index participants (74 children, 106 adults) and 515 of their household contacts (266 children, 249 adults). A total of 487 household contacts (94.6%) (246 children, 241 adults) had SARS-CoV-2 antibody testing, of whom 239 had a positive result (secondary attack rate 49.1%, 95% confidence interval [CI] 42.9%-55.3%). Eighty-eight (36.8%, 95% CI 29.3%-43.2%) of the 239 were asymptomatic; asymptomatic rates were similar for children (51/130 [39.2%, 95% CI 30.7%-48.5%]) and adults (37/115 [32.2%, 95% CI 24.2%-41.4%]) (odds ratio [OR] 1.3, 95% CI 0.8-2.1). Adults were more likely than children to transmit SARS-CoV-2 (OR 2.2, 95% CI 1.3-3.6). The odds of transmission from asymptomatic (OR 0.6, 95% CI 0.2-1.4) versus symptomatic (OR 0.9, 95% CI 0.6-1.4) index participants to household contacts was uncertain. Predictors of household transmission included household density (number of people per bedroom), relationship to index participant and number of cases in the household. INTERPRETATION: The rate of SARS-CoV-2 transmission within households was nearly 50% during the study period, and children were an important source of spread. The findings suggest that children are an important driver of the COVID-19 pandemic; this should inform public health policy.

A randomized education trial of spaced versus massed instruction to improve acquisition and retention of paediatric resuscitation skills in emergency medical service (EMS) providers.

AIM: Resuscitation courses are typically taught in a massed format despite existing evidence suggesting skill decay as soon as 3 months after training. Our study explored the impact of spaced versus massed instruction on acquisition and long-term retention of provider paediatric resuscitation skills. METHODS: Providers were randomized to receive a paediatric resuscitation course in either a spaced (four weekly sessions) or massed format (two sequential days). Infant and adult chest compressions [CC], bag mask ventilation [BMV], and intraosseous insertion [IO] performance was measured using global rating scales. RESULTS: Forty-eight participants completed the study protocol. Skill performance improved from baseline in both groups immediately following training. 3-months post-training the infant and adult CC scores remained significantly improved from baseline testing in both the massed and spaced groups; however, the infant BMV and IO scores remained significantly improved from baseline testing in the spaced: BMV (pre, 1.8 ±â€¯0.7 vs post-3-months, 2.2 ±â€¯7; P = 0.005) IO (pre, 2.5 ±â€¯1 vs post-3-months, 3.1 ±â€¯0.5; P = 0.04) but not in the massed groups: BMV (pre, 1.6 ±â€¯0.5 vs post-3-months, 1.8 ±â€¯0.5; P = 0.98) IO (pre, 2.6 ±â€¯1.1 vs post-3-months, 2.7 ±â€¯0.2; P = 0.98). CONCLUSION: 3-month retention of CC skills are similar regardless of training format; however, retention of other resuscitation skills may be better when taught in a spaced format.