Improving Efficiency and Communication around Sedated Fracture Reductions in a Pediatric Emergency Department.

INTRODUCTION: Procedural sedation for fracture reduction in the pediatric emergency department (ED) is a time-consuming process requiring multidisciplinary coordination. We implemented a quality improvement initiative aimed at (1) decreasing mean ED length of stay (LOS) for children with sedated long bone fracture reductions by 15% over 12 months and (2) improving interdisciplinary communication around procedural sedation. METHODS: Pediatric emergency medicine fellows at a children's hospital designed and implemented an initiative targeting the efficiency of the sedation process. Interventions included a centralized sedation tracking board, a team member responsibility checklist, family handouts, early discharge initiatives, and postsedation review forms. We tracked progress via statistical process control charts and interdisciplinary communication by intermittent surveys. RESULTS: Pediatric emergency medicine fellows performed 2,246 sedations during the study period. Mean LOS decreased from 361 to 340 minutes (5.8%) after implementation and demonstrated sustainability over the postintervention period. One hundred eight providers completed the preimplementation communication survey, with 58 and 64 completing surveys at 4 and 9 months postimplementation, respectively. The proportion reporting somewhat or strong satisfaction with communication increased from 68% at baseline to 86% at 4 months (P = 0.02) and 92% at 9 months (P < 0.001 versus baseline). CONCLUSIONS: A quality improvement initiative created a sustainable process to reduce ED LOS for sedated reductions while improving satisfaction with interdisciplinary communication.

A Child With an Unusual Retained Oral Foreign Body.

BACKGROUND: Pediatric foreign-body ingestions are common. Oral foreign bodies are rare but can be life-threatening. Management of their extraction requires knowledge and careful consideration of removal techniques, pharmacology, and potential complications. CASE REPORT: A 5-year-old boy presented to the emergency department with a wooden block retained in his mouth after a fall. The block was lodged behind the patient's primary central incisors without causing apparent oral or dental trauma. Initial manipulation was unsuccessful given patient apprehension and muscle spasm. The patient was given i.v. diazepam for anxiolysis and muscle relaxation, and a tenaculum was used to extract the object. He was observed for a period of time and had no complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Retained oral foreign bodies in children require a careful approach and understanding of pharmacologic anxiolysis, as patients may not be candidates for moderate sedation. Emergency physicians must be aware of potential complications of oral foreign bodies, including palatal injury, temporomandibular joint dislocation, epiglottitis, and retained foreign bodies.

Carbon Monoxide Poisoning In Children: Diagnosis And Management In The Emergency Department.

Approximately 5000 children present to the emergency department annually with unintentional carbon monoxide poisoning. Children may be more vulnerable to carbon monoxide poisoning because of their increased metabolic demand and their inability to vocalize symptoms or recognize a dangerous exposure, and newborn infants are more vulnerable to carbon monoxide poisoning because of the persistence of fetal hemoglobin. Mild carbon monoxide poisoning may present as viral symptoms in the absence of fever. While headache, nausea, and vomiting are the most common presenting symptoms in children, the most common symptom in infants is consciousness disturbance. This review discusses the limitations of routine pulse oximetry and carboxyhemoglobin measurement in determining carbon monoxide exposure, and notes effects of co-ingestions and comorbidities. Although the mainstay of treatment is 100% oxygen, the current evidence and controversies in the use of hyperbaric oxygen therapy in pediatric patients is reviewed, along with its possible benefit in preventing delayed neurologic sequelae.