Advances in pediatric emergency from 2023.

Most children receive emergency care by general emergency physicians and not in designated children's hospitals. There are unique considerations in the care of children that differ from the care of adults. Many management principles can be extrapolated from adult studies, but the unique pathophysiology of pediatric disease requires specialized attention and management updates. This article highlights ten impactful articles from the year 2023 whose findings can improve the care of children in the Emergency Department (ED). These studies address pediatric resuscitation, traumatic arrest, septic shock, airway management, nailbed injuries, bronchiolitis, infant fever, cervical spine injuries, and cancer risk from radiation (Table 1). The findings in these articles have the potential to impact the evaluation and management of children (Table 2).

Pediatric emergency medicine literature 2020.

Most children are treated at general Emergency Departments (EDs) and not specialized pediatric EDs. Therefore, it is crucial for emergency medicine physicians to be aware of recent developments in pediatric emergency medicine. Often impactful articles on pediatric emergency medicine are not published in the journals regularly studied by general emergency medicine physicians. We selected ten studies that we found impactful, robust, and relevant for practicing general emergency physicians. This review includes studies of status epilepticus, cardiac arrest, asthma, infant fever, wound care, rapid sequence intubation, coronavirus, and trauma.

Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma?: The Rational Clinical Examination Systematic Review.

IMPORTANCE: Adults with apparently minor head trauma (Glasgow Coma Scale [GCS] scores ≥13 who appear well on examination) may have severe intracranial injuries requiring prompt intervention. Findings from clinical examination can aid in determining which adults with minor trauma have severe intracranial injuries visible on computed tomography (CT). OBJECTIVE: To assess systematically the accuracy of symptoms and signs in adults with minor head trauma in order to identify those with severe intracranial injuries. DATA SOURCES: We performed a systematic search of MEDLINE (1966-2015) and the Cochrane Library to identify studies assessing the diagnosis of intracranial injuries. STUDY SELECTION: Studies were included that measured the performance of findings for identifying intracranial injury with a reference standard of neuroimaging or follow-up evaluation. Fourteen studies (range, 431-7955 patients) met inclusion criteria with patients having GCS scores between 13 and 15 and 50% or more older than 18 years. DATA EXTRACTION AND SYNTHESIS: Three authors independently performed critical appraisal and data extraction. RESULTS: The prevalence of severe intracranial injury (requiring prompt intervention) among the 23,079 patients with minor head trauma was 7.1% (95% CI, 6.8%-7.4%) and the prevalence of injuries leading to death or requiring neurosurgical intervention was 0.9% (95% CI, 0.78%-1.0%). The presence of physical examination findings suggestive of skull fracture (likelihood ratio [LR], 16; 95% CI, 3.1-59; specificity, 99%), GCS score of 13 (LR, 4.9; 95% CI, 2.8-8.5; specificity, 97%), 2 or more vomiting episodes (LR, 3.6; 95% CI, 3.1-4.1; specificity, 92%), any decline in GCS score (LR range, 3.4-16; specificity range, 91%-99%;), and pedestrians struck by motor vehicles (LR range, 3.0-4.3; specificity range, 96%-97%) were associated with severe intracranial injury on CT. Among patients with apparent minor head trauma, the absence of any of the features of the Canadian CT Head Rule (≥65 years; ≥2 vomiting episodes, amnesia >30 minutes, pedestrian struck, ejected from vehicle, fall >1 m, suspected skull fracture, or GCS score <15 at 2 hours) had an LR of 0.04 (95% CI, 0-0.65), lowering the probability of severe injury to 0.31% (95% CI, 0%-4.7%). The absence of all the New Orleans Criteria findings (>60 years, intoxication, headache, vomiting, amnesia, seizure, or trauma above the clavicle) had an LR of 0.08 (95% CI, 0.01-0.84), lowering the probability of severe intracranial injury to 0.61% (95% CI, 0.08%-6.0%). CONCLUSIONS AND RELEVANCE: Combinations of history and physical examination features in clinical decision rules can identify patients with minor head trauma at low risk of severe intracranial injuries. Certain findings, including signs of skull fracture, GCS score of 13, 2 or more vomiting episodes, decrease in GCS score, and pedestrians struck by motor vehicles, may help identify patients at increased risk of severe intracranial injuries.

Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study.

STUDY OBJECTIVE: We evaluate the diagnostic accuracy of clinical decision rules and physician judgment for identifying clinically important traumatic brain injuries in children with minor head injuries presenting to the emergency department. METHODS: We prospectively enrolled children younger than 18 years and with minor head injury (Glasgow Coma Scale score 13 to 15), presenting within 24 hours of their injuries. We assessed the ability of 3 clinical decision rules (Canadian Assessment of Tomography for Childhood Head Injury [CATCH], Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE], and Pediatric Emergency Care Applied Research Network [PECARN]) and 2 measures of physician judgment (estimated of <1% risk of traumatic brain injury and actual computed tomography ordering practice) to predict clinically important traumatic brain injury, as defined by death from traumatic brain injury, need for neurosurgery, intubation greater than 24 hours for traumatic brain injury, or hospital admission greater than 2 nights for traumatic brain injury. RESULTS: Among the 1,009 children, 21 (2%; 95% confidence interval [CI] 1% to 3%) had clinically important traumatic brain injuries. Only physician practice and PECARN identified all clinically important traumatic brain injuries, with ranked sensitivities as follows: physician practice and PECARN each 100% (95% CI 84% to 100%), physician estimates 95% (95% CI 76% to 100%), CATCH 91% (95% CI 70% to 99%), and CHALICE 84% (95% CI 60% to 97%). Ranked specificities were as follows: CHALICE 85% (95% CI 82% to 87%), physician estimates 68% (95% CI 65% to 71%), PECARN 62% (95% CI 59% to 66%), physician practice 50% (95% CI 47% to 53%), and CATCH 44% (95% CI 41% to 47%). CONCLUSION: Of the 5 modalities studied, only physician practice and PECARN identified all clinically important traumatic brain injuries, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.

Traumatic intracranial injury in intoxicated patients with minor head trauma.

OBJECTIVES: Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. METHODS: This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. RESULTS: A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. CONCLUSIONS: In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury.

Validation of rules to predict emergent surgical intervention in pediatric trauma patients.

BACKGROUND: Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC). STUDY DESIGN: We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated. RESULTS: There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively. CONCLUSIONS: Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.

Physicians' assessment of pediatric returns to the Emergency Department.

BACKGROUND: Return visits to the Emergency Department (ED) requiring admission are frequently reviewed for the purpose of quality improvement. Treating physicians typically perform this review, but it is unclear if they accurately identify the reasons for the returns. OBJECTIVES: To assess the characteristics of pediatric return visits to the ED, and the ability of treating physicians to identify the root causes for these return visits. METHODS: This retrospective cohort study reviewed all returns within 96 h of an initial visit over a 2-year period at a tertiary care pediatric ED. Baseline characteristics were determined from review of patients' charts. The treating physicians, the primary author, and independent reviewers identified the root cause for the returns. RESULTS: There were 97,374 patients that presented to the ED during the study, and 1091 (1.1%) of these children returned to the ED and were admitted. Returns were most common among children aged<5 years, arriving between 3:00 p.m. and 11:00 p .m. via private transportation, with infectious diseases. The physician involved in the care of the patient attributed 3.1% of returns to potential deficiencies in medical management, whereas the independent reviewers attributed 13% to potential deficiencies. CONCLUSIONS: Both returns and the subset of returns due to potential deficiencies in management are more common than previously estimated, rendering review of returns a valuable quality improvement tool. However, EDs should not rely exclusively on the treating physicians to identify the reason for returns, as they seem to underestimate the frequency of returns due to potential deficiencies in medical management.

Emergent pediatric thoracotomy following traumatic arrest.

OBJECTIVES: Emergent thoracotomy is a potentially life-saving procedure following traumatic cardiac arrest. The procedure has been studied extensively in adults, but its role in pediatric traumatic cardiac arrest remains unclear. We aimed to determine the prevalence of survival following emergent resuscitative thoracotomy in children. METHODS: This was a retrospective cohort study that included consecutive patients<18 years old who underwent emergent thoracotomy following traumatic cardiac arrest over a 15-year period. Factors previously associated with survival following thoracotomy in adults were measured. RESULTS: During the study period, 29 patients underwent emergent thoracotomy. Of these, 3 (10%, 95% confidence interval [CI]: 2-27%) survived to hospital discharge. All survivors sustained penetrating trauma to the heart and had signs of life on arrival of emergency medical services. Of the 13 patients who sustained blunt trauma, 0 (0%, 95% CI: 0-25%) survived, despite 69% (9/13) demonstrating signs of life on arrival of emergency medical services and 38% (5/13) having temporary return of spontaneous circulation. CONCLUSIONS: Emergent thoracotomy is a potentially life-saving procedure for children following traumatic cardiac arrest. It appears most successful in children suffering penetrating trauma to the heart with signs of life on arrival of emergency medical services. Larger studies are needed to determine the factors associated with this survival benefit for emergent thoracotomy in children.

Cervical spine injuries in children, part I: mechanism of injury, clinical presentation, and imaging.

BACKGROUND: Cervical spine injuries are difficult to diagnose in children. They tend to occur in different locations than in adults, and they are more difficult to identify based on history or physical examination. As a result, children are often subjected to radiographic examinations to rule out cervical spine injury. OBJECTIVES: This two-part series will review the classic cervical spine injuries encountered in children based on age and presentation. Part I will discuss the mechanisms of injury, clinical presentations, and the use of different imaging modalities, including X-ray studies and computed tomography (CT). Part II discusses management of these injuries and special considerations, including the role of magnetic resonance imaging, as well as injuries unique to children. DISCUSSION: Although X-ray studies have relatively low risks associated with their use, they do not identify all injuries. In contrast, CT has higher sensitivity but has greater radiation, and its use is more appropriate in children over 8 years of age. CONCLUSION: With knowledge of cervical spine anatomy and the characteristic injuries seen at different stages of development, emergency physicians can make informed decisions about the appropriate modalities for diagnosis of pediatric cervical spine injuries.

Cervical spine injuries in children, part II: management and special considerations.

BACKGROUND: The diagnosis and management of cervical spine injury is more complex in children than in adults. OBJECTIVES: Part I of this series stressed the importance of tailoring the evaluation of cervical spine injuries based on age, mechanism of injury, and physical examination findings. Part II will discuss the role of magnetic resonance imaging (MRI) as well as the management of pediatric cervical spine injuries in the emergency department. DISCUSSION: Children have several common variations in their anatomy, such as pseudosubluxation of C2-C3, widening of the atlantodens interval, and ossification centers, that can appear concerning on imaging but are normal. Physicians should be alert for signs or symptoms of atlantorotary subluxation and spinal cord injury without radiologic abnormality when treating children with spinal cord injury, as these conditions have significant morbidity. MRI can identify injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal X-ray study or CT scan. CONCLUSION: With knowledge of these variations in pediatric anatomy, emergency physicians can appropriately identify injuries to the cervical spine and determine when further imaging is needed.