Utility of electroencephalogram in the pediatric emergency department.

INTRODUCTION: Electroencephalograms (EEG) can be helpful in evaluating patients presenting to the emergency department (ED). METHODS: We reviewed the charts of patients who had an EEG done in the ED at Dayton Children's Hospital in Dayton, Ohio from 2010 to 2018. We divided the indication for EEG into 6 categories, 1) suspected new onset seizures, 2) recurrent seizures, 3) altered mental status, 4) death, 5) non-convulsive status epilepticus, and 6) psychogenic seizures. We collected data on age, gender, suspected diagnosis, EEG result, outcome of the visit in terms of discharge versus inpatient admission, follow up of the patient with respect to a) diagnosis, b) medication, c) recurrent visit to the ED, and d) clinical outcome over a two-year follow up. We also collected data on the results of the subsequent video EEG in patients who had an EEG in the ED and determined whether the video EEG had the same results and/or added any additional information. RESULTS: We studied 162 patients (mean ± SD age 7.8 ± 5.8 years, 42.6% females) with routine EEG in the ED from 2010 to 2018. In 142 patients (87.7%), the EEG was helpful in confirming or ruling out the suspected diagnosis. For the indications of new onset seizures (n = 90), recurrent seizures (n = 48), acute mental status change (n = 22), and psychogenic seizures (n = 5), the EEG was useful in 91.1%, 81.3%, 81.8%, and 100% respectively. Of the 162 patients, 58 were discharged and 104 were admitted. For the 142 patients in whom the routine EEG was diagnostically useful, 59.9% were admitted, compared to 95.0% of the 20 patients in whom the EEG did not help in clarifying the diagnosis (p = 0.002). In 31 of the admitted patients, a video EEG was done. In the 31 patients who obtained video EEG, it did not add any additional information in 23 patients while in 8 patients (25.8%) the video EEG provided additional information that was useful for diagnosis and management. CONCLUSIONS: EEG done in the ED is a useful diagnostic tool that may prevent admission to the hospital. Video EEGs should be considered in patients where the diagnosis is uncertain despite obtaining a routine EEG in the ED.

Adverse Childhood Experiences and Healthcare Utilization of Children in Pediatric Emergency Departments.

OBJECTIVE: To determine the prevalence of adverse childhood experiences (ACEs) and healthcare utilization patterns of children seen in pediatric emergency departments (PEDs). STUDY DESIGN: In this cross-sectional study, caregivers of patients who presented to 2 urban PEDs completed a survey regarding their children's ACEs, health care utilization patterns, and acceptance of PED-based ACEs screening and resources. Inclusion criteria were English-speaking caregivers of patients 0-17 years of age not requiring acute stabilization. Prevalence estimates were compared with national and state data from the National Survey of Children's Health by calculating risk differences and 95% CIs. The association of cumulative ACEs with caregiver-reported health care utilization patterns was evaluated using ORs. RESULTS: Among 1000 participants, 28.1% (95% CI 25.3-30.9) had 1 ACE; 17.8% (95% CI15.4-20.2) had ≥2 ACEs. Notably, children with higher cumulative ACEs were seen in the PED more frequently (0, 1, ≥2 visits) (OR 1.18, 95% CI 1.06-1.30, P = .002) and more likely to seek care in PEDs for sick visits (OR 1.16, 95% CI 1.04-1.30, P = .01). About 9% of children exposed to ACEs did not have a primary care provider. Over 85% of caregivers reported never discussing ACEs with their primary care provider. Most caregivers felt comfortable addressing ACEs in PEDs (84.4%) and would use referral resources (90.4%). CONCLUSIONS: Given higher PED utilization in children with more ACEs and caregiver acceptance of PED-based screening and intervention, PEDs may represent a strategic and opportune setting to both assess and respond to ACEs among vulnerable populations.

The impact of a child abuse guideline on differences between pediatric and community emergency departments in the evaluation of injuries.

BACKGROUND: Although child physical abuse is missed more frequently in community (CEDs) vs. pediatric emergency departments (PEDs), little information exists describing how evaluations of high-risk injuries differ between these settings. OBJECTIVES: To determine differences in evaluations of infants for abuse between a PED and CEDs and whether a child abuse guideline reduced these differences. PARTICIPANTS AND SETTING: Infants presenting to one PED (n = 162) and three CEDs (n = 159) with 3 injury categories: 1) Injuries for which the American Academy of Pediatrics recommends skeletal survey (SS) testing (infants <5-months with an oral injury or bruising, <9-months with a non-skull fracture, and < 12-months with an intracranial hemorrhage); 2) an oral injury or high-risk bruising in older infants; and 3) multiple types of high-risk injuries. METHODS: We assessed differences in SS testing and child protective services (CPS) reporting between the PED and CEDs before and after implementation of a child abuse guideline. RESULTS: The median (IQR) age was 4 months (2-7). Before guideline implementation, infants with injuries in categories 1 and 2 had an increased odds of SS testing in the PED vs. the CEDs (Category 1: aOR 2.83, 95% CI: 1.01-8.10; Category 2: aOR 10.1, CI: 1.2-88.0) and CPS reporting (Category 1: aOR 7.96, CI: 2.3-26.7; Category 2: aOR 12.0, CI: 1.4-103.5). After guideline implementation, there were no statistically significant differences in testing and reporting for any injury category. CONCLUSIONS: Implementation of a child abuse guideline minimized differences between a PED and CEDs in the evaluation of infants with injuries concerning for abuse.

Road accidents in children involving light electric vehicles cause more severe injuries than other similar vehicles.

Road accidents in Israel were responsible for 23% of injuries in pediatric population between 2013 and 2017. In recent years, the massive entrance of e-bike and other light electric vehicles (called collectively LEV) into the roads is significantly changing the epidemiology of road accidents among children. The study aims to describe the causes, injury types, and other epidemiological characteristics of children injured in road accident and compare injuries of LEV to regular bicycles and other light non-electric vehicles (called collectively LNEV). This retrospective study included all referrals to pediatric emergency department due to road accidents, from April 2015 through March 2017. The details of the accidents and injuries were retrieved, and the subjects' characteristics were compared based on vehicle type. A total of 1531 children met the inclusion criteria. The study found that LEV road accidents among children cause more severe injuries than other LNEV in terms of injury severity score (ISS) (mean ISS 5.8 ± 4.9 vs. 4.7 ± 3.6, P = 0.001), head and neck injuries (18.7% vs. 12.9%, respectively, P < 0.05), lower extremities (36.5% vs. 23.9%, P = 0.001), and multisystem injuries (58.6% vs. 31.8%, P < 0.001). The findings of the current study suggest that the use of LEVs is changing the epidemiology of road accidents, which requires adjustments in accident and injury prevention strategies.Conclusion: The study results should encourage authorities to provide appropriate community-based programs to promote helmet use, introduce mandatory training and licensing program for LEV riders, and enhance enforcement. What is Known: • Road accidents are the leading cause of death among children and young adults (5 to 29 years). • In recent years, there is a massive entrance of e-bikes and other light electric vehicles on the roads. What is New: • LEV (light electric vehicle) accidents among children impose more severe injuries than other LNEVs (light non-electric vehicles) in terms of ISS, hospitalizations, and multisystem injuries. • The use of LEV is changing the epidemiology of road accidents. This change requires enhancing accident and injury prevention strategies.

Parent and Nurse Satisfaction Using Pacidose® Oral Medication Delivery Device in the Pediatric Emergency Department: A Pilot Study.

PURPOSE: Administering oral medication to infants is challenging for caregivers, often resulting in incomplete delivery of the intended dose. Pacidose® is an oral medication delivery device that consists of a syringe attached to a tunneled pacifier. This study aimed to determine caregiver and nurse satisfaction and success rate of the Pacidose in the administration of acetaminophen to infants in the pediatric emergency department (ED). DESIGN AND METHODS: This was a prospective trial involving a convenience sample of patients who presented to a pediatric ED between November 2015 and August 2016. Patients younger than 24 months with a physician order for acetaminophen were eligible. Each child received a single dose of acetaminophen delivered by the Pacidose. Nurses, parents, and observing investigators were surveyed with a standardized questionnaire regarding the effectiveness, satisfaction and success rate of Pacidose. RESULTS: 61 patients were enrolled. The median age was 10 months and Pacidose was successful in 77% of patients. Those who required an alternative delivery route were older and no longer used pacifiers. Nurses reported that Pacidose helped administer the medication more easily in 66% of infants and 95% of parents preferred the Pacidose over standard delivery devices. CONCLUSIONS: Pacidose was well tolerated by infants, and both parents and nurses were highly satisfied with this method of administering acetaminophen. PRACTICE IMPLICATIONS: Pacidose is an easy to implement device that can help nurses with oral medication administration. It may have the greatest impact in younger children with recent pacifier use.

Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department.

BACKGROUND: The co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. OBJECTIVE: Our objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED). METHODS: This was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21 years of age. The attending physician administered either ketamine 1 mg/kg i.v. or ketamine 0.5 mg/kg and propofol 0.5 mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5 mg/kg/dose) or ketamine/propofol (0.25 mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores. RESULTS: Ninety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores by providers, including nurses, were higher for KM, although parents were equally satisfied with both sedation regimens. CONCLUSIONS: We found no significant differences in adverse events between the KM and CoKP groups. While CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

Test characteristics of quick brain MRI for shunt evaluation in children: an alternative modality to avoid radiation.

OBJECT: Quick brain magnetic resonance imaging (QB-MRI) is a rapid, radiation-free technique to detect life-threatening CSF shunt malfunction. QB-MRI has not been widely studied or adopted. The primary objective of this study was to evaluate the test characteristics of QB-MRI for detecting shunt malfunction. Test characteristics of brain computed tomography (CT) and QB-MRI were then compared. Secondary objectives included comparison of time to study completion and use of sedatives for both modalities, as well as comparison of time to study completion for QB-MRI before and after implementation of a Pediatric Emergency Department (PED) shunt clinical pathway. METHODS: A retrospective chart review was performed at 2 tertiary care hospital PEDs. The authors reviewed the charts of children who underwent QB-MRI or CT for suspected shunt malfunction between July 2008 and June 2012. They also reviewed the patients' neuroradiology reports and classified ventricular size as positive (enlarged) or negative (normal, smaller, or unchanged). Shunt malfunction was defined by surgical revision within 30 days. RESULTS: Nine hundred ninety-seven PED visits (involving 724 QB-MRIs and 273 CTs) were included. Surgical revision was performed in 235 cases (23.6%). For QB-MRI, sensitivity was 58.5% (95% CI 51.1%-65.6%) and specificity was 93.3% (90.8%-95.3%). For CT, sensitivity was 53.2% (95% CI 38.1%-67.9%) and specificity was 95.6% (92%-97.9%). The mean time to completion of QB-MRI was 115 minutes versus 83 minutes for CT (difference 32 minutes, 95% CI, 22-42 minutes, p < 0.001). The mean time from presentation to completion of QB-MRI prior to application of the CSF shunt pathway was 132 minutes versus 112 minutes after application of the CSF shunt pathway (difference 20 minutes, 95% CI 5-35 minutes, p = 0.01). Anxiolytic medications were used in 3.7% of CT studies and 4.4% of QB-MRI studies (p = 0.74). CONCLUSIONS: QB-MRI and CT have similar test characteristics for detecting CSF shunt malfunction in children and similar requirements for sedation. The longer interval from order placement to imaging completion for QB-MRI is arguably justified by reduction of radiation exposure in this population subject to frequent brain imaging.