Emergency Department Arrival Modes: Time for Mandatory Pediatric Readiness.

INTRODUCTION: Because small children can be transported by private vehicles, many children seek emergency care outside of Emergency Medical Services (EMS). Such transports may access the closest emergency departments (EDs) without knowledge of their pediatric competence. This study quantifies this practice and the concept of mandatory pediatric readiness. METHODS: The electronic health records of 3 general EDs and 2 pediatric EDs were queried for all pediatric and young adult visits for the year 2022. Data collected included patient age, ED type, arrival mode (EMS/police or private mode), and disposition (admission/transfer or discharge). Study patients were categorized as "small children" if aged younger than 10 years, "large children" if 10 to 18 years, and "young adult" if 19 to 40 years. Associations between mode of arrival, ED type, and disposition were analyzed through χ 2 and analysis of variance. RESULTS: The study population included 37,866 small children, 19,108 large children, and 68,293 young adults. When compared with EMS/police transports, a private arrival mode was selected by 96.1% of small children, 90.0% of large children, and 85.4% of young adults ( P < 0.0001). For the admission/transfer patients, private transportation was selected by 87.4% of small children, 73.8% of large children, and 78.8% of young adults ( P < 0.0001). For admitted/transferred children, the private mode was used by 80.4% of those in the general ED and 81.9% in the pediatric ED ( P > 0.41). CONCLUSIONS: Pediatric patients seeking ED care overwhelmingly arrive through a private mode regardless of the severity of their problem or type of ED in which treated. Emergency Medical Services programs and state hospital regulatory agencies need to recognize this practice and assure the pediatric competence of every ED within their system.

Evidence-based management of pulmonary embolism in the emergency department.

Patients with pulmonary emboli present both diagnostic and therapeutic challenges to the emergency clinician, because initial symptoms can be variable and overlap with other medical conditions. This issue reviews treatment options for patients with pulmonary emboli based on risk stratification scores of low, intermediate-low, intermediate-high, and high risk classifications. The evidence on laboratory testing and imaging is presented, as well as treatment strategies that include anticoagulation, thrombolytics, and mechanical or surgical thrombectomy. Management decisions regarding pregnancy and COVID-19 are discussed, as well as considerations for outpatient treatment of low-risk patients.

Proximal tibiofibular joint dislocation in young children: Is this the nursemaid's elbow of the lower extremity?

Anterolateral dislocation of the Proximal Tibiofibular Joint (PTFJ) is a rare injury of the knee commonly resulting from violent athletic injuries in adults. Reported here are examples of this injury in a 19 month old and a 4 year old following trivial mechanisms of injury. These cases raise the question of whether this injury may be an unrecognized cause of refusal to bear weight in children in this age group.

Respiratory support for adult patients with COVID-19.

The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS).

Emergency Department Care of the Post-Metabolic and Bariatric Surgery Patient.

Metabolic and bariatric surgical procedures have increased in the pediatric-age population over the past decade. Three operations, laparoscopic adjustable gastric banding, vertical sleeve gastrectomy, and Roux-en Y gastric bypass, are the most commonly performed procedures for weight reduction. This article will examine the specifics of each procedure along with the complications associated with any metabolic or bariatric surgery. Complications unique to each operation will be reviewed as well as recommendations for the management of these patients.

Sources of Variability in Pediatric Head Computed Tomography Use Among Emergency Departments in New Jersey.

OBJECTIVE: Published guidelines have been developed to limit ionizing radiation exposure in children related to diagnostic computed tomography (CT). This study examines the sources of variability in head CT use in children in emergency departments (EDs) in New Jersey despite the presence of such consensus recommendations. METHODS: The New Jersey Hospital Association (NJHA) Clinical Repository was queried for study data on all patients younger than 18 years discharged from the ED over a 1-year period. Patient information collected included: treating hospital, patient age, discharge diagnosis, use of head CT, children's hospital (CH) certification, presence of licensed in-patient pediatric beds, association with a hospital system and hospital annual pediatric ED volume. A potential diagnosis requiring a head CT (PDRCT) was defined as one of the following discharge diagnoses: Head Injury, Seizure, Syncope or Headache. Analysis of CT use per 10,000 ED visits was performed through ANOVA, analysis of means for variances, and χ. RESULTS: A total of 735,866 ED visits were examined with 16,942 (2.3%) undergoing head CTs. Mean Pediatric Head CT use per 10,000 ED visits for the state was 275 (±16; range, 27-640). During the study period 47,169 (6.4%) ED visits met the PDRCT criteria, 11,495 (27%) of which underwent head CTs. Mean Pediatric Head CT use in this group per 10,000 PDRCT visits was 2948 (±152; range, 728-5806). Characteristics associated with lowest use of head CTs in the PDRCT group included: ED census greater than 10,000 visits per year, CH designation, and younger patient. The presence of in-patient pediatric beds and association with a hospital system with or without an in system CH were not associated with lower head CT use. CONCLUSIONS: Despite existing recommendation regarding head CTs in children, there exists a large degree of variability in use of this diagnostic study in EDs in New Jersey.

Alternative to the finger in the dike: use of the vascular closure button to control postdialysis bleeding in a haemodialysis access conduit.

OBJECTIVE: The purpose of this case series is to describe the application of a vascular closure button (VCB) for the repair of haemodialysis access bleeding. The VCB's main function is not to assist in bleeding control, but instead to provide easy access for removal of tightly placed sutures in the repair. METHODS: A retrospective review of patients undergoing ED repair of persistent bleeding from puncture sites in haemodialysis access conduits (HACs) using a VCB was conducted. Study patients were collected from ED visits to Our Lady of Lourdes Medical Center in Camden, New Jersey, USA, between May 2013 and August 2017. Patients were followed until the time of definitive repair of the underlying pathology or until the end of the study period. RESULTS: Seventeen VCBs were used to control persistent bleeding from HACs in the ED. Sixteen bleeds were the result of recent haemodialysis punctures, while one was from a bleeding site ulcer. All repairs were successful at controlling the bleeding with preserved HAC function in the ED and no delayed thrombosis. Follow-up time ranged from 1 day to 778 days. CONCLUSION: Vascular control buttons provide an effective means to control HAC postdialysis bleeding and allow for ease of suture removal without disruption of a repair with no long-term complications.

Lack of fetal effect from adenosine administration in a pregnant patient.

Supraventricular Tachycardias are the most common cardiac rhythm disturbances in pregnant patients. Adenosine is the recommended medication to treat these arrhythmias in part because the medication is projected to be metabolized prior to crossing the placenta and producing any fetal effects. Reported here is a case of a pregnant patient treated with adenosine in which the fetal heart activity was monitored through point of care ultrasonography with documentation of no fetal impact from this medication. This is the first documentation of a lack of fetal effect from adenosine.

Physician Assistant Management of Pediatric Patients in a General Community Emergency Department: A Real-World Analysis.

PURPOSE: Multiple studies have documented the nonclinical characteristics of physician assistant (PA) practices in the emergency department (ED). This study examines the clinical care PAs provide to younger pediatric patients in a general community ED. METHODS: The electronic medical record database of an urban community general ED was queried to identify pediatric patients aged 6 years or younger. This age group was selected because it was considered to be representative of physiologic and pathologic conditions unique to children. The 72-hour recidivism rates were used as an objective outcome measure to compare the care provided by PAs with the care of attending emergency physicians (EPs). Three different treatment groups were defined for the analysis: EPs alone, PAs alone, and PAs with consults from EPs (PA & EP). RESULTS: A total of 10,369 children aged 6 years or younger were seen during a 24-month study period. The mean (SD) age of the patients was 2.2 (0.2) years, with 2909 (28%) aged 1 year or younger. A total of 807 (7.8%) patients returned within 72 hours of their initial ED visit with 57 (0.55%) subsequently admitted. Recidivism rates for the 3 clinical groups were as follows: PA (6.8%), EP (8.0%), and PA & EP (9.3%) (P < 0.03). Patients admitted to the hospital on their return visits for the 3 clinical groups were as follows: PA (0.4%), EP (0.6%), and PA & EP (0.7%) (P = 0.2). CONCLUSIONS: Based on the outcome measure of 72-hour recidivism, PA management of pediatric patients 6 years or younger is similar to that of attending EPs.

Outcomes of emergency department placement of transvenous pacemakers.

PURPOSE: Placement of TVPs is a core EM procedure. Despite this, there is no specific outcome data on this procedure in the ED setting. This study examines the success of Emergency Physician (EP) attempted TVPs as well as their hospital courses and survivals. METHODS: The charts of patients undergoing TVP placement in the ED of an urban community hospital were prospectively collected by a department billing abstractor and then underwent a structured review. All patients had a TVP placed by a board eligible or board certified EP or by a PGY2 EM resident under the direct supervision of an attending EP. All TVPs were placed utilizing a 5 Fr balloon tipped bi-polar pacer without fluoroscopic visualization. RESULTS: Over a 36 month period, 43 patients met the study criteria. The mean age was 76.6 (+/- 1.49) years with 27 females (62.7%). Successful pacemaker capture was achieved in 41(95.4%) of TVP attempts. All of the patients were transferred from the ED with vital signs, 41 (95.4%) to a critical care unit and 2 (4.6%) to the electrophysiology laboratory. A total of 26 (60%) patients received permanent pacemakers. Four patients (9.3%) expired during their hospital stay. The remaining patients were discharged to the following: 31 (72%) to home, 5 (11.6%) to a subacute rehabilitation facility, 3 (7%) to a nursing home. CONCLUSION: EP placed TVPs have a high rate of successful capture and patients undergoing this procedure have a good prognosis.

Interrogation of Patient Smartphone Activity Tracker to Assist Arrhythmia Management.

A 42-year-old man presented to the emergency department (ED) with newly diagnosed atrial fibrillation of unknown duration. Interrogation of the patient's wrist-worn activity tracker and smartphone application identified the onset of the arrhythmia as within the previous 3 hours, permitting electrocardioversion and discharge of the patient from the ED.

Enrollment with a primary care provider does not preclude ED visits for patients with woman's health-related problems.

OBJECTIVE: The Affordable Care Act places primary care at the cornerstone of health maintenance. It is believed that increasing access to primary health care providers will limit emergency department (ED) use. This study examines woman's health-related ED visits by patients enrolled in an obstetric/gynecologic (OB/GYN) clinic. METHODS: A database was created combining patient information from a hospital-affiliated OB/GYN clinic and the electronic medical records from the ED of the affiliated hospital. This database was used to evaluate woman's health-related ED use by patients registered in this OB/GYN clinic compared with patients not affiliated with the clinic. RESULTS: Over an 23-month period, there were 41,791 ED visits made by 21,223 individual women >12 years of age. A total of 7251 (17.4%) of the ED visits were for OB/GYN-related conditions. There were 6430 individual women registered at the OB/GYN clinic, 1411 (22.0%) of whom made 2415 woman's health-related visits to the ED. Of the OB/GYN-related ED visits by clinic patients, 1794 (74.3%) were made during weekdays and 1023 (42.3%) were made during hours when the clinic was open for care. Study patients had diagnostic studies beyond a urine analysis or pregnancy test performed during 61% of ED visits, with an admission rate of 2%. CONCLUSION: Enrollment with a primary care provider alone does not eliminate the need for ED use in women with health-related conditions.