A National Simulation-Based Study of Pediatric Critical Care Transport Teams Performance.

OBJECTIVES: To assess pediatric critical care transport (CCT) teams' performance in a simulated environment and to explore the impact of team and center characteristics on performance. STUDY DESIGN: This observational, multicenter, simulation-based study enlisted a national cohort of pediatric transport centers. Teams participated in 3 scenarios: nonaccidental abusive head injury, sepsis, and cardiac arrest. The primary outcome was teams' simulation performance score. Secondary outcomes were associations between performance, center and team characteristics. RESULTS: We recruited 78 transport teams with 196 members from 12 CCT centers. Scores on performance measures that were developed were 89% (IQR 78-100) for nonaccidental abusive head injury, 63.3% (IQR 45.5-81.8) for sepsis, and 86.6% (IQR 66.6-93.3) for cardiac arrest. In multivariable analysis, overall performance was higher for teams including a respiratory therapist (0.5 points [95% CI: 0.13, 0.86]) or paramedic (0.49 points [95% CI: 0.1, 0.88]) and dedicated pediatric teams (0.37 points [95% 0.06, 0.68]). Each year increase in program age was associated with an increase of 0.04 points (95% CI: 0.02, 0.06). CONCLUSIONS: Dedicated pediatric teams, inclusion of respiratory therapists and paramedics, and center age were associated with higher simulation scores for pediatric CCT teams. These insights can guide efforts to enhance the quality of care for children during interfacility transports.

Vibratory Impact of 3 Different Ambulance Suspension Systems on the Simulated Neonate and Health Care Provider During Normal Driving Conditions.

OBJECTIVE: Patients and health care providers experience varying degrees of vibration during interfacility ground transport. The impact of vibration on term and preterm neonates may result in physiologic instability and increased risk of intracranial hemorrhage, whereas the impact on health care providers has been shown to include an increase in perceived and physiologic stress levels and may contribute to chronic back and neck pain. This study aimed to evaluate 3 common ambulance suspension systems and the corresponding vibratory impact produced during typical interfacility driving conditions on adult caregiver and neonatal patient mannequins. METHODS: Type 3 ambulances with air, liquid, and traditional suspensions were evaluated using various driving tests to simulate typical road conditions. Vibrations were measured using triaxial accelerometers placed on the chassis, upon the head of a seated caregiver mannequin in the ambulance bench seat, and the head of a neonatal mannequin supine and secured in an isolette. Data analysis included the average vibration frequency, root mean square values, and maximum vibration amplitudes. RESULTS: The results showed that the supine neonatal mannequin experienced the highest vibration frequency and amplitude in the vertical (x) direction, whereas the adult caregiver mannequin experienced higher vibration frequencies in both parallel (y) and lateral (z) directions and the highest vibration amplitude in the y direction. The liquid suspension system consistently demonstrated the lowest vibration levels in all driving conditions and directions, whereas traditional suspension had the highest values. CONCLUSION: This study provides important insights into the vibrations incurred by simulated neonatal patients and health care providers during ambulance transport. The directional vibration frequency and amplitude differ between a neonatal mannequin and an adult mannequin when placed in typical positions with typical restraints during varied ambulance driving conditions. In all directional movements and driving conditions, a liquid suspension system decreases vibration frequency and amplitude more than air or traditional systems. The live patient and caregiver impact of these results should be further investigated.

Appropriate Needle Length for Emergent Pediatric Needle Thoracostomy Utilizing Computed Tomography.

Objective: Needle thoracostomy is a life-saving procedure. Advanced Trauma Life Support guidelines recommend insertion of a 5 cm, 14-gauge needle for pneumothorax decompression. High-risk complications can arise if utilizing an inappropriate needle size. No study exist evaluating appropriate needle length in pediatric patients. Utilizing computed tomography (CT), we determined the needle length required to access the pleural cavity in children matched to Broselow™ Pediatric Emergency Tape color. Methods: Three investigators reviewed chest CTs of children <13 years of age obtained between 2010 and 2015. Patient exclusions included those with a chest wall mass, muscle disease, pectus deformity, anasarca, prior open thoracotomy, inadequate imaging, or missing height documentation. We established 4 groups based upon Broselow™ color as determined by recorded height. Investigators, trained by a pediatric board-certified radiologist, obtained standardized CT measurements of chest wall thickness at 4 points: right/left second intercostal space at the midclavicular line (ICS-MCL) and right/left fourth intercostal space in the anterior axillary line (ICS-AAL). Our outcome was the median chest wall thickness and 95% confidence intervals for each Broselow grouping and anatomic site. Results: A total of 273 chest CTs were reviewed, of which 23 were excluded, for a resultant study population of 250 scans and 498 total measurements. Median patient age was 4 years, 52.8% were male. Children measuring Broselow Gray/Pink (<68 cm), had a median chest wall thickness at the 2nd ICS-MCL of 1.57 cm (95% CI 1.42 cm, 1.72 cm), 4th ICS-AAL 1.67 cm (95% CI 1.48 cm, 1.86 cm). Broselow Red/Purple (68.1-90 cm): 2nd ICS-MCL of 1.96 cm (95% CI 1.84 cm, 2.08 cm), 4th ICS-AAL 1.73 cm (95% CI 1.62 cm, 1.84 cm). Broselow Yellow/White (90.1-115cm): 2nd ICS-MCL of 2.12 cm (95% CI 2.03 cm, 1.22 cm), 4th ICS-AAL 1.91 cm (95% CI 1.8 cm, 2.01 cm). Broselow Blue/Orange/Green (>115.1 cm): 2nd ICS-MCL of 2.45 cm (95% CI 2.3 cm, 2.6 cm), 4th ICS-AAL 2.19cm (95% CI 2.02 cm, 2.36 cm). Conclusion: Median chest wall thickness varies little by height or location in children <13 years of age. The standard 5-cm needle is twice the chest wall thickness of most children. Commercially available 14 g or 16 g standard-length 3.8 cm (1½ inch) needles are of adequate length to access the pleural cavity, regardless of height as measured by Broselow LBT.

Etomidate for short pediatric procedures in the emergency department.

OBJECTIVE: This study aimed to prospectively determine the etomidate dose associated with adequate sedation and few significant respiratory events for procedures of short duration in children. METHODS: This is a prospective cohort study in an urban pediatric emergency department of patients 4 to 18 years requiring sedation and analgesia for painful procedures of short duration. Patients received fentanyl 1 µg/kg followed by intravenously administered etomidate 0.1 to 0.2 mg/kg as a loading dose. An additional dose of etomidate 0.1 mg/kg was intravenously administered if needed. The level of sedation was determined by The Children's Hospital of Wisconsin Sedation Score. The primary outcome was to determine the etomidate dose associated with an adequate level of sedation and procedural completion. RESULTS: Sixty patients were enrolled. The most frequent procedure was fracture reduction (50/60, 83.3%). Procedures were successfully completed for 59 (98.3%) of 60 patients. The initial dose of etomidate associated with adequate sedation was 0.2 mg/kg intravenously administered for 33 (66.7%) of 50 patients requiring fracture reduction and for 6 (60.0%) of 10 patients receiving a procedure other than fracture reduction. Respiratory depression was noted in 9 (16.4%) of 55 patients, and oxygen desaturation was noted in 23 (39.0%) of 59 patients. Of 58 patients, 21 (36.2%) experienced a respiratory adverse event requiring brief intervention including oxygen supplementation, stimulation, and/or airway repositioning. No patient experienced a significant adverse respiratory event, defined as positive pressure ventilation. Median time to discharge-ready was 21 minutes. CONCLUSIONS: For short-duration painful emergency department procedures, etomidate 0.2 mg/kg intravenously administered after fentanyl was associated with effective sedation, successful procedural completion, and readily managed respiratory adverse events in children.