An epidural brain abscess and thrombus in the superior sagittal sinus in a 12 year-old with sinusitis.

BACKGROUND: Upper respiratory infections can be complicated by acute bacterial sinusitis in pediatric patients, and usually resolve with antibiotic therapy (DeMuri and Wald, 2011). However, intracranial complications such as: epidural abscess, meningitis and more rarely cerebral sinus venous thrombosis (CSVT) can occur (Germiller et al., 2006). We report an unusual case of sinusitis complicated by an epidural abscess and later a CSVT in a young previously healthy patient. CASE DESCRIPTION: A 12-year-old female presented to the emergency department with a 9-day history of headaches and a 3-day history of fevers, rigors, nasal congestion and nonproductive cough. She later tested positive for Covid-19. CT and MRI showed extensive paranasal sinus disease and a right frontal epidural collection. MRV showed no sinovenous thrombosis. Washout and burr hole drainage alongside endoscopic sinus surgery was completed and post-op imaging showed evacuation of the epidural abscess with a small residual collection. Six days after the procedure, she experienced worsening headaches and MRV showed a nonocclusive thrombus in the superior sagittal sinus, which was treated with anticoagulation therapy. Upon follow-up, the patient showed improvement of the sinusitis, abscess and thrombus. CONCLUSION: This specific case encourages clinicians to be aware of complications, though rare, and to diagnose and treat sinusitis cases quickly. It is also important to be aware of any risk factors for thrombus formation, including an inflammatory and hypercoagulable state. In the patient's case, it was perceived that the CSVT was provoked due to the patient's Covid-19 infection, abscess, and sinus disease.

Impact of an accessory cavitated uterine mass on fertility: case presentation and review of the literature.

Objective: We report a case of an accessory cavitated uterine mass (ACUM) in a patient with infertility and chronic pelvic pain. In addition, we summarize the literature to better characterize ACUM diagnosis and management. Design: A comprehensive literature search using the PubMed database was performed through April 2023. Historical ACUM diagnostic criteria were applied as inclusion criteria. Descriptive statistics and statistical evaluation were reported. Results: A 31-year-old nulligravid woman presented with chronic pelvic pain, dysmenorrhea, primary infertility, and history of endometriosis. Three-dimensional ultrasonography identified an ACUM and laparoscopic excision provided complete resolution of symptoms. Subsequently, she conceived without assistance twice with uncomplicated vaginal deliveries. A total of 154 articles were identified, 34 papers met inclusion criteria and were individually reviewed, consisting of 70 reported cases. The most common presenting complaints were dysmenorrhea (81.4%), chronic pelvic/abdominal pain (54.1%), and refractory pain (34.3%). Diagnostic imaging included magnetic resonance imaging (62.9%) and transvaginal ultrasound (55.7%). Management included resection via laparoscopy (75.7%) or laparotomy (18.6%), or hysterectomy (5.7%). Of cases with reported outcomes, 90.7% had complete relief of symptoms after surgery. Conclusion: ACUM often presents with dysmenorrhea, chronic pelvic pain, or abdominal pain and is identifiable on magnetic resonance imaging as a hyperenhancing mass. Three-dimensional transvaginal ultrasound can also accurately identify ACUM. A total of 90.7% of patients had complete relief of symptoms after intervention. It is important to identify ACUM early to relieve pain and reduce unnecessary interventions. Like our patient, other reports have demonstrated concomitant infertility and endometriosis. However, further investigation is needed to explore the association between infertility and ACUM.

Classic Presentation of Catecholaminergic Polymorphic Ventricular Tachycardia: A Case Report.

Syncope is a common reason for children and adolescents to seek care in the emergency department. Often syncopal episodes are benign and most commonly due to a vasovagal event. Occasionally an underlying cardiac arrhythmia is responsible. We present a case report of a 17-year-old male who collapsed during an emotional event and went into cardiac arrest. Emergency department evaluation including imaging, laboratory studies, and EKG indicated the cause of cardiac arrest was likely a primary cardiac arrhythmia. An initial clinical diagnosis of catecholaminergic polymorphic ventricular tachycardia (CPVT) was made based on symptom onset during an emotional event, family history of sudden cardiac death, patient age, past episodes of chest pain and palpitations, absence of structural heart defect, and lack of EKG changes after the return of spontaneous circulation (ROSC). The diagnosis was later confirmed with genetic testing. The patient was started on a beta-blocker and a subcutaneous implantable cardioverter-defibrillator (S-ICD, Boston Scientific, Marlborough, MA) was placed. Given the rarity of this condition, this diagnosis is often missed, which contributes to increased mortality rates. In children and young adults presenting with syncope without clear etiology in the presence of high-risk features, further evaluation should be performed including referral to cardiology to rule out chronic cardiac arrhythmias.

A chart review tool to systematically assess the safety of prehospital care for children with out-of-hospital cardiac arrest.

Objective: Create an easy-to-use pediatric out-of-hospital cardiac arrest (OHCA)-specific chart review tool to reliably detect severe adverse safety events (ASEs) in the prehospital care of children with OHCA. Methods: We revised our previously validated pediatric prehospital adverse event detection system (PEDS) tool, used to evaluate ASEs in the prehospital care of children during emergent calls, to create an OHCA-specific chart review tool. We developed decision support for reviewers, reviewer training, and a dedicated section for chart data abstraction. We randomly selected 28 charts for independent review by 2 expert reviewers who determined the presence or absence of a severe ASE for each care episode and identified the domain of care and preventability for each ASE. We calculated inter-rater agreement in the assessment of the presence or absence of a severe ASE using Gwet's first-order agreement coefficient (AC1). Results: The PEDS-OHCA chart review tool has 6 sections, with a minimum of 70 and maximum of 667 total possible fields. We found inter-rater agreement of 0.83 (95% confidence interval, 0.63-0.99) between our 2 reviewers for the overall detection of a severe ASE and an average time to complete of 8 minutes (range, 2-25 minutes). Inter-rater agreement in the detection of a severe ASE in each individual domain ranged from 0.36 to 0.96. Conclusions: The PEDS-OHCA is the first chart review tool to systematically evaluate the safety and quality of EMS care for children with OHCA. This tool may help improve understanding of the quality of EMS care for children with OHCA, which is essential to improving outcomes.

Thoracic spinal arteriovenous malformation in a 16-year-old presenting with headache.

Spinal arteriovenous malformations (sAVM) are abnormally developed spinal blood vessels with an increased risk of hemorrhage. Current literature regarding sAVMs is sparse and describes classic presentations in very young children or adults. We report a unique case of a sAVM in an adolescent patient. A 16-year-old female patient presented to the emergency department with a 3-day history of headaches. Initial CT showed no abnormalities. Worsening headaches led the patient to a neurology clinic and a fundoscopy revealed papilledema. The patient was transferred to a pediatric emergency department where repeat head CT showed a possible subarachnoid hemorrhage, and a cranial MRI/MRV showed what appeared to be a non-occlusive sinus venous thrombosis. CT angiography of the head and neck showed no evidence of thrombosis, but it did reveal possible upper thoracic vascular abnormalities. Thoracic MRI revealed an intradural sAVM at T3-T5. The sAVM was successfully resected with thoracic laminectomy with reconstructive laminoplasty. The patient experienced complications with development of right lower extremity motor and sensory deficits intra-op, but is showing continued improvement. This unique case encourages emergency medicine clinicians to expand the differential diagnoses for pediatric patients presenting with a headache and intracranial hypertension without a clear intracranial cause.

The Effects of Leadership Curricula With and Without Implicit Bias Training on Graduate Medical Education: A Multicenter Randomized Trial.

PURPOSE: To determine whether a brief leadership curriculum including high-fidelity simulation can improve leadership skills among resident physicians. METHOD: This was a double-blind, randomized controlled trial among obstetrics-gynecology and emergency medicine (EM) residents across 5 academic medical centers from different geographic areas of the United States, 2015-2017. Participants were assigned to 1 of 3 study arms: the Leadership Education Advanced During Simulation (LEADS) curriculum, a shortened Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum, or as active controls (no leadership curriculum). Active controls were recruited from a separate site and not randomized to limit any unintentional introduction of materials from leadership curricula. The LEADS curriculum was developed in partnership with the Council on Resident Education in Obstetrics and Gynecology and Council of Residency Directors in Emergency Medicine as a novel way to provide a leadership toolkit. Both LEADS and the abbreviated TeamSTEPPS were designed as six 10-minute interactive web-based modules.The primary outcome of interest was the leadership performance score from the validated Clinical Teamwork Scale instrument measured during standardized high-fidelity simulation scenarios. Secondary outcomes were 9 key components of leadership from the detailed leadership evaluation measured on 5-point Likert scales. Both outcomes were rated by a blinded clinical video reviewer. RESULTS: One hundred ten obstetrics-gynecology and EM residents participated in this 2-year trial. Participants in both LEADS and TeamSTEPPS had statistically significant improvement in leadership scores from "average" to "good" ranges both immediately and at the 6-month follow-up, while controls remained unchanged in the "average" category throughout the study. There were no differences between LEADS and TeamSTEPPS curricula with respect to the primary outcome. CONCLUSIONS: Residents who participated in a brief structured leadership training intervention had improved leadership skills that were maintained at 6-month follow-up.

Ovarian Torsion and Its Remediation in a Three-Year-Old Girl.

Ovarian torsion is a rare, emergent occurrence seen in the premenarchal population. If detected promptly, ovarian torsion can be treated via detorsion. We present a case of a three-year-old girl whose ovary spontaneously torsed and was corrected via ovarian detorsion. The patient presented with sudden-onset abdominal pain and emesis; a transabdominal ultrasound with Doppler was performed, which led to the diagnosis of ovarian torsion. The patient was directly taken into surgery for correction, after which she quickly recovered and was subsequently discharged. The choice of ovarian detorsion to protect fertility in pediatric patients is supported by this case and by the related literature. The key to safeguarding fertility in these patients lies in rapid detection, which remains a challenge in the pediatric population. By raising widespread awareness of the use of Doppler ultrasound as well as symptom presentation, the protection of fertility in cases of pediatric ovarian torsion can be improved.

Characterizing prehospital response to neonatal resuscitation.

OBJECTIVE: To evaluate performance of initial steps of newborn resuscitation according to the American Heart Association and American Academy of Pediatrics' Neonatal Resuscitation Program (NRP) guidelines in the prehospital setting. STUDY DESIGN: Observational study of 265 paramedics and Emergency Medical Technicians (EMTs) from 45 EMS teams recruited from public fire and private transport agencies in a major metropolitan area. Participants completed a baseline questionnaire assessing demographics, experience, and comfort in caring for children. Simulations were conducted April 2015 to March 2016. Technical performance was evaluated by blinded video review. NRP actions were assessed using a structured performance tool. RESULTS: Two hundred sixty-five EMS providers responded to survey questions and participated in simulations. In total, 16% reported feeling very or extremely comfortable caring for children <30 days of age (vs. 71% for children aged 12-18 years). Among 45 EMS teams participating in simulations, 22% (n = 10) dried, 18% (n = 8) stimulated, and 2% (n = 1) warmed within 30 s from arrival and 11% (n = 5) provided BMV within 60 s from arrival, as recommended by NRP. All teams provided BMV. Eighty-eight percent bagged below NRP rate recommendations and 96% bagged with tidal volume exceeding guidelines. Looking over the entire 10-min simulation for ever performing measures, 73% started to dry the baby within a median of 51 (range 0-539) seconds from arrival, 38% started to stimulate the baby within a median of 34 s (range 0-181), and 44% started to warm the baby within a median 291 s (range 27-575 s). CONCLUSIONS: These data from field simulations suggest NRP steps recommended for the first minute after birth are seldom performed in a timely manner and suggests opportunities for improvement.

Retrospective chart review and survey to identify adverse safety events in the emergency medical services care of children with out-of-hospital cardiac arrest in the USA: a study protocol.

INTRODUCTION: Efforts to improve the quality of emergency medical services (EMS) care for adults with out-of-hospital cardiac arrest (OHCA) have led to improved survival over time. Similar improvements have not been observed for children with OHCA, who may be at increased risk for preventable adverse safety events during prehospital care. The purpose of this study is to identify patient and organisational factors that are associated with adverse safety events during the EMS care of paediatric OHCA. METHODS AND ANALYSIS: This is a large multisite EMS study in the USA consisting of chart reviews and agency surveys to measure, characterise and evaluate predictors of our primary outcome severe adverse safety events in paediatric OHCA. Using the previously validated Paediatric prehospital adverse Event Detection System tool, we will review EMS charts for 1500 children with OHCA from 2013 to 2019 to collect details of each case and identify severe adverse safety events (ASEs). Cases will be drawn from over 40 EMS agencies in at least five states in geographically diverse areas of the USA. EMS agencies providing charts will also be invited to complete an agency survey to capture organisational characteristics. We will describe the frequency and proportion of severe ASEs in paediatric OHCA across geographic regions and clinical domains, and identify patient and EMS organisational characteristics associated with severe ASEs using logistic regression. ETHICS AND DISSEMINATION: This study has been approved by the Oregon Health & Science University Institutional Review Board (IRB Approval# 00018748). Study results will be disseminated through scientific publications and presentations, and to EMS leaders and staff through local EMS medical directors, quality and training officers and community engagement activities.

Association between measured teamwork and medical errors: an observational study of prehospital care in the USA.

OBJECTIVES: The goal of this study was to examine the relationship between measured teamwork and adverse safety events in the prehospital emergency care of children using high-fidelity simulation. We posit that non-technical skills such as leadership, teamwork, situation awareness and decision-making are associated with the clinical success of teams. DESIGN: Observational study. SETTING: Emergency medical services (EMS) responders were recruited from public fire and private transport agencies in Oregon State to participate in four simulations of paediatric emergencies using high-fidelity patient simulators, scene design, and professional actors playing parents and bystanders. PARTICIPANTS: Forty-four fire/transport teams consisting of 259 EMS professionals consented to participate and completed simulations. PRIMARY AND SECONDARY OUTCOME MEASURES: Teams were assessed using the Clinical Teamwork Scale (CTS), a validated instrument that measures overall teamwork and 15 specific elements in five overarching domains: communication, decision-making, role responsibility (leadership and followership), situational awareness/resource management and patient-friendliness. We used generalised estimating equations to estimate the odds of error with increasing overall CTS teamwork score while adjusting for clinical scenario and potential clustering by team. RESULTS: Across 176 simulations, the mean overall score on the CTS was 6.04 (SD 2.10; range 1=poor to 10=perfect) and was normally distributed. The distribution of scores was similar across the four clinical scenarios. At least one error was observed in 82% of the simulations. In simulations with at least one observed error, the mean CTS score was 5.76 (SD 2.04) compared with 7.16 (SD 1.95) in scenarios with no observed error. Logistic regression analysis accounting for clustering at the team level revealed that the odds of an error decreased 28% with each unit increase in CTS (OR 0.72, 95% CI 0.59 to 0.88). CONCLUSIONS: This study found that overall teamwork among care delivery teams was strongly associated with the risk of serious adverse events in simulated scenarios of caring for critically ill and injured children.

Implicit gender bias among US resident physicians.

BACKGROUND: The purpose of this study was to characterize implicit gender bias among residents in US Emergency Medicine and OB/GYN residencies. METHODS: We conducted a survey of all allopathic Emergency Medicine and OB/GYN residency programs including questions about leadership as well as an implicit association test (IAT) for unconscious gender bias. We used descriptive statistics to analyze the Likert-type survey responses and used standard IAT analysis methods. We conducted univariate and multivariate analyses to identify factors that were associated with implicit bias. We conducted a subgroup analysis of study sites involved in a multi-site intervention study to determine if responses were different in this group. RESULTS: Overall, 74% of the programs had at least one respondent. Out of 14,234 eligible, 1634 respondents completed the survey (11.5%). Of the five sites enrolled in the intervention study, 244 of 359 eligible residents completed the survey (68%). Male residents had a mean IAT score of 0.31 (SD 0.23) and females 0.14 (SD 0.24), both favoring males in leadership roles and the difference was statistically significant (p < 0.01). IAT scores did not differ by postgraduate year (PGY). Multivariable analysis of IAT score and participant demographics confirmed a significant association between female gender and lower IAT score. Explicit bias favoring males in leadership roles was associated with increased implicit bias favoring males in leadership roles (r = 0.1 p < 0.001). CONCLUSIONS: We found that gender bias is present among US residents favoring men in leadership positions, this bias differs between male and female residents, and is associated with discipline. Implicit bias did not differ across training years, and is associated with explicit bias.