Management of Acute Injury and Illness in Pediatric Athletes by Athletic Trainers: Compliance With Emergency Medicine and Athletic Trainer Evidence-Based Guidelines.

OBJECTIVE: This study aimed to determine athletic trainer compliance with emergency medicine and athletic training evidence-based guidelines for the on-the-field management of common pediatric sports-related injury and illness. METHODS: A questionnaire was distributed electronically to selected members of the National Athletic Trainer Association. The questionnaire included 10 clinical scenarios describing common sports-related injury/illness (closed head injury, cervical spine injury, blunt chest injury, blunt abdominal injury, ankle injury, knee injury with laceration, heat-related illness). On-the-field management decisions for each scenario were compared with selected emergency medicine and athletic training guidelines. RESULTS: Analysis was performed on 564 completed questionnaires (9% response rate). Responders were compliant with practice guidelines for both emergency medicine and athletic training except for blunt chest trauma with tachycardia, closed head injury with loss of consciousness, closed head injury with repetitive speech, closed head injury with a fall higher than 5 feet, cervical spine injury with paresthesias, and heat-related illness with persistent symptoms. Discrepancies between emergency medicine and athletic training guidelines included closed head injury with repetitive speech, closed head injury and height of fall, closed head injury and unequal pupils, and cervical spine injury with neck pain and paresthesias. CONCLUSIONS: Based on our sample, athletic trainers were compliant with many guidelines supported by both emergency medicine and athletic training. We identified several deficiencies in the availability of evidence-based guidelines and discrepancies between these guidelines and athletic trainer responses. To provide optimal care to pediatric athletes who sustain injury or illness, emergency medicine and athletic training organizations should collaborate to improve these discrepancies.

Referrals for Pediatric Appendicitis to a Tertiary Care Children's Hospital.

OBJECTIVES: This study aimed to analyze pediatric referrals for definite or possible appendicitis, to compare clinical predictors and laboratory values between patients with and without a final diagnosis of appendicitis, and to determine the accuracy of prereferral diagnostic interpretations of computed tomography scans, ultrasound, and magnetic resonance imaging modalities. METHODS: We conducted a retrospective analysis of pediatric patients referred from 2015 to 2019 to a tertiary care children's emergency department with definitive or possible appendicitis. Data abstracted included patient demographics, clinical symptoms, physical examination findings, laboratory results, and diagnostic imaging findings (by the referring center and the pediatric radiologist at the accepting center). An Alvarado and Appendicitis Inflammatory Response (AIR) score was calculated for each patient. RESULTS: Analysis was performed on 381 patients; 226 (59%) had a final diagnosis of appendicitis. Patients with appendicitis were more likely to have symptoms of nausea ( P < 0.0001) and vomiting ( P < 0.0001), have a higher mean temperature ( P = 0.025), right lower quadrant abdominal pain to palpation ( P = <0.0001), rebound tenderness ( P < 0.0001), a higher mean Alvarado score [5.35 vs 3.45 ( P < 0.0001)], and a higher mean AIR score [4.02 vs 2.17 ( P < 0.0001)]. Of the 97 diagnostic images initially interpreted as appendicitis by the referring center, 10 (10.3%) were read as no evidence of appendicitis. Of the 62 diagnostic images initially interpreted as "possible appendicitis" by the referring center, 34 (54.8%) were read as no evidence of appendicitis. Of those diagnostic images initially interpreted as "appendicitis" or "possible appendicitis" by the referring center, 24/89 (27.0%) of computed tomography scans, 17/62 (27.4%) of ultrasounds, and 3/8 (37.5%) of magnetic resonance imaging results were read as no evidence of appendicitis. CONCLUSIONS: Usage of established scoring algorithms, such as Alvarado and AIR, may decrease the unnecessary cost of diagnostic imaging and transfer to tertiary care. Virtual radiology consultations may be 1 potential solution to improve the referral process for pediatric appendicitis if initial interpretation is uncertain.

Pediatric Urgent Care Center Management of Traumatic Injuries in Infants and Children: Adherence to Evidence-Based Practice Guidelines.

OBJECTIVES: To determine pediatric urgent care (PUC) clinician adherence to evidence-based practice guidelines in the management of pediatric trauma and to evaluate PUC emergency preparedness for conditions such as severe hemorrhage. METHODS: A questionnaire covering acute management of 15 pediatric traumatic injuries, awareness of the Stop the Bleed initiative, and presence of emergency equipment and medications was electronically distributed to members of the Society for Pediatric Urgent Care. Clinician management decisions were evaluated against evidence-based practice guidelines. RESULTS: Eighty-three completed questionnaires were returned (25% response rate). Fifty-three physician and 25 advanced practice provider (APP) questionnaires were analyzed. Most respondents were adherent to evidence-based practice guidelines in the following scenarios: cervical spine injury; head injury without neurologic symptoms; blunt abdominal injury; laceration without bleeding, foreign body, or signs of infection; first-degree burn; second-degree burn with less than 10% total body surface area; animal bite with and without probable tenosynovitis; and orthopedic fractures. Fever respondents were adherent in the following scenarios: head injury with altered mental status (adherence: physicians, 64%; APPs, 44%) and laceration with foreign body and persistent hemorrhage (adherence: physicians, 52%; APPs, 41%). Most respondents (56%) were unaware of Stop the Bleed and only 48% reported having a bleeding control kit/tourniquet at their urgent care. CONCLUSIONS: Providers in our sample demonstrated adherence with pediatric trauma evidence-based practice guidelines. Increased PUC provider trauma care certification, PUC incorporation of Stop the Bleed education, and PUC presence of equipment and medications would further improve emergency preparedness.

School Nurses on the Front Lines of Healthcare: Emergencies Associated With Sport and Physical Activities (Part 3): Shortness of Breath in a Pediatric Athlete During a Track Event.

Sport participation is an important part of the development, both physically and mentally, of children and adolescents in the United States. Illness and injury associated with sport and physical activities may occur in the school setting. Although most sport-related illness and injury in students are considered minor emergencies, life-threatening illnesses or injuries may occur. It is important for the school nurse to recognize potential life-threatening emergencies associated with sport and physical activity, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow-up at their primary healthcare provider's office, or directly to the closest emergency department [ED] via Emergency Medical Services [EMS]). This article specifically describes the initial assessment and management of shortness of breath in an adolescent athlete during a track event.

School Nurses on the Front Lines of Healthcare: Emergencies Associated With Sport and Physical Activities (Part 4)-The Assessment of Pediatric Shoulder and Hip Injuries Utilizing the "SPASMS" Mnemonic.

Sport participation is an important part of the development, both physically and mentally, of children and adolescents in the United States. Illness and injury associated with sport and physical activities may occur in the school setting. Although most sport-related illness and injury in students are considered minor emergencies, life-threatening illnesses or injuries may occur. It is important for the school nurse to recognize potential life-threatening emergencies associated with sport and physical activity, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow up at their primary healthcare provider's office, or directly to the closest emergency department [ED] via Emergency Medical Services [EMS]). This article specifically describes the initial assessment and management of shoulder and hip injuries in pediatric athletes.

School Nurses on the Front Lines of Health Care: Clinical Presentations Associated With COVID-19 Infection.

Over the past 2 years, COVID-19 has swept through the United States and our world, infecting millions of people. Due to the high transmissibility of this communicable disease, school-age children are at a unique risk because of close contact with others throughout the day. Many children who contract COVID-19 will go on to have asymptomatic or mild noncomplicated symptomatic infections. However, some children will develop severe or persistent symptoms. Given the unique position of school nurses in seeing a large volume of children and adolescents, it is important that they are familiar with the variable presentations and complications of COVID-19. Throughout this article, we discuss three cases of students presenting to the school nurse's office with signs and symptoms associated with COVID-19 infection.

School Nurses on the Front Lines of Healthcare: Getting aHEAD of EmergENT Eye, Ear, Nose, and Throat Infections.

School nurses may deal with various common infectious eye, ear, nose, and throat-related chief complaints in regular practice. Recognizing the signs and symptoms of severe infection is paramount to preventing life-threatening complications that can have both acute and long-term implications. Distinguishing urgent and emergent eye, ear, nose, and throat conditions to send to the emergency department is integral to reducing the morbidity associated with these conditions. This article discusses three different students presenting with various chief complaints, from the initial assessment by the school nurse to the appropriate disposition and follow-up.

School Nurses on the Front Lines of Healthcare: Recognizing "BONES" and Knowing When to Pick Up the Phone: Eating Disorders Among Students in the School Setting.

Through a case presentation, this article describes the assessment and management of a student presenting with a history of disordered eating and weight loss. As medical concerns are brought to the attention of the school nurse, it is important for the school nurse to be aware of common signs and symptoms seen in students with undiagnosed or established eating disorders, as well as possible medical complications associated with untreated or poorly controlled eating disorders. Possible signs and symptoms associated with eating disorders that require outpatient referral or emergent management is delineated in this article, and school nurses are provided with a helpful mnemonic called "BONES" to aid in the recognition of eating disorders in the school setting.

School Nurses on the Front Lines of Healthcare: Emergencies Associated With Sport and Physical Activities (Part 2): Sudden Cardiac Arrest, Hypovolemic Shock, and Spinal Cord Injury.

Sport participation is an important part of the development, both physically and mentally, of children and adolescents in the United States. Illness and injury associated with sport and physical activities may occur in the school setting. Although most sport-related illness and injury in students are considered minor emergencies, life-threatening illnesses or injuries may occur. It is important for the school nurse to recognize potential life-threatening emergencies associated with sport and physical activity, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow up at their primary healthcare provider's office, or directly to the closest emergency department via Emergency Medical Services). This article specifically describes the initial assessment and management of three potentially life-threatening conditions associated with sport and physical activity, namely sudden cardiac arrest, hypovolemic shock, and spinal cord injury.

School Nurses on the Front Lines of Healthcare: The Approach to a Student With Anxiety and Posttraumatic Stress Disorder.

Mental illness is common, and its severity ranges from subclinical to severe, where the condition affects daily social and academic functioning. Because of its ubiquity, it is necessary that school nurses have an enhanced understanding of some of the mental health conditions that children and adolescents may be facing. As will be discussed, some mental health concerns present with somatic symptoms that may bring the student into the school nurse's office. If the nurse identifies mental health symptoms, he or she may be able to intervene, provide support, and direct the student for further management if necessary. This article will focus on anxiety in general before focusing on specific anxiety disorders, including posttraumatic stress disorder. We will begin by defining these conditions and then move into discussing potential present-day stressors, such as fear and anxiety associated with the recent coronavirus disease 2019 pandemic, and screening tools before closing with some suggestions for practice and a case wrap-up.

School Nurses on the Front Lines of Healthcare: Children With Medical Devices-Central Venous Access Device Malfunctions and Infections.

An important subgroup of children with special healthcare needs are children with medical complexities that require long-term intensive healthcare interventions and treatments. As medical technology continues to advance and children with complex medical needs survive the neonatal period and progress into school-age, it is essential for school nurses to be able to recognize and acutely manage complications and malfunctions of devices in children requiring assistance from medical devices. An example of a common medical device includes central venous access devices that allow for access to the bloodstream to obtain blood for laboratory testing or to infuse medications or nutrition. These devices put children at serious medical or surgical risk when they malfunction or become infected, so it is important for healthcare providers, especially school nurses who are the first responders in schools, to recognize malfunctions and initiate appropriate care management.

School Nurses on the Front Lines of Healthcare: Red Flags and Red Herrings: Improving the Recognition of Bruises and Burns Associated With Physical Abuse in School-Age Children.

Through a series of case scenarios, this article describes the assessment and management of suspected physical child abuse presenting as bruises and burns. Although it is not uncommon for school-age children to have accidental injuries, recognizing patterns associated with physical child abuse and understanding red flags for abuse is vital. Failure to recognize injury patterns suspicious for physical child abuse, and thus failure to intervene appropriately, may leave children at risk for more serious injury or death.

School Nurses on the Front Lines of Healthcare: Children With Medical Devices-A "BOLUS" of Information About Gastrostomy Tube Malfunctions and Infections.

An important subgroup of children with special healthcare needs are children with medical complexities that require long-term, intensive healthcare interventions and treatments. As medical technology continues to advance and children with complex medical needs survive the neonatal period and progress into school-age, it is essential for school nurses to be able to recognize and acutely manage complications and malfunctions of devices in children requiring assistance from medical devices. An example of a common medical device includes gastrostomy tubes (aka G-tubes or GJ-tubes), ensuring nutrition in children with failure to thrive, significant developmental delay, swallowing dysfunction, or severe gastroesophageal reflux. These devices put children at serious medical or surgical risk when they malfunction, so it is important for healthcare providers, especially school nurses who are the first responders in schools, to recognize malfunctions and initiate appropriate care management.

School Nurses on the Front Lines of Healthcare: Children With Medical Devices-Shunt System Malfunctions and Infections.

An important subgroup of children with special healthcare needs are those children with medical complexities who require long-term intensive healthcare interventions and treatments. As medical technology continues to advance and children with complex medical needs survive the neonatal period and progress into school-age, it is essential for school nurses to be able to recognize and acutely manage complications and malfunctions of devices in children requiring assistance from medical devices. An example of a common medical device includes shunts systems (e.g., a ventriculoperitoneal shunt) to drain excess cerebrospinal fluid. These devices put children at serious medical or surgical risk when they malfunction or become infected, so it is important for healthcare providers, especially school nurses who are the first responders in schools, to recognize malfunctions and initiate appropriate care management. This article describes the initial assessment and management of common medical emergencies in students who have those devices.

School Nurses on the Front Lines of Healthcare: A Guide in the Recognition of and Response to Teen Dating Violence in Your Schools.

Teen dating violence (TDV) has become more prevalent in our schools, exacerbated by the omnipotent presence of social media and portals of what dating and gender roles "should be" in Hollywood films and television shows. It is important to recognize that TDV is a threat to mental health, and potentially physical health, and school nurses should develop a framework for recognizing problematic social, physical, and emotional interactions between students. This article describes typical presentations of TDV through a case, providing a mnemonic for recognition and resources for prevention.

School Nurses on the Front Lines of Healthcare: Recognizing the Signs and Putting the "BRAKES" on the Commercial Sexual Exploitation of Children.

Through a presented case scenario, this article describes the assessment and management of the commercial sexual exploitation of children (CSEC), which includes sex trafficking, as relevant for the school nurse. CSEC is a major public health problem globally, nationally, and locally, even infiltrating school hallways. School nurses may be the last point of possible intervention for potential or actual victims of CSEC, therefore, it is vital for a school nurse to be able to recognize, report, and assist with advocacy and prevention efforts in the school community to put the brakes on the exploitation of children.

School Nurses on the Front Lines of Healthcare: Serious Infections in Students and Their Common Presenting Complaints.

School nurses occasionally deal with students presenting with serious infections associated with common chief complaints. Although rare, the implications of missing the signs and symptoms of these infections are potentially life-threatening and devastating, with both immediate and long-term complications. Rapid recognition and stabilization, with immediate transfer to the closest emergency department via emergency medical services for antibiotic administration, is the key to reducing morbidity and mortality associated with these serious infections. We discuss three students presenting with febrile illnesses associated with chest pain, headache, and back pain, focusing on the initial assessment and management of these students and their common presenting complaints.

School Nurses on the Front Lines of Healthcare: Infectious Diseases Popularized in the News.

School nurses may deal with students presenting with symptoms associated with infections popularized in the news. Although rare, the implications of missing or misdiagnosing these infections are potentially life-threatening and devastating. We present three students presenting with febrile illnesses associated with neurologic symptoms, a rash, and fatigue, focusing on the initial assessment and management of these students and their associated "hot topic" infection. The authors also discuss two public health organizations, Centers for Disease Control and Prevention (https://www.cdc.gov/) and the World Health Organization (https://www.who.int/), online references for the school nurse to research both emerging and common infectious diseases.

School Nurses on the Front Lines of Healthcare: The Approach to Maintaining Student Health and Wellness During COVID-19 School Closures.

In response to the novel coronavirus disease 2019 (COVID-19) pandemic, most states in the United States enacted statewide school closures, ranging in duration from 1 month to the remainder of the academic year. The extended durations of these closures present unique challenges, as many families rely on the school as a source of physical activity, mental health services, psychosocial support, child care, and food security. While the school doors may be closed, the school nurse can still play a vital role in emergency management. This article discusses challenges and proposes solutions to maintaining student health and wellness during extended school closures due to the COVID-19 pandemic. Furthermore, it is inevitable that until a vaccine for coronavirus is developed and readily available, many schools will continue to see future closures, though likely for shorter periods of time, as they respond to local outbreaks.

School Nurses on the Front Lines of Medicine: When You Don't Need to "STOP AT AN ER STAT!"-The Role of Urgent Care Centers in the Management of Students With Nonemergent Chief Complaints.

In the midst of our nation's growing primary care provider shortage and subsequent overutilization of the emergency room (ER), urgent care centers represent an accessible, convenient, and affordable alternative for the management of "urgencies" or nonemergent illnesses and injuries. Despite the presence of competent healthcare providers and a wide array of services at urgent care centers, patients continue to pursue care in the ER for urgencies. School nurses may utilize urgent care centers for the evaluation and management of students with nonemergent medical or traumatic chief complaints. This article discusses the field of urgent care medicine, describes the pediatric services provided at urgent care centers, and summarizes the capabilities of centers to deal with potential urgencies versus emergencies in children and adolescents based on their chief complaint.