Child Passenger Restraint System Misuse in Rural Versus Urban Children: A Multisite Case-Control Study.

OBJECTIVES: Motor vehicle crashes are the leading cause of childhood fatality, making use of properly installed child passenger restraint system (CRS) a public health priority. Motor vehicle crashes in rural environments are associated with increased injuries and fatalities, and overall CRS use tends to be lower compared with urban populations. However, it remains unclear if proper installation of car seats is lower in a rural population compared with a similar matched urban population. METHODS: A multisite (Alabama, Arkansas, Illinois), observational, case-control study was performed using data from community child passenger safety checkup events in rural (economically and population-controlled) and urban locations. Data were matched to the primary child assessed in a vehicle, and stratified by age, site, and year with urban unscheduled CRS check data. All CRS checks were performed using nationally certified CRS technicians who used the best practice standards of the American Academy of Pediatrics and collected subject demographics, car seat misuse patterns, and interventions using identical definitions. RESULTS: Four hundred eighty-four CRS checks (242 rural and 242 urban) involving 603 total children from 3 states (Alabama, 43 [7%]; Arkansas, 442 [73%]; Illinois, 118 [20%]) were examined; of which, 86% had at least 1 documented CRS misuse. Child passenger restraint system misuse was more common in rural than urban locations (90.5% vs 82.6%; P = 0.01). Child passenger restraint system misuse was more common in rural children aged 4 to 8 years (90.3% vs 80.6%; P = 0.02). CONCLUSIONS: In this multisite study, rural location was associated with higher CRS misuse. Child passenger restraint system education and resources that target rural populations specifically appear to be justified.

Intubation Performance of Advanced Airway Devices in a Helicopter Emergency Medical Service Setting.

OBJECTIVE: This study attempts to determine if newer indirect laryngoscopes or intubating devices are superior to a standard laryngoscope for intubation success among helicopter emergency medical service (HEMS) personnel. METHODS: Flight nurses and paramedics intubated standardized mannequins with a normal airway, a trauma airway, and a difficult airway using a standard laryngoscope, a gum elastic bougie, the Airtraq laryngoscope (King System Corp, Noblesville, IN), the Glidescope Ranger laryngoscope (Verathon Inc, Bothell, WA), and the S.A.L.T. device (Microtek Medical, Inc, Lehmberg, IN) in grounded helicopters wearing helmets and flight gear. Participant demographics, time to glottic view, the modified Cormack-Lehane score, total intubation time, number of attempts, and overall successful intubation were recorded for each type of airway. RESULTS: Two-hundred thirty-six subjects were initially enrolled across 107 bases in 15 states, and 177 completed the study. First-attempt success rates did not vary by device for the normal airway (P = .203), but the Airtraq laryngoscope and the S.A.L.T. device were highest in the difficult airway (82.0% and 85.0%, respectively; P < .0001). The time to first-attempt success in the difficult airway was lowest for the S.A.L.T. device and the Airtraq laryngoscope (mean = 9.72 seconds and 19.70 seconds, respectively; P < .0001). CONCLUSION: Using HEMS providers, the Airtraq laryngoscope and the S.A.L.T. device showed the fastest and highest intubation success on the first attempt in difficult simulated HEMS airway scenarios.

Death before disco: the effectiveness of a musical metronome in layperson cardiopulmonary resuscitation training.

BACKGROUND: A novel musical memory aid has been proposed for aiding laypersons in complying with the American Heart Association (AHA) cardiopulmonary resuscitation (CPR) guidelines of 100 compressions per minute (cpm). OBJECTIVE: This study tested usefulness of such a memory aid to improve layperson long-term compliance with CPR compression rate guidelines. METHODS: A prospective randomized controlled trial was conducted using CPR-untrained laypersons. Subjects received either a standard CPR educational experience (AHA Heartsaver® CPR class) or an experimental CPR educational experience (AHA Heartsaver® CPR class augmented with a musical metronome). Experimental group subjects were taught to perform compressions to the cadence of a pop music song (The Bee Gees "Stayin' Alive"; Saturday Night Fever, The Original Movie Soundtrack; Polygram International Music, 1977) with a tempo of 100 beats/min. Compression rates, depth of compressions, and correct compressions were measured initially and upon retesting ≥6 weeks post-training. RESULTS: Control subjects had a higher mean compression rate both immediately (121 [standard deviation {SD} = 21] vs. 109 [SD = 15] cpm; 95% confidence interval [CI] of mean difference 4-19; p = 0.002) and at follow-up (120 [SD = 20] vs. 111 [SD = 13] cpm; 95% CI of mean difference 2-16; p = 0.014). Compression rates stratified to 100-120 cpm demonstrated no difference between groups initially (39% vs. 48%; p = 0.382), but more experimental subjects maintained these rates at follow-up (43% vs. 74%; p = 0.003). CONCLUSIONS: Subjects trained to use a musical metronome more often maintained a compression rate of 100-120 cpm at ≥6-week follow-up, suggesting the memory aid may improve long-term guideline adherence.

Pediatric Extracorporeal Membrane Oxygenation: An Introduction for Emergency Medicine Physicians.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) therapy has supported critically ill pediatric patients in the intensive care unit setting with cardiac and respiratory failure. This therapy is beginning to transition to the emergency department setting. OBJECTIVE OF REVIEW: This article describes the fundamentals of ECMO and familiarizes the emergency medicine physician with its use in critically ill pediatric patients. DISCUSSION: ECMO can be utilized as either venoarterial (VA) or venovenous (VV), to support oxygenation and perfusion in respiratory failure, sepsis, cardiac arrest, and environmental hypothermia.

Effectiveness of a pediatric verbal lead exposure screening protocol in emergency department patients.

PURPOSE: The population demographics found in many urban emergency departments (EDs) often mirrors those of children at risk for elevated serum lead levels. We evaluated the effectiveness of a verbal lead screening program for screening high-risk children presenting to the ED. METHODS: A prospective observational cohort study was conducted of children aged 9 months to 6 years, living in 2 target counties and presenting to an urban, academic, Midwestern ED. Those with a prior lead level, enrolled in a program requiring lead testing, or with an unstable medical condition were excluded. A 6-question validated verbal survey was administered to all parents of eligible children, and the results recorded in the patient's electronic medical record. Children who screened positive were referred to their local health department for blood lead testing. Health department records were reviewed for follow-up visits and blood lead levels. RESULTS: During the study period, 3513 children were eligible (mean age, 2.6 years; 53.3% male), with 815 patients screened and 209 (25.6%) screening positive. Most positively screened patients (71.8%) documented only 1 affirmative question, most often indicating they lived in a home built before 1978. Of those children who screened positive, 14.8% (31/209) had a blood lead level performed within 6 months. Of those tested, 4 children had an elevated lead level (>10 µg/dL). CONCLUSIONS: Use of an ED verbal lead exposure screening tool identified children requiring additional follow-up testing. However, health department-referred children had poor follow-up, and few children were ultimately documented with elevated lead levels.

"Stayin' alive": a novel mental metronome to maintain compression rates in simulated cardiac arrests.

BACKGROUND: A novel and yet untested memory aid has anecdotally been proposed for aiding practitioners in complying with American Heart Association (AHA) cardiopulmonary resuscitation (CPR) compression rate guidelines (at least 100 compressions per minute). OBJECTIVES: This study investigates how subjects using this memory aid adhered to current CPR guidelines in the short and long term. METHODS: A prospective observational study was conducted with medical providers certified in 2005 AHA guideline CPR. Subjects were randomly paired and alternated administering CPR compressions on a mannequin during a standardized cardiac arrest scenario. While performing compressions, subjects listened to a digital recording of the Bee Gees song "Stayin' Alive," and were asked to time compressions to the musical beat. After at least 5 weeks, the participants were retested without directly listening to the recorded music. Attitudinal views were gathered using a post-session questionnaire. RESULTS: Fifteen subjects (mean age 29.3 years, 66.7% resident physicians and 80% male) were enrolled. The mean compression rate during the primary assessment (with music) was 109.1, and during the secondary assessment (without music) the rate was 113.2. Mean CPR compression rates did not vary by training level, CPR experience, or time to secondary assessment. Subjects felt that utilizing the music improved their ability to provide CPR and they felt more confident in performing CPR. CONCLUSIONS: Medical providers trained to use a novel musical memory aid effectively maintained AHA guideline CPR compression rates initially and in long-term follow-up. Subjects felt that the aid improved their technical abilities and confidence in providing CPR.

All-terrain vehicle dealership point-of-sale child safety compliance in Illinois.

OBJECTIVES: In 2008, an estimated 37,700 children younger than 16 were treated in US emergency departments for nonfatal all-terrain vehicle (ATV) injuries. This study identifies safety guidelines and recommendations dealers convey to consumers at the point of sale. METHODS: A telephone survey of all 2004 licensed motorcycle dealers in Illinois was conducted. Trained investigators, using aliases and posing as a parent of a 13-year-old teenager, spoke with dealership personnel. Investigators indicated they wished to purchase an ATV with the dealership, but had no knowledge of ATV use or safety issues. The telephone call's true purpose was concealed during the survey. Specific responses from the salesperson, models and brands of ATVs, price quotes, engine sizes, and safety information/recommendations were recorded in a written survey instrument. RESULTS: One hundred twenty-seven ATV dealers completed the survey. A salesperson most often fielded the telephone interview (124/127). Telephone interviews by male investigators were longer than those by female interviewers (5 minutes 37 seconds vs 3 minutes 51 seconds; P = 0.001). Dealers recommended Consumer Product Safety Commission-based child-size ATVs (<90 mL engine size) during 75% of the calls. Nearly all dealers recommended helmet use (108/127), and few (3/127) labeled the vehicles as "safe." Most dealers (83.5%) recommended some form of rider training, with half (49.6%) offered point-of-purchase training. CONCLUSIONS: All-terrain vehicle dealers in Illinois recommend child-size vehicles, safety training, and helmet use for the majority of telephone inquiries. Injury prevention efforts targeting ATV dealers may be less needed than those using other populations.

Definition and measurement of rider-intrinsic physical attributes influencing all-terrain vehicle safety.

OBJECT: All-terrain vehicle (ATV) usage has grown tremendously over the years, reaching 9.5 million vehicles in use in 2007. Accompanying this growth has been a concomitant increase in rider morbidity (including traumatic brain and spine injuries) and death, especially in children. The purpose of this study was to define and measure, through field testing, those physical attributes intrinsic to riders, such as height, weight, and wingspan, which may have implications for ATV riders' safety. METHODS: Three field tests (J-hook, brake, and bump) were developed and performed to allow direct measurement of the lateral, longitudinal, and vertical dynamics in 5 riders of varying heights, weights, and wingspans. Two ATVs, a utility and a sport model, were tested for further comparisons. Data were acquired using a comprehensive data acquisition system attached to the ATVs. Assignment of individual rider/ATV test safety ratings and a rider/ATV Total Safety Rating were made from the results of these field tests. RESULTS: The J-hook test results demonstrated that larger rider wingspans positively influence ATV rider safety and mitigate against lateral instability. From the brake test it was determined that a 10-in (25.4-cm) longitudinal displacement, such as that experienced during a sharp deceleration, for a rider of any height or weight, breached the level of defined safety. As rider weight increased, displacement decreased. The bump test provided evidence that increased rider weight also mitigates against vertical displacement. CONCLUSIONS: Individuals with light weights and small wingspans, such as those in the pediatric population, are under considerable risk of injury when operating an ATV due to lateral, longitudinal, and vertical operational instability.

Core Practical Objectives: a means to standardize the 4th-year emergency medicine clerkship.

BACKGROUND: Core Practical Objectives (CPOs) are clinical emergency medicine (EM) experiences (including suggested number of patient encounters) that students use to self-direct clerkship progress. PURPOSE: This study investigates feasibility of implementing EM clerkship CPOs, describes characteristics of students fulfilling CPO guidelines, and relates CPO completion to outcome measures (exam scores and grades). METHODS: Cross-sectional research was conducted comparing students completing and not completing CPOs by gender, month of rotation, total patients evaluated, clerkship exam score, and final grade. RESULTS: Over 4 years, 117 students completed an EM clerkship utilizing CPO guidelines. Gender and clerkship month were not associated with fulfilling CPOs. Total CPOs completed correlated positively with percent score on written exam and grade for rotation. Completion of specific CPOs was associated with exam scores and final grade. CONCLUSIONS: CPOs were successfully integrated into an EM clerkship. Preliminary data suggest that CPO guidelines can be used to standardize EM clerkships.

Unmet clinical laboratory need in patients hospitalized for acute poisoning from long-acting anticoagulant rodenticides.

The importance of real-time, quantitative toxicology data available for physicians treating poisoned patients was illustrated during the 2018 outbreak in Illinois of severe coagulopathy caused by inhaling illicit synthetic cannabinoids products contaminated with commercially-available brodifacoum, difenacoum, and bromadiolone, three potent, long-acting anticoagulant rodenticides (LAARs). Identification and quantification of these life-threatening toxins in blood samples of hospitalized patients required toxicology testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) that was not available in clinical laboratories of hospitals at the time of the outbreak. This highly-sensitive, quantitative assay can provide critical information to guide patient care during and after hospitalization, including identification of offending LAARs, estimates of the ingested dose, and dosage and discontinuation of oral vitamin K1 therapy after hospital discharge once plasma LAARs concentrations decreased to a safe level (<10 ng/mL). Accordingly, we propose an action plan to enable treating physicians to quantify plasma concentrations of several LAARs simultaneously in poisoned patients. It involves rapid (<15 min), sensitive, and validated LC-MS/MS methods developed, tested and validated in our laboratory. This will allow treating physicians to request quantitative plasma LAARs testing, report test results in the patient's hospital discharge summary, and recommend regular monitoring of plasma LAARs concentrations in the outpatient setting.

Severe Vitamin K-dependent Coagulopathy from Rodenticide-contaminated Synthetic Cannabinoids: Emergency Department Presentations.

INTRODUCTION: Synthetic cannabinoids are a rapidly expanding subset of designer drugs widely available in the United States since 2008. In Illinois during the spring of 2018, over 160 documented cases of bleeding and prolonged coagulopathy occurred secondary to contaminated synthetic cannabinoids. METHODS: We conducted a retrospective cohort study consisting of 38 patients to describe the initial emergency department (ED) presentation, diagnosis, and treatment. RESULTS: Through serum testing we found that three long-acting anticoagulant rodenticides (LAAR) were detected in patients who had inhaled these tainted products: brodifacoum, difenacoum, and bromodialone. DISCUSSION: This study encompasses the largest ED presentation of LAAR poisoning via the inhalational route known to date. CONCLUSION: The emergency physician should be aware of the potential for tainted coingestants as the cause of undifferentiated coagulopathy.

Diagnostic utility of the genital Gram stain in ED patients.

OBJECTIVE: The study aimed to determine the diagnostic usefulness of the genital Gram stain in an emergency department (ED) population. METHODS: A linked-query of an urban, tertiary-care, university- affiliated hospital laboratory database was conducted for all completed Chlamydia trachomatis and Neisseria gonorrhoeae DNA probes, Trichomonas vaginalis wet preps, and genital Gram stains performed on ED patient visits between January and December 2004. Positive criteria for a Gram stain included greater than 10 white blood cells per high-power field, gram-negative intracellular/extracellular diplococci (suggesting N gonorrhoeae), clue cells (suggesting T vaginalis), or direct visualization of T vaginalis organisms. DNA probes were used as the gold standard definition for N gonorrhoeae and C trachomatis infection. RESULTS: Of 1511 initially eligible ED visits, 941 were analyzed (genital Gram stain and DNA probe results both present), with a prevalence of either C trachomatis or N gonorrhoeae of 11.4%. A positive genital Gram stain was 75.7% sensitive and 43.3% specific in diagnosing either C trachomatis and/or N gonorrhoeae infection, and 80.4% sensitive and 32.2% specific when the positive cutoff was lowered to more than 5 white blood cells/high-power field. No Gram stains were positive for T vaginalis (with 47 positive wet mounts), and clue cells were noted on 117 Gram stains (11.6%). CONCLUSION: Gram stains in isolation lack sufficient diagnostic ability to detect either C trachomatis or N gonorrhoeae infection in the ED.

Effects of vitamin K1 treatment on plasma concentrations of long-acting anticoagulant rodenticide enantiomers following inhalation of contaminated synthetic cannabinoids.

Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy.Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers.Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances.Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTSIn patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital.LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.

The effect of a community crash reenactment program on teen alcohol awareness and behavior.

Background: Motor vehicle crashes (MVCs) are the leading cause of death in US teens, encompassing greater than one in three deaths. Mock crash reenactments have been used to promote awareness in communities about the effects of drinking and driving.  The majority of these programs are for alcohol injury prevention, target high school students, and often involve a scenario of a student driving while under the influence (DUI) and sustaining a fatal car crash. Objective: The purpose of this study is to evaluate the effectiveness of a regional mock crash reenactment upon the students' drinking and driving knowledge and behaviors. Methods: An observational pre-post study was conducted.  The survey had seven five-point Likert-scale questions (1 being strongly disagree and 5 strongly agree) measuring outcomes. Students were surveyed before and after the crash reenactment concerning their knowledge and attitudes related to drinking and driving. The survey also included questions that queried participant's age, gender, alcohol consumption history, and seatbelt usage. Results: The final study population included 947 pre-surveys and 840 post-surveys.  Students demonstrated no significant increase in knowledge-based drinking and driving questions.  However, after the reenactment program, students were 1.39 times less likely to report drinking and driving in the future or that they would get into a car with someone who would drive drunk. Students were 1.7 times more likely to report thinking about the risks associated with drinking and driving after participating in the program. Conclusion: After viewing a mock crash reenactment, students reported they were less likely to drink and drive in the future or get into a car with someone who would drive drunk, and were more likely often think the risks associated with drinking and driving.

Posttraumatic internal jugular vein thrombosis presenting as a painful neck mass in a child.

An uncommon case of a pediatric traumatic internal jugular vein thrombosis is presented. A 7-year-old boy developed severe neck pain after falling from a bunk bed. Initially, the child was diagnosed and treated for a lymphadenitis with a possible abscess formation. Contrast-enhanced computed tomography and Doppler ultrasound imaging of the neck revealed the presence of an occlusive thrombosis of the left internal jugular vein. The patient was treated with intravenous antibiotics and followed closely over the next year. He had full resolution of his symptoms without the development of complications associated with this injury process. Internal jugular vein thrombosis is an uncommon and potentially life-threatening disorder caused by various conditions. This case illustrates the need for a systematic approach when evaluating neck masses, and internal jugular venous thrombosis should be included in the differential of anterior neck swelling.

Emergency department pediatric all-terrain vehicle injuries in West Central Illinois.

OBJECTIVES: This study was prepared to evaluate pediatric all-terrain vehicle-related injuries treated in a tertiary care emergency department in West Central Illinois. METHODS: A retrospective descriptive study was performed of local emergency department cases entered into the US Consumer Product Safety Commission database. All visits involving an all-terrain vehicle-related injury in children younger than 18 years from January 1994 to December 2001 were explicitly reviewed and compared with aggregate national Consumer Product Safety Commission pediatric all-terrain vehicle data. RESULTS: One hundred eighty-seven children (age range, 2-17 years) from 14 West Central Illinois counties were treated in the emergency department during the study period. Injury patterns followed a national trend of an increasing annual incidence after 1998 (P = 0.05). The majority of patients were boys (78%) and were 12 years or younger (71%). Contusions (31.8%), fractures (25%), and lacerations (18.8%) accounted for the majority of injuries. Although observed injuries correlated well with national injury estimates for injury position, age, and sex, more head and chest injuries were noted locally. Derived injury severity scores had a mean of 3.1 (range, 1-50), and no difference was noted in the injury severity score for helmet use, sex, or age younger than 12 years. CONCLUSIONS: Overall, the incidence of all-terrain vehicle-related injuries in West Central Illinois in the emergency department is increasing, and local injury patterns correlate well with those reported on a national level.