Pediatric Toxidrome Simulation Curriculum: Jimson Weed Toxicity.

Introduction: Jimson weed is a poisonous plant containing tropane alkaloids that can cause anticholinergic toxicity. Recognition of anticholinergic toxidrome is important for prevention and management of potentially life-threatening complications of severe toxicity, including dysrhythmia and seizure. Methods: Designed for pediatric emergency medicine (PEM) fellows, this simulation featured a 15-year-old female presenting to the emergency department (ED) with agitation and hallucinations. The team was required to perform a primary survey of the critically ill patient, recognize anticholinergic toxidrome from jimson weed intoxication, and treat complications of severe anticholinergic toxicity. Learners practiced critical resuscitation skills such as management of generalized tonic-clonic seizure, endotracheal intubation, synchronized cardioversion, and external cooling measures. A debriefing guide and participant evaluation forms were utilized. This simulation was created as both an in-person and a virtual simulation experience to accommodate COVID-19 social distancing guidelines. Results: Seventeen PEM fellows completed this simulation across three institutions (two in person, one virtual). Using 5-point Likert scales (with 5 being the most relevant or effective), participants rated the simulation as relevant to their work (M = 4.8, SD = 0.5) as well as effective in teaching basic resuscitation skills (M = 4.7, SD = 0.5), management of generalized tonic-clonic seizure (M = 4.8, SD = 0.5), and treatment of ventricular tachycardia with appropriate interventions (M = 4.6, SD = 0.5). Discussion: This simulation scenario allows pediatric medicine trainees in the ED to practice recognition and management of anticholinergic toxicity and its severe complications secondary to jimson weed ingestion.

Belhassen Tachycardia in a Pediatric Patient: A Simulation for Pediatric Emergency Medicine Fellows.

Ventricular tachycardia in pediatric emergency department patients is a high-risk, low-frequency event well suited for education through simulation. This technical report describes a simulation-based curriculum for Pediatric Emergency Medicine fellows and senior residents involving the evaluation and management of a 10-year-old female presenting with palpitations who is ultimately diagnosed with Belhassen tachycardia. The curriculum highlights the features that differentiate Belhassen tachycardia (idiopathic left posterior fascicular ventricular tachycardia) from supraventricular or other tachycardias, building upon foundational pediatric resuscitation skills and Pediatric Advanced Life Support (PALS) algorithms for advanced learners.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS) Telesimulation Series: Hyperleukocytosis.

Introduction: Hyperleukocytosis, an infrequent presentation of new-onset leukemia, is a medical emergency requiring prompt recognition and treatment. It can include altered mental status, fever, critical electrolyte derangements, and coagulopathies. Due to the COVID-19 pandemic, this simulation was created as a telesimulation in order to adhere to mandatory physical distancing guidelines while addressing learning objectives. Methods: This simulation was designed for pediatric emergency medicine fellows and featured a pediatric patient presenting with fever, altered mental status, and respiratory distress. After an initial assessment and appropriate workup, the patient developed tumor lysis syndrome, coagulopathies, and new-onset neurologic changes requiring appropriate interventions. A debriefing guide and participant evaluation form were utilized. Results: This telesimulation was implemented at five different institutions, with evaluation surveys completed by 22 pediatric emergency medicine fellows. The scenario was rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) and was generally well received, with participants rating the simulation as effective in teaching the recognition (M = 4.8) and management (M = 4.6) of hyperleukocytosis. Participants felt that virtual telesimulation was effective compared to other distance learning methods (M = 3.9). Discussion: This simulation-based curriculum allows learners to practice identifying and managing hyperleukocytosis. We found that it was well received in both in-person and virtual formats.

Pediatric Rattlesnake Envenomation: A Simulation Scenario With Optional Health Equity, Virtual Facilitation, and Senior Learner Modifications.

Rattlesnake envenomation is an uncommon but urgent cause of presentation for emergency care. Recognition of envenomation, timely administration of antivenom when indicated, and recognition of antivenom reactions are of critical importance to mitigate the local, hematologic, and systemic effects of Crotaline venom. This technical report describes the presentation and use of a simulation-based scenario of an envenomated child who requires treatment with antivenom. Optional additions to this scenario are described and include antivenom reaction, health equity considerations, and virtual facilitation.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Pediatric Diabetic Ketoacidosis.

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening illness which classically presents with polyuria, polydipsia, and polyphagia that can rapidly progress to severe dehydration and altered mental status from cerebral edema. Younger patients may present with subtle or atypical symptoms that are critical to recognize and emergently act upon. Such patients are often cared for by teams in the emergency department (ED) requiring multidisciplinary collaboration. Methods: This simulation case was designed for pediatric emergency medicine fellows and residents. The case was a 14-month-old male who presented to the ED with respiratory distress and dehydration. The team was required to perform an assessment, manage airway, breathing and circulation, and recognize and initiate treatment for DKA including judicious fluid administration and an insulin infusion. The patient developed altered mental status with signs of cerebral edema requiring the initiation of cerebral protection strategies. We created a debriefing guide and a participant evaluation form. Results: Forty-two participants completed this simulation across seven institutions including attendings, residents, fellows, and nurses. The scenario was rated by participants on a 5-point Likert scale and was generally well received (M = 5.0). Participants rated the simulation case as effective in teaching how to recognize (M = 4.8) and manage (M = 4.5) DKA with cerebral edema in a pediatric patient. Discussion: This simulation represents a resource for learners in the pediatric ED in the recognition and management of a toddler with DKA and can be adapted to learners at all levels and tailored to various learning environments.

Pediatric Emergency Medicine Simulation Curriculum: Vitamin K Deficiency in the Newborn.

Introduction: The American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB. Methods: This simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials. Results: The simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management. Discussion: This simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.

Point-of-Care Ultrasound for Confirmation of Nasogastric and Orogastric Tube Placement in Pediatric Patients.

OBJECTIVES: The aim of the study was to investigate the role of point-of-care ultrasound (POCUS) as an alternative imaging modality to confirm proper placement for nasogastric tubes (NGTs) and orogastric tubes (OGTs) in pediatric patients. METHODS: This was a prospective descriptive study performed at a tertiary care free-standing children's hospital. Patients 21 years and younger requiring radiographic confirmation of NGT or OGT placement were eligible for enrollment. Bedside ultrasonography examination of the epigastric area was performed by a blinded pediatric emergency medicine physician. An abdominal radiograph was obtained to confirm NGT or OGT placement in all patients. RESULTS: A total of 26 patients with a mean age of 2.6 years (standard deviation, 3.9 years) were enrolled. All 26 patients had x-ray confirmation of NGT and OGTs correctly placed in the stomach. Confirmation of NGT or OGT placement by ultrasound was obtained in 23 patients. For these 23 patients, POCUS agreed with radiographic findings. For 3 patients, the NGT and OGT was unable to be identified by ultrasound. The sensitivity of ultrasound for detecting a properly placed tube was 88% (95% confidence interval, 70.0%-97.6%). CONCLUSIONS: This pilot study described ultrasound confirmation of NGT or OGT placement. If confirmed in larger studies, POCUS can be used as an objective tool for the confirmation of NGT or OGT placement in pediatric patients and limit the need for routine x-ray confirmation.

Wilderness Medicine (Hypothermia, Dehydration, and Ankle Injury): A Pediatric Simulation Case for Medical Trainees.

Introduction: Wilderness recreation is increasingly popular among people of all ages. Pediatric providers should have the skills to counsel on risk reduction and respond to medical emergencies in remote settings. However, few physicians receive training in wilderness medicine, and this simulation-based curriculum aims to address that gap. Methods: The scenario features an adolescent male in a remote setting with hypothermia, dehydration, and an ankle injury. The simulation is not resource intensive, utilizing a simulated patient actor and minimal equipment. The case includes a case description, learning objectives, instructor notes, example of ideal scenario flow, and anticipated management mistakes. A didactic PowerPoint highlighting the learning objectives is included. Results: The simulation was carried out over 1 year in various settings, including urban parks, the wilderness, and the classroom, with 35 medical trainees. Thirty participants (11 medical students, eight residents, and 11 fellows) completed postsimulation surveys; more than 86% gave the highest score of 5 (strongly agree) when asked if the simulation improved their understanding of managing hypothermia, dehydration, and ankle injury in the wilderness. Discussion: This simulation case trains responders to recognize an injured hiker; activate the emergency response system; initiate appropriate treatment for hypothermia, dehydration, and an ankle injury; and stabilize for transport. It reinforces medical conditions unique to the wilderness, improvisation in managing medical issues outside of the usual health care environment, and teamwork/communication skills. This case has been found to be an effective learning tool for medical students, residents, and fellow physicians alike.

"It's Not a Tumor": A Rare Case of Symptomatic Cerebellar Developmental Venous Anomaly.

Cerebral developmental venous anomalies (DVAs) are benign anatomical variants of the venous system and are commonly described as an incidental finding without clinical significance. Neurologic symptoms or abnormal examination findings are rare and usually attributed to hemorrhagic complications related to coexisting cavernous malformations. There have been limited case reports of symptomatic, uncomplicated DVAs described in the literature. The following case describes a previously healthy child who presented to the emergency department with an acute onset of altered mental status, headache, and focal neurologic examination abnormalities. Magnetic resonance imaging revealed a prominent cerebellar DVA. There was no evidence of a cavernous angioma, hemorrhage, or acute parenchymal injury. This case report illustrates a clinically symptomatic, uncomplicated posterior fossa DVA. It provides additional evidence regarding the potential for a cerebral venous malformation in causing focal neurologic deficits.

Pediatric Emergency Medicine Simulation Curriculum: Cardiac Tamponade.

Introduction: Cardiac tamponade is an uncommon presentation to the pediatric emergency department and requires early recognition and emergent intervention. Methods: We developed this patient simulation case to simulate a low-frequency, high-acuity scenario for pediatric emergency medicine fellows and resident physicians in emergency medicine, pediatrics, and family medicine. We ran the case in a pediatric emergency department using a high-fidelity pediatric mannequin and equipment found in the clinical environment, including a bedside ultrasound machine. The case involved a 10-year-old patient with Hodgkin lymphoma who presented with fever, neutropenia, and shock and was found to have a pericardial effusion with tamponade after evaluation. The providers were expected to identify signs and symptoms of shock, as well as cardiac tamponade, and demonstrate appropriate emergent evaluation and management. Required personnel included a simulation technician, instructors, and a nurse. Debriefing tools tailored specifically for this scenario were created to facilitate a formal debriefing and formative learner assessment at the end of the simulation. Results: This case has been implemented with 10 pediatric emergency medicine fellows during two 3-year cycles of fellow education. Session feedback reflected a high level of satisfaction with the case and an increased awareness of bedside ultrasound in the identification of cardiac tamponade. Discussion: This resource for teaching the critical components for diagnosing and managing unstable cardiac tamponade in the pediatric patient, including use of bedside ultrasound, was well received by pediatric emergency medicine fellows.

Delirium Upon Presentation to the Pediatric Emergency Department: A Case Series.

The following cases describe children who presented to the emergency department (ED) with a constellation of symptoms consistent with delirium. In each case, there was no identified inciting cause (eg, fever, medications) other than the presence of influenza. All children had variable workups, with 2 children undergoing extensive neurologic evaluation and testing. Clinical recognition of delirium in the pediatric acute care setting can be challenging, but heightened awareness by ED and primary care physicians may lead to earlier diagnosis, prevent unwarranted investigations, and decrease hospitalization. Children with influenza may be at increased risk of developing delirium. A prospective study to assess the prevalence of delirium in pediatric patients presenting to the ED with influenza is warranted.

A Readily Available, Inexpensive, and Reusable Simulation Model for Teaching Ultrasound-Guided Abscess Identification and Drainage.

BACKGROUND: The use of point-of-care ultrasonography as a noninvasive diagnostic tool for soft tissue infections has been shown to be superior to clinical judgment alone in determining the presence or absence of an occult abscess. As ultrasound-guided procedures become standard of care, there is an increasing demand to develop better and inexpensive simulation models to educate trainees. To date, there are no low-cost models for abscess simulation that can be constructed with minimal preparation time, be reused, and withstand multiple procedural attempts. OBJECTIVE: To create an inexpensive, readily available, and reusable homemade ultrasound phantom that simulates a superficial soft tissue abscess and can be easily constructed. DISCUSSION: We experimented with precooked polenta to create a model that would appear similar to human soft tissue under ultrasound examination. Paintballs were embedded in the polenta and evaluated at different depths until a sonographically satisfactory phantom abscess model was obtained. The use of a precooked commercial polenta phantom and commercial paintballs required minimal preparation and closely replicated a superficial soft tissue abscess on ultrasonographic examination. Various paintball brands and sizes were evaluated to confirm ease of reproducibility. The polenta can be reshaped easily and the model may be punctured or incised multiple times. CONCLUSION: A homemade high-fidelity simulation phantom that simulates an abscess in superficial soft tissue can be made inexpensively in <5 min and reused for numerous trainees. This model allows for training for procedures such as ultrasound-guided abscess drainage.

Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU*.

OBJECTIVE: To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool. DESIGN: Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared with an assessment by consultation liaison child psychiatrist using the Diagnostic and Statistical Manual IV criteria as the "gold standard" for diagnosis of delirium. An initial series of duplicate Cornell Assessment of Pediatric Delirium assessments were performed in blinded fashion to assess interrater reliability. Nurses recorded the time required to complete the Cornell Assessment of Pediatric Delirium screen. SETTING: Twenty-bed general PICU in a major urban academic medical center over a 10-week period, March-May 2012. PATIENTS: One hundred eleven patients stratified over ages ranging from 0 to 21 years and across developmental levels. INTERVENTION: Two hundred forty-eight paired assessments completed. MEASUREMENTS AND MAIN RESULTS: The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8-98.8%) and specificity of 79.2% (95% CI, 73.5-84.9%). Overall Cronbach's α of 0.90 was observed, with a range of 0.87-0.90 for each of the eight items, indicating good internal consistency. A scoring cut point of 9 demonstrated good interrater reliability of the Cornell Assessment of Pediatric Delirium when comparing results of the screen between nurses (overall κ = 0.94; item range κ = 0.68-0.78). In patients without significant developmental delay, sensitivity was 92.0% (95% CI, 85.7-98.3%) and specificity was 86.5% (95% CI, 75.4-97.6%). In developmentally delayed children, the Cornell Assessment of Pediatric Delirium showed decreased specificity of 51.2% (95% CI, 24.7-77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5-100%). The Cornell Assessment of Pediatric Delirium takes less than 2 minutes to complete. CONCLUSIONS: With an overall prevalence rate of 20.6% in our study population, delirium is a common problem in pediatric critical care. The Cornell Assessment of Pediatric Delirium is a valid, rapid, observational nursing screen that is urgently needed for the detection of delirium in PICU settings.

Neuroblastoma and pediatric delirium: a case series.

Delirium occurs frequently in critically ill children, and children with neuroblastoma may be at particular risk. Early diagnosis and treatment may improve short- and long-term outcomes. In this case series, we present four critically ill children with neuroblastoma who were diagnosed with delirium in the post-operative period. In all four patients, the diagnosis of delirium facilitated targeted intervention and improvement. Heightened awareness by pediatric oncologists, surgeons, and intensivists may lead to earlier diagnosis and improvement in clinical outcomes.

Large subcapsular liver hematoma following single-incision laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Many laparoscopic surgeons are now transitioning from standard multiple-port laparoscopic cholecystectomy to single-incision laparoscopic surgery (SILS) in an attempt to improve cosmetic outcomes and decrease postoperative morbidity. However, little has been published regarding the potential complications of SILS operations. METHODS: We report the case of a patient undergoing SILS cholecystectomy who developed the complication of a large hepatic hematoma, resulting in significant postoperative morbidity, blood transfusion requirement, and reoperation. RESULTS: After an in-depth internal review of the postoperative morbidity of this case, it appears that the causative factor may be instrument shaft torque on the liver surface. CONCLUSION: Single-incision laparoscopic surgery may pose significant and unique risks that warrant additional operative caution. Quantitative comparison of SILS to the gold-standard laparoscopic cholecystectomy is needed to further elucidate definitive benefits and complications of this novel technique.