Direct Oral Anticoagulant Reversal in the Pediatric Emergency Department.

ABSTRACT: Direct oral anticoagulants have been used in the adult population for years and are being used more frequently in pediatrics. Direct oral anticoagulants are chosen preferentially because they do not require close outpatient monitoring, have an equal or better safety profile, and are easy for patients to take. Warfarin is the previous, more commonly used oral anticoagulant and acts as a vitamin K antagonist. Direct oral anticoagulants mechanism of action is different in that they directly inhibit part of the coagulation cascade accomplishing the same end goal. Given their differing mechanisms, they require alternate medications for proper reversal when concerned about overdose of life-threatening bleeds. This review will outline the most commonly used direct oral anticoagulants in pediatric populations and the supporting (mainly adult) data available for proper reversal of these medications in times of need.

Waterfalls and Handoffs: A Novel Physician Staffing Model to Decrease Handoffs in a Pediatric Emergency Department.

STUDY OBJECTIVE: Patient handoffs at shift change in the emergency department (ED) are a well-known risk point for patient safety. Numerous methods have been implemented and studied to improve the quality of handoffs to mitigate this risk. However, few have investigated processes designed to decrease the number of handoffs. Our objective is to evaluate a novel attending physician staffing model in an academic pediatric ED that was designed to decrease patient handoffs. METHODS: A multidisciplinary team met in August 2012 to redesign the attending physician staffing model. The team sought to decrease patient handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. The original model required multiple handoffs at shift change. This was replaced with overlapping "waterfall" shifts. This was a retrospective quality improvement study of a process change that evaluated the percentage of intradepartmental handoffs before and after implementation of a new novel attending physician staffing model. In addition, surveys were conducted among attending physicians and charge nurses to inquire about perceived impacts of the change. RESULTS: A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%. A survey of physicians and charge nurses demonstrated improved perceptions of patient safety, ED flow, and job satisfaction. CONCLUSION: This new emergency physician staffing model with overlapping shifts decreased the proportion of patient handoffs. This innovative system can be implemented and scaled to suit EDs that have more than single-physician coverage.

Improving Time to Antibiotics for Pediatric Oncology Patients With Suspected Infections: An Emergency Department-Based Quality Improvement Intervention.

OBJECTIVE: Studies in pediatric patients with fever and neutropenia demonstrate that shorter time to antibiotics is associated with a decrease in pediatric intensive care unit admissions and in-hospital mortality. In 2012, a 2-phase quality improvement intervention was implemented in a pediatric emergency department (ED) to improve care for this high-risk patient population.The objective was to determine if the introduction of (1) a rapid absolute neutrophil count (ANC) test and (2) a standardized prearrival process decreased time to antibiotics for febrile hematology/oncology(heme/onc) patients presenting to the ED. METHODS: The rapid ANC test introduced in February 2012 decreased turn-around-times in the laboratory from 60 to 10 minutes. The standardization of the prearrival communication between the heme/onc team and ED was implemented in August 2012 as part of a clinical standard work pathway for heme/onc patients who presented to the ED with fever and possible neutropenia. Time from arrival to the ED to administration of first antibiotic was measured.Data from January 2011 to December 2013 were analyzed using statistical process control. RESULTS: Seven hundred eighteen encounters for 327 patients were included. After the rapid ANC test, the proportion of patients who received antibiotics within 60 minutes of arrival increased from 47% to 60%. There was further improvement to 69% with implementation of the clinical standard work pathway. Mean time to antibiotics decreased from 83 to 65 minutes (21% decrease). CONCLUSION: This 2-phase quality improvement intervention increased the proportion of patients who received antibiotics within 60 minutes of arrival to the ED. Similar processes may be implemented in other pediatric EDs to improve timeliness of antibiotic administration.

Dispensing Medications at the Hospital Upon Discharge From an Emergency Department.

Although most health care services can be provided in the medical home, children will be referred or require visits to the emergency department (ED) for a variety of conditions ranging from nonurgent to emergent. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of follow-up instructions and adherence to medication administration recommendations. Barriers to obtaining medications after ED visits include lack of access because of pharmacy hours, affordability, and lack of understanding the importance of medication as part of treatment. ED visits often occur at times when community-based pharmacies are closed. Caregivers are typically concerned with getting their ill or injured child directly home once discharged from the ED. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing medications at ED discharge from the outpatient pharmacy within the health care facility is a major convenience that helps to overcome this obstacle, improving the likelihood of medication adherence. Emergency care encounters should routinely be followed by visits to the primary care provider medical home to ensure complete and comprehensive care.

Toddler with seizures due to ingesting camphor at an Indian celebration.

We report a 3-year-old girl who presented to the emergency department with seizures. Earlier in the evening, the patient was with her parents at an Indian celebration where she vomited once and then became hyperactive. Fifteen minutes later, she became unresponsive and had an episode characterized by eye blinking, teeth grinding, and posturing that lasted 2 to 3 minutes. To our knowledge, this is the first report of seizure after ingestion of ceremonial camphor tablets at an Indian ceremony. Given the inadequate packaging and use of many grams of camphor at these ceremonies, the pediatric population specifically is at risk for camphor toxicity from this source. Health care professionals should be aware of this unique and culturally specific source of potential camphor toxicity.

Crataegus mexicana (Tejocote) Exposure Associated with Cardiotoxicity and a Falsely Elevated Digoxin Level.

INTRODUCTION: A species of hawthorn, Crataegus mexicana (tejocote), has been marketed as a weight-loss supplement that is readily available for purchase online. While several hawthorn species have shown clinical benefit in the treatment of heart failure owing to their positive inotropic effects, little is known about hawthorn, and tejocote in particular, when consumed in excess. We describe a case of tejocote exposure from a weight-loss supplement resulting in severe cardiotoxicity. CASE REPORT: A healthy 16-year-old girl presented to an emergency department after ingesting eight pieces of her mother's tejocote root weight-loss supplement. At arrival, she was drowsy, had active vomiting and diarrhea, and had a heart rate of 57 with normal respirations. Her initial blood chemistries were unremarkable, except for an elevated digoxin assay of 0.7 ng/mL (therapeutic range 0.5-2.0 ng/mL). All other drug screens were negative. She later developed severe bradycardia and multiple episodes of hypopnea that prompted a transfer to our institution, a tertiary pediatric hospital. Her ECG demonstrated a heart rate of 38 and Mobitz type 1 second-degree heart block. She was subsequently given two vials of Digoxin Immune Fab due to severe bradycardia in the setting of suspected digoxin-like cardiotoxicity after discussion with the regional poison control center. No clinical improvement was observed. Approximately 29 hours after ingestion, subsequent ECGs demonstrated a return to normal sinus rhythm, and her symptoms resolved. DISCUSSION: Tejocote root toxicity may cause dysrhythmias and respiratory depression. Similar to other species of hawthorn, tejocote root may cross-react with some commercial digoxin assays, resulting in a falsely elevated level.

Pediatric tramadol ingestion resulting in seizurelike activity: a case series.

Tramadol has been reported to cause seizures in therapeutic dosing and in overdose. We present a series of 2 infants poisoned with tramadol, both presenting with abnormal neurologic findings: either seizures or seizurelike activity. Tramadol poisoning should be considered in the differential diagnosis of dystonia and seizures.

Massive ibuprofen overdose requiring extracorporeal membrane oxygenation for cardiovascular support.

OBJECTIVE: Ibuprofen is rarely associated with severe toxicity. We report a massive ibuprofen overdose that resulted in refractory hypotension requiring extracorporeal membrane oxygenation (ECMO) for cardiovascular support. DESIGN: Individual case report. SETTING: Pediatric intensive care unit of a tertiary care hospital. PATIENT: A 14-yr-old male presented with apnea and cardiovascular collapse after a nonaccidental ingestion of approximately 50 g of ibuprofen. His laboratory evaluation demonstrated an anion gap metabolic acidosis and elevated lactate levels. INTERVENTIONS: The patient required pressor support with norepinephrine, phenylephrine, and vasopressin infusions. Due to refractory hypotension, he was placed on ECMO. His serum ibuprofen level at an estimated 5-10 hrs postingestion was 776 microg/mL (therapeutic 20-30 microg/mL). Urine toxicological screen for drugs of abuse, serum acetaminophen, salicylate, and carboxyhemoglobin levels showed that these levels were not elevated. The patient developed high-output renal failure, pulmonary hemorrhage, and gastric bleeding, all of which resolved by hospital day 3. MEASUREMENTS AND MAIN RESULTS: ECMO was discontinued on hospital day 4, inotropic support was discontinued, and the patient was extubated on hospital day 5. He was transferred to an inpatient psychiatric unit on hospital day 9 with no identifiable medical sequelae. CONCLUSIONS: Although ibuprofen overdose typically has few consequences, severe hypotension, renal failure, and gastrointestinal bleeding can occur. We report the first known case of successful ECMO therapy for ibuprofen overdose.

Coca tea consumption causes positive urine cocaine assay.

BACKGROUND: Coca tea, derived from the same plant that is used to synthesize cocaine, is commonly consumed in South America and easily obtained in the United States. OBJECTIVES: To determine whether consumption of coca tea would result in a positive urine toxicology screen for cocaine metabolites. METHODS: Five healthy adult volunteers consumed coca tea and underwent serial quantitative urine testing for cocaine metabolites by fluorescence polarization immunoassay. The cutoff for a positive assay was chosen at 300 ng/ml, the National Institute on Drug Abuse standard. RESULTS: Each participant's urine cocaine assay was positive (level exceeding 300 ng/ml) by 2 h after ingestion. Three out of five participants' samples remained positive at 36 h. Mean urine benzoylecgonine concentrations in all postconsumption samples was 1777 ng/ml (95% confidence interval: 1060-2495). CONCLUSIONS: Coca tea ingestion resulted in a positive urine assay for cocaine metabolite. Healthcare professionals should consider a history of coca tea ingestion when interpreting urine toxicology results.

Teaching Spanish to pediatric emergency physicians: effects on patient satisfaction.

BACKGROUND: Language barriers are known to negatively affect patient satisfaction. OBJECTIVE: To determine whether a course of instruction in medical Spanish for pediatric emergency department (ED) physicians is associated with an increase in satisfaction for Spanish-speaking-only families. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION: Nine pediatric ED physicians completed a 10-week medical Spanish course. Mock clinical scenarios and testing were used to establish an improvement in each physician's ability to communicate with Spanish-speaking-only families. Before (preintervention period) and after (postintervention period) the course, Spanish-speaking-only families cared for by these physicians completed satisfaction questionnaires. Professional interpreters were equally available during both the preintervention and postintervention periods. MAIN OUTCOME MEASURES: Responses to patient family satisfaction questionnaires. RESULTS: A total of 143 Spanish-speaking-only families completed satisfaction questionnaires. Preintervention (n = 85) and postintervention (n = 58) cohorts did not differ significantly in age, vital signs, length of ED visit, discharge diagnosis, or self-reported English proficiency. Physicians used a professional interpreter less often in the postintervention period (odds ratio [OR], 0.34; 95% confidence interval [CI], 0.16-0.71). Postintervention families were significantly more likely to strongly agree that "the physician was concerned about my child" (OR, 2.1; 95% CI, 1.0-4.2), "made me feel comfortable" (OR, 2.6; 95% CI, 1.1-4.4), "was respectful" (OR, 3.0; 95% CI, 1.4-6.5), and "listened to what I said" (OR, 2.9; 95% CI, 1.4-5.9). CONCLUSIONS: A 10-week medical Spanish course for pediatric ED physicians was associated with decreased interpreter use and increased family satisfaction.

Compliance with poison center fomepizole recommendations is suboptimal in cases of toxic alcohol poisoning.

We sought to examine hospital compliance with poison center antidotal alcohol dehydrogenase inhibition recommendations in cases of ethylene glycol (EG) and methanol (ME) ingestion. A 2-year analysis of all potential EG and ME ingestion cases reported to a regional poison center was conducted. Excluded from analysis were exposures without an ingestion, without a confirmatory EG or ME serum assay, or without complete medical charting. During the study period, 579 EG or ME exposures were reported to the poison center: 133 cases met study eligibility as an ingestion. Of the 133 cases, 102 (77%) had complete data and were included in the analysis. Immediate alcohol dehydrogenase inhibition was recommended by the poison center in 79 of the 102 cases. Fomepizole was recommended in 61/79 (77%); ethanol was recommended as an alternative therapeutic choice in 32/61 (52%) of these cases if fomepizole was not immediately available. Ethanol alone was recommended in 18/79 (23%). Fomepizole was eventually administered in 39/61 (64%) cases where recommended. The mean time to antidote administration was 3 times longer in cases where a choice in antidote was given [57 min (95% confidence interval, 43-70) vs. 146 min (95% confidence interval, 93-200)]. Despite its ease of administration, fomepizole is used less frequently than recommended by poison center staff. Delays to antidote administration occurred more commonly in cases where the poison center gave a choice in antidotal therapy.

Accidental clonidine patch ingestion in a child.

A case of a pediatric ingestion of a clonidine patch is described. Symptoms included lethargy, bradycardia, and miosis. Treatment included naloxone, charcoal administration, and whole bowel irrigation. Gastrointestinal absorption of active drug can result in significant toxicity and treatment should focus on aggressive decontamination techniques.

Interpretation of traumatic lumbar punctures: who can go home?

OBJECTIVE: To determine whether a ratio of observed to predicted (O:P) cerebrospinal fluid (CSF) white blood cells (WBCs) after a traumatic lumbar puncture (LP) can be used to predict which patients do not have meningitis and can safely be discharged from the hospital. METHODS: A retrospective medical record review was performed on 2 cohorts of previously healthy children who had received an LP at Children's Memorial Hospital in Chicago, IL. All children were older than 1 month and had a red blood cell (RBC) count in the CSF >500/mm(3). Cohort 1 consisted of children who were examined in 1990 through 1999 and had CSF cultures positive for a bacterial pathogen. Cohort 2 consisted of children who were tested during January through December 1999 and had a CSF culture negative for any bacterial pathogen. Exclusion criteria included patients who received antibiotics within 72 hours before evaluation, patients with a previous neurosurgical procedure or CNS bleed, and patients whose complete blood count was not done within 6 hours of LP. The predicted CSF WBC count was calculated using the formula CSF WBC (predicted) = CSF RBC x (blood WBC/blood RBC). The O:P ratio was obtained by dividing the observed CSF WBC by the predicted CSF WBC. The simple ratio of WBCs to RBCs was also calculated. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated to predict the absence of disease. Receiver operator characteristic curves were generated for the O:P ratio and the WBC:RBC ratio. Continuous variables were analyzed with Mann-Whitney U test. RESULTS: Among the 57 patients who fit all of the study criteria, 12 (21%) had positive CSF cultures for bacterial pathogens. The patients with meningitis were significantly older (median: 7.8 months; range: 1-106 months) than the patients without meningitis (median: 1.3 months; range: 1-139 months). The O:P ratio was significantly lower in the patients without meningitis (median: 0.064; range: 0.000054-1.09) as compared with patients with meningitis (median: 1.26; range: 0.045-4.72). The WBC:RBC ratio was significantly lower in the patients without meningitis (median: 0.001; range: 0-4.46) as compared with patients with meningitis (median: 1.98; range: 0.04-24.45). The specificity and positive predictive value of an O:P ratio