Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler.

Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.

Characteristics and behavioral risk factors of firearm-exposed youth in an urban emergency department.

Assessing firearm access among adolescents with behavioral health risk factors is important for the primary prevention of suicide and interpersonal violence. We describe self-reported firearm access and the associated behavioral risk factors and demographic characteristics in a cross-sectional study conducted in the emergency department of an urban pediatric hospital from June 2013 to June 2014. A total of 2258 adolescents received a behavioral health survey to assess access to firearms inside and outside the home, mental health symptoms, and risk behaviors. One of 6 patients in our sample (15%) endorsed access to a firearm. Male gender, lifetime alcohol use, lifetime marijuana use, and lifetime other drug use were associated with access. Participants reporting access were more likely to report clinical levels of lifetime suicidality and depression. The odds of current suicidality were highest in those with 24-h access (OR 2.77 CI 1.73-4.46), compared to those who did not endorse access.

Dexamethasone Compared to Prednisone for the Treatment of Children With Acute Asthma Exacerbations.

Systemic corticosteroids are recommended in clinical practice guidelines for the treatment of acute asthma exacerbation based on evidence demonstrating reduced hospitalizations and improved outcomes after administration in the emergency department. Although prednisone and related oral preparations have been recommended previously, researchers have assessed dexamethasone as an alternative based on its longer biologic half-life and improved palatability. Systematic reviews of multiple small trials and 2 larger trials have found no difference in revisits to the emergency department compared to prednisone for dexamethasone given either as an intramuscular injection or orally. Studies of oral administration have found reduced emesis for dexamethasone compared to prednisone both in the emergency department and for a second oral dose, typically given 24 to 48 hours later. Studies assessing a single dose of dexamethasone have found equivalent improvement at follow-up but with some evidence of increased symptoms and increased need for additional corticosteroids compared to multiple doses of prednisone. Future research could further assess dexamethasone dose, formulation, and frequency and measure other related adverse effects such as behavior change. Consideration of baseline differences within the heterogeneous population of children requiring acute care for asthma may also guide the design of an optimal dexamethasone regimen.

Medulloblastoma With Obstructive Hydrocephalus in a Young Infant.

Medulloblastoma is the most common posterior fossa tumor diagnosed in young infants. The presentation of posterior fossa tumors in neonates is highly variable. We report the case of a 2-month-old child who presented with poor feeding and lethargy and was noted to have a fixed downward gaze. Head computed tomography revealed a posterior fossa mass that was pathologically consistent with a medulloblastoma. This case demonstrates the uncommon presentation of posterior fossa tumors in young infants.