Severe traumatic brain injury in children: an evidence-based review of emergency department management.

More than 1.7 million traumatic brain injuries occur in adults and children each year in the United States, with approximately 30% occurring in children aged <14 years. Traumatic brain injury is a significant cause of morbidity and mortality in pediatric trauma patients. The early management of severe traumatic brain injury is focused on mitigation and prevention of secondary injury, specifically by avoiding hypotension and hypoxia, which have been associated with poorer outcomes. This review discusses methods to maintain adequate oxygenation, maximize management of intracranial hypertension, and optimize blood pressure in the emergency department to improve neurologic outcomes following pediatric severe traumatic brain injury.

Disparities in Prehospital Non-Traumatic Pain Management.

Introduction: While prior research has identified racial disparities in prehospital analgesia for traumatic pain, little is known about non-traumatic pain. Using a national prehospital dataset, we sought to evaluate for racial and ethnic disparities in analgesia given by EMS for non-traumatic pain.Methods: We analyzed the 2018 and 2019 data from the ESO Data Collaborative, a collection of de-identified prehospital electronic health records from nearly 1,300 participating EMS agencies in the US. We included all transported, adult, non-traumatic encounters with a primary or secondary impression of a pain complaint, and we stratified encounters based on race and ethnicity as recorded by the EMS clinicians. We performed a mixed model analysis, modeling EMS agency as a random intercept and adjusting for age, sex, pain location, level of service, location of incident, and highest pain score. With non-Hispanic White patients as the reference group, we then evaluated the association between race/ethnicity and receiving any pain medication (acetaminophen, non-steroidal anti-inflammatories, or opioids), receiving opioid pain medication, and receiving pain medication within 20 minutes of EMS arrival.Results: We included 1,035,486 patients; 67.5% non-Hispanic White, 26.8% Black, 4.9% Hispanic, 0.5% Asian, 0.1% Native Hawaiian or Other Pacific Islander, and 0.2% American Indian or Alaska Native patients. 4.7% of patients received pain medications. Compared to White patients (5.1%), Black patients were less likely to receive pain medication (3.3%, aOR 0.7; 95% CI 0.7-0.7) and Hispanics were more likely to receive pain medication (7.6%, aOR 1.5; 95% CI 1.4-1.6). Black patients were also less likely to receive opioids (1.8% for Black v 3.0% for White, aOR 0.7; 95% CI 0.6-0.7), while Hispanic patients were more likely to receive opioids (4.9%, aOR 1.4; 95% CI 1.3-1.5). The odds of receiving pain medication within 20 minutes was lower for Black patients (aOR 0.9; 95% CI 0.8-0.95) but no different for Hispanic patients (aOR 1.0; 95% CI 0.9-1.1), when compared to White patients.Conclusion: Pain medication administration is uncommon for non-traumatic pain complaints. While Black patients were less likely than White patients to receive pain medications and receive pain medication within 20 minutes, Hispanics were more likely to receive pain medications.

Physician Training for Electrocardiogram Interpretation: A Systematic Review and Meta-Analysis.

PURPOSE: Using electrocardiogram (ECG) interpretation as an example of a widely taught diagnostic skill, the authors conducted a systematic review and meta-analysis to demonstrate how research evidence on instruction in diagnosis can be synthesized to facilitate improvement of educational activities (instructional modalities, instructional methods, and interpretation approaches), guide the content and specificity of such activities, and provide direction for research. METHOD: The authors searched PubMed/MEDLINE, Embase, Cochrane CENTRAL, PsycInfo, CINAHL, ERIC, and Web of Science databases through February 21, 2020, for empirical investigations of ECG interpretation training enrolling medical students, residents, or practicing physicians. They appraised study quality with the Medical Education Research Study Quality Instrument and pooled standardized mean differences (SMDs) using random effects meta-analysis. RESULTS: Of 1,002 articles identified, 59 were included (enrolling 17,251 participants). Among 10 studies comparing instructional modalities, 8 compared computer-assisted and face-to-face instruction, with pooled SMD 0.23 (95% CI, 0.09, 0.36) indicating a small, statistically significant difference favoring computer-assisted instruction. Among 19 studies comparing instructional methods, 5 evaluated individual versus group training (pooled SMD -0.35 favoring group study [95% CI, -0.06, -0.63]), 4 evaluated peer-led versus faculty-led instruction (pooled SMD 0.38 favoring peer instruction [95% CI, 0.01, 0.74]), and 4 evaluated contrasting ECG features (e.g., QRS width) from 2 or more diagnostic categories versus routine examination of features within a single ECG or diagnosis (pooled SMD 0.23 not significantly favoring contrasting features [95% CI, -0.30, 0.76]). Eight studies compared ECG interpretation approaches, with pooled SMD 0.92 (95% CI, 0.48, 1.37) indicating a large, statistically significant effect favoring more systematic interpretation approaches. CONCLUSIONS: Some instructional interventions appear to improve learning in ECG interpretation; however, many evidence-based instructional strategies are insufficiently investigated. The findings may have implications for future research and design of training to improve skills in ECG interpretation and other types of visual diagnosis.

Survey-based Evaluation of Resident and Attending Financial Literacy.

INTRODUCTION: Physician finances are linked to wellness and burnout. However, few physicians receive financial management education. We sought to determine the financial literacy and educational need of attending and resident physician at an academic emergency medicine (EM) residency. METHODS: We performed a cross-sectional, survey study at an academic EM residency. We devised a 49-question survey with four major domains: demographics (16 questions); Likert-scale questions evaluating value placed on personal finances (3 questions); Likert-scale questions evaluating perceived financial literacy (11 questions); and a financial literacy test based on previously developed and widely used financial literacy questions (19 questions). We administered the survey to EM attendings and residents. We analyzed the data using descriptive statistics and compared attending and resident test question responses. RESULTS: A total of 44 residents and 24 attendings responded to the survey. Few (9.0% of residents, 12.5% of attendings) reported prior formal financial education. However, most respondents (70.5% of residents and 79.2% of attendings) participated in financial self-learning. On a five-point Likert scale (not at all important: very important), respondents felt that financial independence (4.7 ± 0.8) and their finances (4.7±0.8) were important for their well-being. Additionally, they valued being prepared for retirement (4.7±0.9). Regarding perceived financial literacy (very uncomfortable: very comfortable), respondents had the lowest comfort level with investing in the stock market (2.7±1.5), applying for a mortgage (2.8±1.6), and managing their retirement (3.0±1.4). Residents scored significantly lower than attendings on the financial literacy test (70.8% vs 79.6%, P<0.01), and residents scored lower on questions pertaining to investment (78.8% v 88.9%, P<0.01) and insurance and taxes (47.0% v 70.8%, P<0.01). Overall, respondents scored lower on questions about retirement (58.8%, P<0.01) and insurance and taxes (54.7%, P<0.01). CONCLUSION: Emergency physicians' value of financial literacy exceeded confidence in financial literacy, and residents reported poorer confidence than attendings. We identified deficiencies in emergency physicians' financial literacy for retirement, insurance, and taxes.

Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients.

Burns are a significant cause of injury-induced morbidity and mortality in pediatric patients. The spectrum of management for pediatric burn victims is vast and relies heavily on both the classification of the burn and the body systems involved. The immediate focus of management includes resuscitation and stabilization, fluid management, and pain control. Additional focus includes decreasing the risk of infection as well as improving healing and cosmetic outcomes. Discharge care and appropriate follow-up instructions need to be communicated carefully in order to avoid long-standing complications. This supplement reviews methods for accurate classification and management of the full range of burns seen in pediatric patients.

Points & Pearls: Evaluation and management of pediatric patients with penetrating trauma to the torso

Children with penetrating trauma to the torso require careful evaluation of the chest, abdomen, pelvis, and genital structures for system-specific injuries that may contribute to rapid decompensation and influence the order of emergent resuscitation. Care of the injured child and the effect on clinical outcomes starts in the prehospital setting, with hemorrhage control and IV fluid resuscitation. The evaluation and disposition of the patient in the ED will depend on the mechanism of injury and the severity of trauma. This issue reviews the diagnostic evaluation and management of pediatric patients with penetrating injuries to the torso. [Points & Pearls is a digest of Pediatric Emergency Medicine Practice.]

Evaluation and management of pediatric patients with penetrating trauma to the torso.

Children with penetrating trauma to the torso require careful evaluation of the chest, abdomen, pelvis, and genital structures for system-specific injuries that may contribute to rapid decompensation and influence the order of emergent resuscitation. Care of the injured child and the effect on clinical outcomes starts in the prehospital setting, with hemorrhage control and IV fluid resuscitation. The evaluation and disposition of the patient in the ED will depend on the mechanism of injury and the severity of trauma. This issue reviews the diagnostic evaluation and management of pediatric patients with penetrating injuries to the torso.

Severe Traumatic Brain Injury In Children: An Evidence-Based Review Of Emergency Department Management.

More than 1.7 million traumatic brain injuries occur in adults and children each year in the United States, with approximately 30% occurring in children aged < 14 years. Traumatic brain injury is a significant cause of morbidity and mortality in pediatric trauma patients. Early identification and management of severe traumatic brain injury is crucial in decreasing the risk of secondary brain injury and optimizing outcome. The main focus for early management of severe traumatic brain injury is to mitigate and prevent secondary injury, specifically by avoiding hypotension and hypoxia, which have been associated with poorer outcomes. This issue discusses methods to maintain adequate oxygenation, maximize management of intracranial hypertension, and optimize blood pressure in the emergency department to improve neurologic outcomes following pediatric severe traumatic brain injury.

Severe traumatic brain injury in children: an evidence-based review of emergency department management [digest].

More than 1.7 million traumatic brain injuries occur in adults and children each year in the United States, with approximately 30% occurring in children aged < 14 years. Traumatic brain injury is a significant cause of morbidity and mortality in pediatric trauma patients. Early identification and management of severe traumatic brain injury is crucial in decreasing the risk of secondary brain injury and optimizing outcome. The main focus for early management of severe traumatic brain injury is to mitigate and prevent secondary injury, specifically by avoiding hypotension and hypoxia, which have been associated with poorer outcomes. This issue discusses methods to maintain adequate oxygenation, maximize management of intracranial hypertension, and optimize blood pressure in the emergency department to improve neurologic outcomes following pediatric severe traumatic brain injury. [Points & Pearls is a digest of Pediatric Emergency Medicine Practice].

Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients.

Burns in patients aged < 14 years are consistently among the top causes of injury-induced mortality in pediatric patients. Pediatric burn victims with large body surface area involvement have a multisystem physiologic response that differs from that of adult patients. The spectrum of management is vast and relies heavily on both the classification of the burn and the anatomy involved. Immediate goals for emergency clinicians include resuscitation and stabilization, fluid management, and pain control. Additional goals include decreasing the risk of infection along with improving healing and cosmetic outcomes. Discharge care and appropriate follow-up instructions need to be carefully constructed in order to avoid long-standing complications. This article reviews methods for accurate classification and management of the full range of burns seen in pediatric patients.