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).

Fat embolism after intraosseous catheters in pediatric forensic autopsies.

In our center, we performed the autopsy of a child who died from drowning and presented, at autopsy, a major pulmonary fat embolism (PFE). A cardiopulmonary resuscitation (CPR) was performed, including infusion by intraosseous catheter (IIC). No other traumatic lesions and diseases classically related to a risk of PFE were detected. According to some animal studies, we considered the IIC as the only possible cause for PFE. However, we could not find literature to confirm this hypothesis in humans, especially in a pediatric population. To verify the occurrence of PFE after IIC in a pediatric population, we retrospectively selected 20 cases of pediatric deaths autopsied in our center, in which a CPR was performed, without bone fractures or other possible causes of PFE: 13 cases with IIC (group A) and 7 cases without IIC (group B). Several exclusion criteria were considered. The histology slides of the pulmonary tissue were stained by Oil Red O. PFE was classified according to the Falzi scoring system. In group A, 8 cases showed PFE: 4 cases with a score 1 of Falzi and 4 cases with a score 2 of Falzi. In group B, no case showed PFE. The difference between the two groups was statistically significant. The results of our study seem to confirm that IIC can lead to PFE in a pediatric population and show that the PFE after IIC can be important (up to score 2 of Falzi). To the best of our knowledge, our study is the first specifically focused on the occurrence of PFE after IIC in a pediatric population by using autoptic data.

Gamification educational intervention improves pediatric nurses' comfort and speed drawing up code-dose epinephrine.

PURPOSE: Drawing up weight-based doses of epinephrine is a vital skill for pediatric nurses; however, non-intensive care unit (ICU) nurses may not routinely perform this skill and may not be as efficient or comfortable doing so during pediatric resuscitations. This study aimed to evaluate the impact of a gamification program on non-ICU pediatric nurses' knowledge and skills regarding epinephrine for pediatric cardiac arrest. DESIGN AND METHODS: Comfort and time to draw up three doses of epinephrine during out-of-ICU in-hospital pediatric cardiac arrest were measured pre- and post- a gamification-centered educational intervention. RESULTS: Nursing comfort improved from 2.93 ± 1.90 to 6.68 ± 1.46 out of 10 (mean difference 3.6 +/- 2.1, p < 0.001). Overall time to draw up three doses of epinephrine decreased after the intervention by an average of 27.1 s (p = 0.019). The number of nurses who could complete the task in under 2 min improved from 23% to 59% (p = 0.031). CONCLUSIONS: At baseline few non-ICU nurses could draw up multiple weight-based doses of epinephrine in under two minutes. A gamification simulation-based educational intervention improved pediatric non-ICU nurses' comfort and speed drawing up epinephrine. PRACTICE IMPLICATIONS: Wide-spread implementation of gamification-centered educational initiatives could result in faster epinephrine administration and improved mortality rates from in-hospital pediatric cardiac arrest.

[How I treat pediatric burn management in emergency department]. / Comment je traite la brûlure de l'enfant aux urgences.

Acute management in emergency department of pediatric burns is challenging for clinicians. Many of these burns are minor and can be treated on an outpatient basis. However, moderate and severe burns require hospitalization. Although management principles are similar between children and adults polytrauma, children have differences in their pathophysiological response to burn injury. Understanding these differences is essential to optimize the patient care. Particularities of acute management of pediatric burns are discussed in this article.

La prise en charge aux urgences d'un enfant brûlé est un défi pour les cliniciens. Souvent superficielles, la plupart des brûlures peuvent être traitées en ambulatoire. Cependant, les brûlures modérées et sévères nécessitent une hospitalisation. Bien que la prise en charge repose sur des principes similaires à ceux des patients polytraumatisés, les enfants présentent des différences dans la réponse physiopathologique à la brûlure. Tenir compte de ces différences est essentiel pour une prise en charge optimale. Les spécificités des modalités thérapeutiques urgentes lors de brûlures chez l'enfant sont discutées dans cet article.

[When pediatric resuscitation and anesthesia teams simulate together]. / Quand des équipes de réanimation et d'anesthésie pédiatrique simulent ensemble.

At the Grenoble-Alpes University Hospital Center, a high-fidelity simulation training project was born from the collaboration of the intensive care and pediatric anesthesia teams. The objective of these sessions was to improve practices by developing the technical and non-technical skills of the teams. Fifteen days were organized from 2018 to 2022, training 170 healthcare professionals. The results highlighted excellent satisfaction and helped improve professional practices.

Catecholaminergic Polymorphic Ventricular Tachycardia: An Unusual Case of Fright-Induced Prehospital Cardiac Arrest in a Healthy 6-Year-Old Child.

Catecholaminergic Polymorphic Ventricular Tachycardia is a rare but often lethal genetic disorder that affects approximately 1 in 10,000 people. It often first manifests as stress or exercise-related syncope or sudden unexplained cardiac death, primarily in the pediatric and young adult population. We present a case of a 6-year-old male who had a sudden unexplained prehospital cardiac arrest after being scared by a domestic animal and who presented in ventricular fibrillation. The patient was subsequently defibrillated with a return of spontaneous circulation. During the course of care, medications with beta-1 and -2 agonist properties were administered, followed by multiple further episodes of polymorphic ventricular tachycardia (PVT)/ventricular fibrillation (VF). Once these medications were discontinued and beta blockers were administered, the patient had no further episodes of PVT/VF and was subsequently discharged from hospital 7 days later, completely neurologically intact. This case suggests the need for caution when considering administering beta agonists in a pediatric cardiac arrest patient with no known history of heart disease who presents in VF or PVT after an incident of extreme stress or strenuous physical activity.

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations.

BACKGROUND: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration. OBJECTIVE: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations. METHODS/DESIGN: We conducted a retrospective review of video recordings of pediatric patients who required critical care ("resuscitation") in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained. RESULTS: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50 seconds [IQR 30,74] and 108 seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR. CONCLUSION: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.

Parents' Experience During a Child's Resuscitation: Getting Through It.

PURPOSE: The purpose of this study was to elucidate the experiences of parents during their child's resuscitation in the hospital setting. DESIGN AND METHODS: This qualitative descriptive study took place in a 280 bed children's hospital with parents whose children experienced resuscitation while they were present in the room or nearby. Semi-structured interviews were conducted between one and twelve months following a child's resuscitation. A rigorous thematic analysis was performed. RESULTS: This study elucidates parent experience during a child's resuscitation using four overarching themes; "Overwhelming chaos", "Getting through it", "Cognitive presence" and "Joy mixed with heartache". Parents described their experience to be stressful, yet identified things that helped them get through it and make sense of the experience. CONCLUSIONS: During a child's resuscitation parents perceived a sense of overwhelming chaos, yet still had an innate need to be present and know what was going on. While emotional support was appreciated, most important was to receive real time clinical information from healthcare staff and to see and feel that the team was personally invested in their child. PRACTICE IMPLICATIONS: During a child's resuscitation, parents should be allowed to choose their level of presence to meet their individual needs. A clinical staff member should answer questions and share clinical information with parents. In addition, clinicians should allow themselves to connect with parents on a personal level. This research provides a foundation for further study, including parents' experience after experiencing a child's resuscitation.

Low-Fidelity, In-Situ Pediatric Resuscitation Simulation Improves RN Competence and Self-Efficacy.

PROBLEM: ED staff lack adequate exposure to critical pediatric patients to develop competence and confidence in resuscitation scenarios. Simulations of various designs have shown success at increasing health care staff performance and self-efficacy. METHODS: We developed a nurse-led, low-fidelity in situ simulation of a pediatric sepsis scenario. The primary goal was to improve staff adherence to resuscitation guidelines, as measured by the Clinical Performance Tool, a set of checklists designed to measure adherence to Pediatric Advanced Life Support algorithms by multidisciplinary teams during simulations. The secondary goal was to improve staff confidence, measured by the Confidence Scale, a 5-item Likert-type scale that can measure any psychomotor skill. RESULTS: A total of 43 RNs participated in 12 simulations over a period of 3 months. Mean Clinical Performance score improved by 74%, from 5.3 to 9.2 (P < 0.001). Mean confidence score for RNs improved by 56%, from 2.48 (standard deviation [SD] 0.83) to 3.88 (SD 0.66) (P < 0.001). Several systems issues were identified and addressed by multidisciplinary teams, such as increasing respiratory therapist response to the emergency department and updating of the Broselow cart. DISCUSSION: In situ low-fidelity simulations led by RNs contributed to significant improvement in adherence to resuscitation guidelines and in staff confidence. The simulation design had minimal impact on staffing and budget and enabled identification and correction of systems issues.

Paediatric cardiopulmonary resuscitation training program in Latin-America: the RIBEPCI experience.

BACKGROUND: To describe the design and to present the results of a paediatric and neonatal cardiopulmonary resuscitation (CPR) training program adapted to Latin-America. METHODS: A paediatric CPR coordinated training project was set up in several Latin-American countries with the instructional and scientific support of the Spanish Group for Paediatric and Neonatal CPR. The program was divided into four phases: CPR training and preparation of instructors; training for instructors; supervised teaching; and independent teaching. Instructors from each country participated in the development of the next group in the following country. Paediatric Basic Life Support (BLS), Paediatric Intermediate (ILS) and Paediatric Advanced (ALS) courses were organized in each country adapted to local characteristics. RESULTS: Five Paediatric Resuscitation groups were created sequentially in Honduras (2), Guatemala, Dominican Republican and Mexico. During 5 years, 6 instructors courses (94 students), 64 Paediatric BLS Courses (1409 students), 29 Paediatrics ILS courses (626 students) and 89 Paediatric ALS courses (1804 students) were given. At the end of the program all five groups are autonomous and organize their own instructor courses. CONCLUSIONS: Training of autonomous Paediatric CPR groups with the collaboration and scientific assessment of an expert group is a good model program to develop Paediatric CPR training in low- and middle income countries. Participation of groups of different countries in the educational activities is an important method to establish a cooperation network.

Use of the Broselow tape in a Mexican emergency department.

BACKGROUND: The Broselow tape is one method for rapid weight estimation in pediatric patients undergoing resuscitation, but it does not perform equally in all populations. To date, we are unaware of any study evaluating its use in a Latin American population. OBJECTIVE: To investigate the accuracy of the Broselow tape in a Mexican emergency department (ED). METHODS: We conducted a prospective, observational study of children presenting to a Mexican ED. Patient weight was estimated using the Broselow tape and the estimate compared to their weight measured on a scale. Researchers were blinded to scale weight and Broselow categories. For analysis, the Broselow tape's nine color zones were divided into three weight categories. RESULTS: Of 815 subjects, 356 (43.7%) were female. In children weighing <10 kg, the tape tended to underestimate weight, whereas it overestimated weight in the other two weight categories. The mean percentage difference between the actual weight and the Broselow tape-predicted weight was <3% in each category, although it differed significantly across the three weight categories. Accuracy of the predicted weight to within 10% of actual weight was lowest for children weighing <10 kg, at 46.2% (confidence interval [CI] ± 6.4%), and greatest for those in the 10-18-kg weight category, at 64.1% (CI ± 5.1%). However, the correlation of color zones predicted by both methods was highest for subjects <10 kg at 64.4% (CI ± 6.1%). It was significantly lower in the other weight categories at 54.5% (CI ± 5.3) for subjects weighing 10-18 kg, and 50.1% (CI ± 6.4%) for subjects weighing >18 kg. The percentage of children for whom the color code differed by two or more categories was <4% overall and for each weight category. CONCLUSION: The Broselow tape-estimated weight was different from the scale weight by more than 10% in a substantial percentage of Mexican children. Nevertheless, the mean percentage difference was <3%, and Broselow tape color zone estimation was accurate in the majority of subjects, suggesting its use would result in clinically appropriate dosing and equipment estimations. Further research is needed to validate its use in this clinical setting.

Ventricular Assist Device Training and Emergency Management Among Pediatric Cardiac Intensive Care Physicians - Multicenter Cross-Sectional Survey.

Background/Aim: Pediatric cardiac intensive care physicians practicing at centers that implant ventricular assist devices (VAD's) are exposed to increasing numbers of VAD patients, with a significant number of VAD-days. We aimed to delineate pediatric cardiac critical care practices surrounding routine and emergency management of VADs. Methodology: We administered a multicenter cross-sectional survey of pediatric cardiac intensive care unit (CICU) physicians in the United States and Canada. Survey distribution occurred between August 31st and October 26th 2021. Results: A total of 254 CICU physicians received a formal invitation to participate, with 108 returning completed surveys (42.5% response rate). Responses came from CICU attending physicians at 26 separate institutions. Respondents' level of experience was well distributed across junior, mid-level, and senior staff: less than 5 years (38%), 5-9 years (25%), and >/= 10 years (37%). Most respondents had received formal training in the management of VAD patients (n = 93, 86.1%), with training format including fellowship (61%), simulation (36%), and national/international conferences (26.5%). Dedicated advanced cardiac therapies teams were available at the institutions of 97.2% of respondents. A total of 78/108 (72.2%) described themselves as "comfortable" or "very comfortable" in pediatric VAD management. While 63% (68/108) of respondents reported that they had never performed (or overseen the performance of) chest compressions in a pediatric patient with a VAD, 37% (40/108) reported performing CPR at least once in a VAD patient. Conclusion: With no existing international guidelines for emergency cardiovascular care in the pediatric VAD population, our survey identifies an important gap in resuscitation recommendations.

Virginia Apgar (1909-1974): The Mother of Neonatal Resuscitation.

Dr. Virginia Apgar was an American anesthesiologist and researcher who heavily influenced the development of neonatal resuscitation in the immediate postpartum period with her simple five-point scoring system. Today, the APGAR scoring system is used around the world in delivery rooms to guide clinicians in the evaluation of newborns and to distinguish which might need urgent resuscitation. With a simple scoring system, timer, and clipboard, Dr. Virginia Apgar shifted focus from the parturient to the neonate, improving infant mortality as a result.

Virtual Reality Simulation in Pediatric Resuscitation for Pre-hospital Providers.

This technical report explored the feasibility and utility of virtual reality (VR) pediatric resuscitation simulations for pre-hospital providers during their scheduled shifts. To our knowledge, neither the pediatric resuscitation VR simulation nor the feasibility of in situ, on-shift training with VR had been previously evaluated in pre-hospital providers. VR headset was available at an urban city fire station for 10 days where a total of 60 pre-hospital providers were scheduled to work. Providers were made aware of the VR module but no formal demonstration was done. There were no facilitators. Participants filled out an anonymous retrospective pre- and post-survey using a five-point Likert scale, rating their confidence from "not confident" to "very confident" in recognizing and managing pediatric emergencies. We found that VR simulation for pediatric resuscitation was a feasible training tool to use in situ as 63% of the providers were able to use it on shift. Furthermore, self-reported confidence increased after the training where responses of "very confident" increased from 20% to 30% for emergency medical technicians and 55% to 63% for paramedics.

Pediatric Cardiac Arrest and Resuscitation.

Pediatric cardiac arrest in the emergency department is rare. We emphasize the importance of preparedness for pediatric cardiac arrest and offer strategies for the optimal recognition and care of patients in cardiac arrest and peri-arrest. This article focuses on both prevention of arrest and the key elements of pediatric resuscitation that have been shown to improve outcomes for children in cardiac arrest. Finally, we review changes to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that were published in 2020.

Economic evaluation of tele-resuscitation intervention on emergency department pediatric visits in the Niagara Region, Canada a pilot study.

Introduction: The use of telemedicine in critical care is emerging, however, there is a paucity of information surrounding the costs relative to health gains in the pediatric population. This study aimed to estimate the cost-effectiveness of a pediatric tele-resuscitation (Peds-TECH) intervention compared to the usual care in five community hospital emergency departments (EDs). Using a decision tree analysis approach with secondary retrospective data from a 3-year time period, this cost-effectiveness analysis was completed. Methods: A mixed methods quasi-experimental design was embedded in the economic evaluation of Peds-TECH intervention. Patients aged <18 years triaged as Canadian Triage and Acuity Scale 1 or 2 at EDs were eligible to receive the intervention. Qualitative interviews were conducted with parents/caregivers to explore the out-of-pocket (OOP) expenses. Patient-level health resource utilization was extracted from Niagara Health databases. The Peds-TECH budget calculated one-time technology and operational costs per patient. Base-case analyses determined the incremental cost per year of life lost (YLL) averted, and additional sensitivity analysis confirmed the robustness of the results. Results: Odds ratio for mortality among cases was 0.498 (95% CI: 0.173, 1.43). The average cost of a patient receiving the Peds-TECH intervention was $2,032.73 compared to $317.45 in usual care. In total, 54 patients received the Peds-TECH intervention. Fewer children died in the intervention group resulting in 4.71 YLL. The probabilistic analysis revealed an incremental cost-effectiveness ratio of $64.61 per YLL averted. Conclusion: Peds-TECH appears to be a cost-effective intervention for resuscitating infants/children in hospital emergency departments.

The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study.

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

Chest Pain and Electrocardiographic Changes in a Child With Duchenne Muscular Dystrophy.

A 12-year-old boy known to have Duchenne muscular dystrophy presented to our Emergency Department with acute onset central chest pain. A 12-lead electrocardiogram (ECG) was performed showing ST-segment elevation with reciprocal changes. An echocardiogram showed reduced left ventricular systolic function with an ejection fraction of 45%. Initial cardiac biomarkers were significantly elevated, with troponin-T result recorded at 7,065 ng/L (reference range: 0-14 ng/L). The patient was admitted to the pediatric intensive care unit with a differential diagnosis of acute myocardial infarction or acute myocardial injury related to cardiomyopathy and commenced on an ACE (angiotensin-converting enzyme) inhibitor. Computed tomography (CT) of the coronary arteries was performed, which showed normal coronary arteries and cardiac anatomy. The patient was discharged on day 5 and continues to follow up in the pediatric cardiology clinic. He was commenced on a beta blocker at one-month follow-up when he was asymptomatic.