Epidemiology of paediatric trauma presenting to US emergency departments: 2006-2012.

BACKGROUND: Traumatic injury is the leading cause of paediatric morbidity and mortality in the USA. We present updated national data on emergency department (ED) discharges for traumatic injury for a recent 7-year period. METHODS: We conducted a descriptive epidemiological analysis of the Nationwide Emergency Department Sample Survey, the largest and most comprehensive database in the USA, for 2006-2012. Among children and adolescents, we tracked changes in injury mechanism and severity, cost of care, injury intent and the role of trauma centres. RESULTS: There was an 8.3% (95% CI 7.7 to 8.9) decrease in the annual number of ED visits for traumatic injury in children and adolescents over the study period, from 8 557 904 (SE=5861) in 2006 to 7 846 912 (SE=5191) in 2012. The case-fatality rate was 0.04% for all injuries and 3.2% for severely injured children. Children and adolescents with high-mortality injury mechanisms were more than three times more likely to be treated at a level 1 trauma centre (OR=3.5, 95% CI 3.3 to 3.7), but were more no more likely to die (OR=0.96, 95% CI 0.93 to 1.00). Traumatic brain injury diagnoses increased 22.2% (95% CI 20.6 to 23.9) during the study period. Intentional assault accounted for 3% (SE=0.1) of all child and adolescent ED injury discharges and 7.2% (SE=0.3) of discharges among 15-19 year-olds. There was an 11.3% (95% CI 10.0 to 12.6) decline in motor vehicle injuries from 2009 to 2012. The total cost of care was $23 billion (SE=0.01), a 78% increase from 2006 to 2012. CONCLUSIONS: This analysis presents a recent portrait of paediatric trauma across the USA. These analyses indicate the important role and value of trauma centre care for injured children and adolescents, and that the most common causes and mechanisms of injury are preventable.

Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma.

STUDY OBJECTIVE: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. METHODS: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT). RESULTS: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. CONCLUSION: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.

Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger.

IMPORTANCE: Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns ("RNA biosignatures") in response to infections may provide an alternative diagnostic approach. OBJECTIVE: To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type. EXPOSURE: RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections. MAIN OUTCOMES AND MEASURES: Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores. RESULTS: Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections-including 32 with bacteremia and 15 with urinary tract infections-and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43). CONCLUSIONS AND RELEVANCE: In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with vs without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.

Benefits of brain magnetic resonance imaging over computed tomography in children requiring emergency evaluation of ventriculoperitoneal shunt malfunction: reducing lifetime attributable risk of cancer.

OBJECTIVES: The rapid growth of computed tomography (CT) has resulted in increased concerns of ionizing radiation exposure and its subsequent risk of cancer development. We evaluated the impact of a new protocol using rapid sequence magnetic resonance imaging (rsMRI) instead of CT in children presenting with possible ventriculoperitoneal shunt (VPS) malfunction to promote patient safety. METHODS: This is a retrospective case series of pediatric patients who received a neuroimaging study for emergency evaluation of possible VPS malfunction at New York University's Tisch Hospital Emergency Department between January 2010 and July 2011. Radiology Charge Master was queried to identify the patient database. The trend in the use of rsMRI and CT was calculated for 3 patient age groups and compared across 3 chronological intervals. The effective dose of ionizing radiation per CT scan was calculated using the CT dose index and dose-length product for each patient. RESULTS: Total of 365 patients with the mean age of 8.87 years received either rsMRI or CT study during the study period. One hundred forty-four of these patients required the imaging studies because of VPS malfunction. Overall, 62% of all VPS malfunction cases used rsMRI instead of CT. The ratio of the number of patients receiving rsMRI divided by CT studies has progressively increased from 1.4:1 to 2.1:1 over 3 chronologic periods. CONCLUSIONS: Children with VPS are subject to multiple neuroimaging studies throughout their lifetime. Rapid sequence MRI is an effective alternative to CT while providing no ionizing radiation exposure or risk of developing radiation-induced cancer.

Association of traumatic brain injuries with vomiting in children with blunt head trauma.

STUDY OBJECTIVE: We aimed to determine the prevalence of traumatic brain injuries in children who vomit after minor blunt head trauma, particularly when the vomiting occurs without other findings suggestive of traumatic brain injury (ie, isolated vomiting). We also aimed to determine the relationship between the timing and degree of vomiting and traumatic brain injury prevalence. METHODS: This was a secondary analysis of children younger than 18 years with minor blunt head trauma. Clinicians assessed for history and characteristics of vomiting at the initial evaluation. We assessed for the prevalence of clinically important traumatic brain injury and traumatic brain injury on computed tomography (CT). RESULTS: Of 42,112 children enrolled, 5,557 (13.2%) had a history of vomiting, of whom 815 of 5,392 (15.1%) with complete data had isolated vomiting. Clinically important traumatic brain injury occurred in 2 of 815 patients (0.2%; 95% confidence interval [CI] 0% to 0.9%) with isolated vomiting compared with 114 of 4,577 (2.5%; 95% CI 2.1% to 3.0%) with nonisolated vomiting (difference -2.3%, 95% CI -2.8% to -1.5%). Of patients with isolated vomiting for whom CT was performed, traumatic brain injury on CT occurred in 5 of 298 (1.7%; 95% CI 0.5% to 3.9%) compared with 211 of 3,284 (6.4%; 95% CI 5.6% to 7.3%) with nonisolated vomiting (difference -4.7%; 95% CI -6.0% to -2.4%). We found no significant independent associations between prevalence of clinically important traumatic brain injury and traumatic brain injury on CT with either the timing of onset or time since the last episode of vomiting. CONCLUSION: Traumatic brain injury on CT is uncommon and clinically important traumatic brain injury is very uncommon in children with minor blunt head trauma when vomiting is their only sign or symptom. Observation in the emergency department before determining the need for CT appears appropriate for many of these children.

The prevalence of traumatic brain injuries after minor blunt head trauma in children with ventricular shunts.

STUDY OBJECTIVE: We compare the prevalence of clinically important traumatic brain injuries and the use of cranial computed tomography (CT) in children with minor blunt head trauma with and without ventricular shunts. METHODS: We performed a secondary analysis of a prospective observational cohort study of children with blunt head trauma presenting to a participating Pediatric Emergency Care Applied Research Network emergency department. For children with Glasgow Coma Scale (GCS) scores greater than or equal to 14, we compared the rates of clinically important traumatic brain injuries (defined as a traumatic brain injury resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights for management of traumatic brain injury in association with positive CT scan) and use of cranial CT for children with and without ventricular shunts. RESULTS: Of the 39,732 children with blunt head trauma and GCS scores greater than or equal to 14, we identified 98 (0.2%) children with ventricular shunts. Children with ventricular shunts had more frequent CT use: (45/98 [46%] with shunts versus 13,858/39,634 [35%] without; difference 11%; 95% confidence interval 1% to 21%) but a similar rate of clinically important traumatic brain injuries (1/98 [1%] with shunts versus 346/39,619 [0.9%] without; difference 0.1%; 95% confidence interval -0.3% to 5%). The one child with a ventricular shunt who had a clinically important traumatic brain injury had a known chronic subdural hematoma that was larger after the head trauma compared with previous CT; the child underwent hematoma evacuation. CONCLUSION: Children with ventricular shunts had higher CT use with similar rates of clinically important traumatic brain injuries after minor blunt head trauma compared with children without ventricular shunts.

Prevalence of occult anemia in an urban pediatric emergency department: what is our response?

OBJECTIVE: Treating or referring patients who are found to be anemic during pediatric emergency department (ED) encounters should lead to improved health in children and young adults. Before establishing guidelines how to approach the anemic in the pediatric ED, it is essential to determine the prevalence of anemia in the ED and our response to the presence of anemia. METHODS: We performed a retrospective cross-sectional study on hemoglobin levels from patients 1 to 23 years evaluated in an inner-city public hospital pediatric ED during a 12-month period. The primary outcome measure was the prevalence of prior unknown or "occult" anemia, stratified by age, sex, and insurance status. The secondary outcome was the proportion of patients with "occult" anemia who had their condition diagnosed during their ED encounter. Descriptive data analysis was performed. RESULTS: Our study population consisted of 2131 patients who had a complete blood count drawn in the ED. Prevalence of "occult" anemia was 13.9% (95% confidence interval [CI], 12.5%-15.4%). Proportions among the subpopulations were 14.8% (95% CI, 10.0%-19.5%) in preschool children, 16.3% (95% CI, 14.2%-18.3%) in females, 18.5% (95% CI, 15.4%-21.7%) in the uninsured, and 20.7% (95% CI, 16.5%-24.9%) in females of childbearing age without insurance. Only 24 patients (8%) with "occult" anemia had the condition identified on discharge. CONCLUSIONS: Anemia has a high prevalence in this pediatric ED population, especially among females of childbearing age and the uninsured. Pediatric emergency medicine physicians are missing on an opportunity to address a common health problem that is easily corrected with appropriate therapy and outpatient follow-up.

Pediatric prehospital evaluation of NYC cardiac arrest survival (PHENYCS).

OBJECTIVES: The objective of this study was to describe the demographics of out-of-hospital cardiac arrests (OOHCAs) in children younger than 18 years and characteristics associated with survival among these children in New York City (NYC). METHODS: A prospective observational cohort of all children younger than 18 years with OOHCA in NYC between April 1, 2002, and March 31, 2003. Data were collected from prehospital providers by trained paramedics utilizing a previously validated telephone interview process. Data included Pediatric Utstein core measures and critical prehospital time intervals. Analyses utilized descriptive statistics and bivariate association with survival. RESULTS: Resuscitation was attempted on 147 pediatric OOHCA patients in NYC during the study period; outcome data were collected on these patients. The median age was 2 years; most (58%) were male. The majority of arrests occurred at home (69%). Lay bystanders witnessed 33% of all OOHCA; 68% of witnesses were family members. Bystander cardiopulmonary resuscitation (CPR) was performed on 30% of children. Median emergency medical services response time was 3.6 minutes (range, 0.4-14.4 minutes). Initial rhythm was as follows: ventricular fibrillation, 2%; asystole, 50%; pulseless electrical activity, 9.5%; other rhythms, 11.6%; no rhythm recorded, 26%. Survival was 4% to hospital discharge and was present only among witnessed arrests (6/58 witnessed vs 0/70 unwitnessed, P < 0.05). CONCLUSIONS: Pediatric OOHCA survival rate is low. Witnessed arrest was the most important determinant of survival. Ventricular fibrillation was an uncommon rhythm measured by emergency medical services. The majority of arrests occurred at home. The rate of bystander CPR was low. Strategies to increase the rate of bystander CPR for children, especially by family members, are needed.

Pediatric prehospital evaluation of NYC respiratory arrest survival (PHENYCS).

OBJECTIVE: The objective of this study was to describe the demographics, epidemiology, and characteristics associated with survival of children younger than 18 years who had an out-of-hospital respiratory arrest (OOHRA) during a 1-year period in a large urban area. METHODS: A prospective observational cohort of consecutive children younger than 18 years with OOHRA cared for by the New York City 911 emergency medical services (EMS) system from April 12, 2002, to March 31, 2003. Following resuscitative efforts, data were collected from prehospital providers by trained paramedics using a previously validated telephone interview process. Data included Pediatric Utstein core measures and critical prehospital time intervals. Analyses used descriptive statistics and bivariate association with survival. RESULTS: Resuscitation was attempted on 109 OOHRAs during the study period. The median age was 7 years, 52% were male. Lay bystanders witnessed 56%. Most occurred at home (77%). Witnesses were family members in 59%. Bystander cardiopulmonary resuscitation (CPR) was performed in 31% of all respiratory arrests (RAs). A chronic medical condition existed in 28%. Median EMS response time was 4.4 minutes (range, 0-12 min). Overall survival was 79% to hospital discharge. Time interval to EMS arrival, witnessed arrest, bystander CPR, and ventilation method were not associated with survival. CONCLUSIONS: Most OOHRAs occurred at home, and bystander CPR occurred infrequently. The majority of children in OOHRA survived. Strategies to increase the rate of bystander CPR, especially by family members, are needed. Out-of-hospital RAs are a large proportion of all arrests in children. Future studies of pediatric arrest should include RA as well as cardiac arrest.

Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results.

It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis. OBJECTIVE: To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results. METHODS: Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results. RESULTS: Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count <4 × 103 cells/mm3 and procalcitonin <0.5 ng/mL. CONCLUSIONS: Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.

BACKGROUND: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. METHODS: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). FINDINGS: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. INTERPRETATION: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. FUNDING: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Screening for developmental delay in high-risk users of an urban pediatric emergency department.

OBJECTIVE: To determine whether screening children in an urban pediatric emergency department (PED) would lead to identification of previously undiagnosed developmental delay. METHODS: This was a cross-sectional study of families presenting to an urban public hospital PED with children 6 to 36 months and no history of developmental delay. Children were screened for possible developmental delay using the Ages and Stages Questionnaire; parents completed an instrument that assesses 5 domains: communication, gross motor, fine motor, problem solving, and personal-social. Sociodemographic data were also obtained. RESULTS: One hundred thirty-eight children were enrolled, all accompanied by their mothers. Mean age of the children was 18.9 months; 51.5% were female; 56.8% of the mothers were high-school graduates; 59.9% were immigrants; 75.4% were Latino. Twenty-one percent did not have a regular source of primary care; 26.8% (95% confidence interval, 20.1%-34.8%) screened positive in at least 1 domain, with a trend toward the highest percentage of positive screens on the communication domain (z = 1.89, P = 0.059). In a simultaneous multiple logistic regression model including all predictor variables, child age of 12 to 30 months was associated with increased adjusted odds of positive screen (adjusted odds ratio, 8.4; 95% confidence interval, 1.4-48.9). Having a primary caregiver born in the United States was statistically significant for screening positive in at least 1 Ages and Stages Questionnaire domain (P = 0.03). CONCLUSIONS: Almost 30% of 6- to 36-month-old children presenting to an urban PED without prior developmental concerns screened positive for possible delay, suggesting the utility of performing routine developmental screening in the PED. Pediatric emergency department use alone may be an indication for screening. Further study is needed for feasibility of screening for delay in the PED.

A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections.

Importance: In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. Objective: To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Design, Setting, and Participants: Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. Exposures: Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures: Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Results: We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109 per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Conclusions and Relevance: We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

Disaster preparedness: hospital decontamination and the pediatric patient--guidelines for hospitals and emergency planners.

In recent years, attention has been given to disaster preparedness for first responders and first receivers (hospitals). One such focus involves the decontamination of individuals who have fallen victim to a chemical agent from an attack or an accident involving hazardous materials. Children often are overlooked in disaster planning. Children are vulnerable and have specific medical and psychological requirements. There is a need to develop specific protocols to address pediatric patients who require decontamination at the entrance of hospital emergency departments. Currently, there are no published resources that meet this need. An expert panel convened by the New York City Department of Health and Mental Hygiene developed policies and procedures for the decontamination of pediatric patients. The panel was comprised of experts from a variety of medical and psychosocial areas. Using an iterative process, the panel created guidelines that were approved by the stakeholders and are presented in this paper. These guidelines must be utilized, studied, and modified to increase the likelihood that they will work during an emergency situation.

Prevalence of Brain Injuries and Recurrence of Seizures in Children With Posttraumatic Seizures.

OBJECTIVES: Computed tomography (CT) is often used in the emergency department (ED) evaluation of children with posttraumatic seizures (PTS); however, the frequency of traumatic brain injuries (TBIs) and short-term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBIs on CT and short-term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED. METHODS: This was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 EDs in the Pediatric Emergency Care Applied Research Network. We evaluated children < 18 years with head trauma and PTS between June 2004 and September 2006. We assessed TBI on CT, neurosurgical interventions, and recurrent seizures within 1 week. Patients discharged from the ED were contacted by telephone 1 week to 3 months later. RESULTS: Of 42,424 children enrolled, 536 (1.3%, 95% confidence interval [CI] = 1.2%-1.4%) had PTS. A total of 466 of 536 (86.9%, 95% CI = 83.8%-89.7%) underwent CT in the ED. TBIs on CT were identified in 72 (15.5%, 95% CI = 12.3%-19.1%), of whom 20 (27.8%, 95% CI = 17.9%-39.6%) underwent neurosurgical intervention and 15 (20.8%, 95% CI = 12.2%-32.0%) had recurrent seizures. Of the 464 without TBIs on CT (or no CTs performed), 457 had recurrent seizure status known, and five (1.1%, 95 CI = 0.4%-2.5%) had recurrent seizures; four of five presented with Glasgow Coma Scale scores < 15. None of the 464 underwent neurosurgical intervention. We found significant associations between likelihood of TBI on CT with longer time until the PTS after the traumatic event (p = 0.006) and longer duration of PTS (p < 0.001). CONCLUSIONS: Children with PTS have a high likelihood of TBI on CT, and those with TBI on CT frequently require neurosurgical interventions and frequently have recurrent seizures. Those without TBIs on CT, however, are at low risk of short-term recurrent seizures, and none required neurosurgical interventions. Therefore, if CT-negative and neurologically normal, patients with PTS may be safely considered for discharge from the ED.

Children requiring psychiatric consultation in the pediatric emergency department: epidemiology, resource utilization, and complications.

METHODS: A cohort of children younger than 18 years presenting to an urban pediatric emergency department (PED) who underwent psychiatric consultation was analyzed. A standardized data collection sheet was prospectively completed and included: patient characteristics, extent of medical evaluation and findings, ancillary diagnostic studies, resources utilized, dangerous behaviors, and disposition. RESULTS: Two hundred ten patients required psychiatric evaluation. Median age was 14 years; 51.9% were boys; 71.9% had a past psychiatric history; 39.0% had prior psychiatric admission(s), and 40.5% were on psychiatric medications. The admission rate was 49.5%. Patients spent a median of 5.7 hours in the PED. Hospital police monitored 51.9% patients. Forty-five patients had 91 dangerous behaviors. Those patients presenting with a complaint of aggressive behavior (P = 0.00006), a past psychiatric history (P = 0.003), or a history of prior psychiatric hospitalization (P = 0.005) were more likely to have dangerous behaviors. Two hundred nine patients underwent a complete medical evaluation, and 207 were considered medically cleared. Patients who had diagnostic evaluations for medically indicated reasons were significantly more likely to have abnormal results than those requested by the psychiatric consultant for screening purposes (43.6% vs. 9.2%; relative risk, 2.33; 95% confidence interval, 1.33-4.08) but were not statistically more likely to result in medical intervention (5.4% vs. 0%, P = 0.243). CONCLUSIONS: PED patients requiring psychiatric consultation and psychiatric admission had a prolonged PED stay and a high incidence of dangerous behaviors requiring intervention. History and physical examination adequately identified medical illness. Laboratory evaluation obtained for psychiatric transfer or admission purposes was of low yield.

Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma.

OBJECTIVE: The objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma. METHODS: This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children <2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes. RESULTS: We enrolled 42,041 patients, of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children <2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI. CONCLUSIONS: The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI.

Headache in traumatic brain injuries from blunt head trauma.

OBJECTIVE: To determine the risk of traumatic brain injuries (TBIs) in children with headaches after minor blunt head trauma, particularly when the headaches occur without other findings suggestive of TBIs (ie, isolated headaches). METHODS: This was a secondary analysis of a prospective observational study of children 2 to 18 years with minor blunt head trauma (ie, Glasgow Coma Scale scores of 14-15). Clinicians assessed the history and characteristics of headaches at the time of initial evaluation, and documented findings onto case report forms. Our outcome measures were (1) clinically important TBI (ciTBI) and (2) TBI visible on computed tomography (CT). RESULTS: Of 27 495 eligible patients, 12 675 (46.1%) had headaches. Of the 12 567 patients who had complete data, 2462 (19.6%) had isolated headaches. ciTBIs occurred in 0 of 2462 patients (0%; 95% confidence interval [CI]: 0%-0.1%) in the isolated headache group versus 162 of 10 105 patients (1.6%; 95% CI: 1.4%-1.9%) in the nonisolated headache group (risk difference, 1.6%; 95% CI: 1.3%-1.9%). TBIs on CT occurred in 3 of 456 patients (0.7%; 95% CI: 0.1%-1.9%) in the isolated headache group versus 271 of 6089 patients (4.5%; 95% CI: 3.9%-5.0%) in the nonisolated headache group (risk difference, 3.8%; 95% CI: 2.3%-4.5%). We found no significant independent associations between the risk of ciTBI or TBI on CT with either headache severity or location. CONCLUSIONS: ciTBIs are rare and TBIs on CT are very uncommon in children with minor blunt head trauma when headaches are their only sign or symptom.

Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults.

OBJECTIVE: To determine the accuracy of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults by a group of clinicians. DESIGN: Prospective observational cohort study. SETTING: Two urban emergency departments. PARTICIPANTS: Patients from birth to age 21 years undergoing chest radiography for suspected community-acquired pneumonia. INTERVENTION: After documenting clinical examination findings, clinicians with 1 hour of focused training used ultrasonography to diagnose pneumonia in children and young adults. MAIN OUTCOMES MEASURES: Test performance characteristics for the ability of ultrasonography to diagnose pneumonia were determined using chest radiography as a reference standard. Subgroup analysis was performed in patients having lung consolidation exceeding 1 cm with sonographic air bronchograms detected on ultrasonography; specificity and positive likelihood ratio (LR) were calculated to account for lung consolidation of 1 cm or less with sonographic air bronchograms undetectable by chest radiography. RESULTS: Two hundred patients were studied (median age, 3 years; interquartile range, 1-8 years); 56.0% were male, and the prevalence of pneumonia by chest radiography was 18.0%. Ultrasonography had an overall sensitivity of 86% (95% CI, 71%-94%), specificity of 89% (95% CI, 83%-93%), positive LR of 7.8 (95% CI, 5.0-12.4), and negative LR of 0.2 (95% CI, 0.1-0.4) for diagnosing pneumonia by visualizing lung consolidation with sonographic air bronchograms. In subgroup analysis of 187 patients having lung consolidation exceeding 1 cm, ultrasonography had a sensitivity of 86% (95% CI, 71%-94%), specificity of 97% (95% CI, 93%-99%), positive LR of 28.2 (95% CI, 11.8-67.6) and negative LR of 0.1 (95% CI, 0.1-0.3) for diagnosing pneumonia. CONCLUSION: Clinicians are able to diagnose pneumonia in children and young adults using point-of-care ultrasonography, with high specificity.

A randomized trial of simulation-based deliberate practice for infant lumbar puncture skills.

BACKGROUND: Infant lumbar puncture (LP) is mandated by the Accreditation Council for Graduate Medical Education for all pediatric trainees. Current training usually involves the apprenticeship model of "see one, do one, teach one" where a trainee's first LP attempt occurs in a high-stakes environment. Simulation training promotes skill development in a safe environment before patient contact. OBJECTIVE: To demonstrate that deliberate practice simulation-based training after audiovisual training (AV) improves infant LP skills compared with a control group receiving AV training only. DESIGN/METHODS: This was a randomized trial of simulation-based training + AV versus AV only for pediatric residents. On enrollment, the subjects' infant LP skills were evaluated through their performance on a simulator. A questionnaire and brief quiz were administered to collect information on the subjects' infant LP experience, knowledge, and confidence. All subjects viewed an educational AV presentation. The intervention group went on to participate in a simulation-based deliberate practice session on the infant LP simulator while the control group did not. Our primary outcome was self-reported clinical success on the first infant LP after training. Secondary outcomes were rates of traumatic clinical LPs, infant LP skills (measured via observed structured clinical examinations on the simulator 6 months after training), and change in participants' knowledge and confidence. RESULTS: Fifty-one residents reported 32 clinical encounters. Sixteen of 17 subjects (94%) in the intervention group who performed a clinical infant LP obtained cerebrospinal fluid compared with 7 of 15 subjects (47%) in the control group (difference = 47%; 95% CI = 16%-70%). There was no difference between groups at 6 months on observed structured clinical examination performance, knowledge, or confidence. CONCLUSIONS: Participation in a simulation-based deliberate practice intervention can improve infant LP skill.