Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines.

OBJECTIVES: Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. METHODS: A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. RESULTS: This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. CONCLUSIONS: Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.

Point-of-Care Ultrasound to Assess Gastric Content in Pediatric Emergency Department Procedural Sedation Patients.

OBJECTIVES: There is debate regarding the timing of procedural sedation and analgesia (PSA) in relation to fasting status. Point-of-care ultrasound (POCUS) provides the ability to measure gastric content and is being used as a surrogate for aspiration risk in anesthesia. We sought to evaluate the gastric content of pediatric emergency department (PED) patients undergoing PSA using POCUS. METHODS: We performed a prospective observational study using a convenience sample of pediatric patients undergoing PSA between July 1, 2018, and June 30, 2019. Following a brief history, gastric content was measured using POCUS in both supine and right lateral decubitus positions at 2-hour intervals until the time of PSA. Qualitative content and calculated volume were classified based on the Perlas Model of anesthesia "Risk" assessment. RESULTS: Ninety-three patients were enrolled with 61.3% male and mean age of 6.5 years. Gastric content was determined in 92 patients. There were 79.3% that had "high risk" content at the time of PSA, with a median fasting time of 6.25 hours and no serious adverse events. Fasting duration had a weak to moderate ability to predict "risk" category (area under the curve = 0.73), with no patient (n = 17) who underwent multiple evaluations awaiting PSA progressing from "high" to "low risk." CONCLUSIONS: The majority of PED patients undergoing PSA at our institution had "high risk" gastric content with no clinically significant change occurring during serial evaluations. This calls into question the utility of delaying PSA based upon fasting status and lends support to a more comprehensive risk-benefit approach when planning pediatric PSA.

Regulatory Challenges to Emergency Medicine Procedural Sedation.

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

Pediatric Emergency Medicine Training in Procedural Sedation: Is It Time for a Standardized Curriculum?

OBJECTIVES: Pediatric procedural sedation (PS) has been performed with increasing frequency by pediatric emergency physicians for recent years. Accreditation Council for Graduate Medical Education Pediatric Emergency Medicine fellowship core competency requirements do not specify the manner in which fellows should become proficient in pediatric PS. We surveyed the variety of training experience provided during fellowship and whether those surveyed felt that their training was sufficient. METHODS: A 35-question survey offered to pediatric emergency fellows and recent (within 10 years) graduates collected data on pediatric PS training during fellowship. A follow-up questionnaire was sent to fellowship directors at programs where fellow or graduate respondents stated that a sedation curriculum that existed asked details of their program. RESULTS: There were 95 respondents to the survey, 62% of which had completed pediatric emergency medicine fellowship training. Of respondents, 65% reported having a formal sedation curriculum during fellowship. Of those who participated in a formal curriculum, 82% of respondents felt comfortable performing sedation, whereas the remaining 18% required additional preceptorship and/or more formal training to feel proficient. Fifty-six percent of respondents reported having to complete a set number of sedations before being allowed to sedate independently. Of 17 programs contacted, 9 fellowship directors responded. All 9 included didactics, 6 (66.6%) of 9 included evidence-based medicine literature review, and 6 (66.6%) of 9 included simulation. Other modalities used included supervised clinical experience in a pediatric sedation unit, a 2-week rotation with a hospital sedation team, online sedation modules, and precepted sedations using each pharmacologic agent including nitrous oxide, ketamine, propofol, and ketamine-propofol combination. Ketamine was the most frequently used agent for sedation (87%). CONCLUSIONS: Pediatric emergency medicine fellowship requirements lack a clearly defined pathway for training in PS. Data collected from both current and former fellows depict inconsistency in training experience and suboptimal comfort level in performing these procedures. We suggest that fellows receive a more comprehensive and varied experience with multiple teaching modalities to improve proficiency with this critical and complex aspect of emergency pediatric care.

Point-of-Care Ultrasound to Assess Gastric Content.

Gastric ultrasound (US) is a growing modality within the point-of-care ultrasound (POCUS) field. It provides the ability to directly measure an individual patient's gastric content and has potential use as both a clinical and a research tool. Here, we review the historical development of current gastric US models and their clinical application within the field of general anesthesia, describe the US findings and technique for using POCUS to assess gastric content, and discuss the current and potential applications of gastric POCUS within the emergency department.

Congenital Vallecular Cyst as a Cause of Neonatal Stridor and Apnea.

An infant who presents with stridor and apnea constitutes a challenge for emergency physicians in terms of diagnosis and management. Among the rarest of causes for these symptoms, congenital vallecular cysts can cause devastating outcomes if left undiagnosed. Reported here is a case of intermittent episodes of stridor and apnea in a 4-day-old neonate with a previously undiagnosed vallecular cyst. The process by which the infant was stabilized, correctly diagnosed, and successfully treated for a life-threatening airway obstruction is explained. After a discussion of vallecular cysts, methods for preparing for and executing proper airway management in an infant who presents with apnea and stridor are considered.

Ataxia and Headache in a Child: A Case of Acute Cerebellar Infarction.

A 4-year-old female patient presents to the pediatric emergency department with acute onset of ataxia and occipital headache. Initial investigation, including computed tomography imaging, failed to demonstrate any focal neurologic lesion. Subsequent studies, however, reveal an acute thrombosis of the superior cerebellar artery. Further work up identified the likely causative factor to be a heterozygous mutation at the methylene tetrahydrofolate reductase gene. In this case report, we will discuss the work-up of pediatric ataxia, the evaluation and management of cerebrovascular accidents in children, and the association between stroke and mutation of the methylene tetrahydrofolate reductase gene.

Extraocular cranial nerve palsies in children.

Visual disturbances resulting from acute nerve paralysis of the muscles controlling eye movements can be challenging to evaluate in the pediatric population. Children may not be capable of describing symptoms or providing an adequate history. Therefore, it is important to have an understanding of the anatomical course of the extraocular cranial nerves and clinical manifestations of their dysfunction. We report 2 cases of extraocular cranial nerve palsies and, in addition to an anatomical review, discuss the common etiologies of paralysis and the importance of ophthalmological and neurological follow-up to ensure optimal long-term visual function.

Successful flumazenil reversal of paradoxical reaction to midazolam in a child.

BACKGROUND: Greater attention to and management of anxiety and pain in pediatric patients signifies a healthy evolution in the care of children in emergency departments (EDs). Interventions to address such distress may involve unanticipated adverse effects. Midazolam, a benzodiazepine commonly administered to children for anxiolysis, may precipitate paradoxical agitation and delirium, a rare but alarming effect that warrants prompt identification and treatment. CASE REPORT: The case presented is that of a 4-year-old girl who received oral midazolam and developed a paradoxical reaction, which was reversed successfully with flumazenil. This is the first such case report in an ED involving a child. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must stay abreast of the adverse and unintended effects of the treatments provided. The literature on benzodiazepine-induced paradoxical reactions is reviewed, and flumazenil as well as other treatment options and anxiolytic alternatives are presented.

Emergency department poisoning visits in children younger than 6 years: comparing referrals by a regional poison control center to referrals by other sources.

OBJECTIVE: The study purpose was to compare medical appropriateness and costs of regional poison control center (RPCC) versus non-RPCC referrals to children's hospital emergency department (ED) for acute poison exposure. METHODS: This is a retrospective cross-sectional study of children (<6 years) during an 8-month period, who presented for poison exposure. Demographic and clinical patient characteristics were abstracted onto a uniform data form. Medical appropriateness was determined by presence of 1 of 4 criteria by 3 independent reviewers blinded to the patients' race, source of referral, charges, and disposition. RESULTS: Determination of medical appropriateness was matched by all 3 reviewers in 187 patients who make up the study population. There were 92 RPCC-referred cases and 95 non-RPCC-referred controls. Groups were comparable by age, sex, toxin, and symptoms. For RPCC referrals, 84 were self-transported, and 8 were transported by emergency medical services. For non-RPCC referrals, 60 were self-referred/transported, 26 were transported by emergency medical services, and 9 were physician referred. Regional poison control center referrals had a 39.1% higher rate of medical appropriateness than did non-RPCC referrals (odds ratio, 13.0; 95% confidence interval, 3.6-36.1). For this sample, mean charges for inappropriate ED poison exposure visits were $313.42, and the cost per RPCC call was $25, thus giving a potential return on investment of 12.54 to 1 favoring RPCC triage. CONCLUSIONS: When compared with other referral sources, RPCC triage results in fewer unnecessary ED visits in this age group. Increasing prehospital use of poison centers would likely decrease unnecessary ED referrals and related costs.

Cerebral sinovenous thrombosis in children: diagnosis and treatment.

Cerebral sinovenous thrombosis (CSVT) is a pediatric stroke syndrome that occurs uncommonly in association with a number of common pediatric problems, most notably dehydration and infection-otitis media in older children, in particular. Cerebral sinovenous thrombosis involves considerable risk of morbidity and mortality. In the pediatric population, neonates are most commonly affected, but no age group is spared. The clinical manifestations of CSVT vary across age groups and include headache, nausea/vomiting, diplopia, seizures, altered mental status, cranial nerve palsies, and papilledema. Neuroimaging is critical to establishing the diagnosis, and although a variety of modalities are available, the diagnosis is most convincingly made via magnetic resonance imaging with venographic sequencing. Management of CSVT combines medical and surgical approaches and should occur in a multidisciplinary pediatric hospital setting. Anticoagulation is a controversial but generally recommended element of CSVT treatment. Prognosis is related to the extent of vessel and brain parenchymal involvement as well to timeliness of diagnosis and institution of therapy. Long-term follow-up should involve pediatric neurology and ophthalmology and, whenever indicated, rehabilitational therapy as well.

Orbital trauma, bradycardia, and vomiting: trapdoor fracture and the oculocardiac reflex: a case report.

The presentation of vomiting and bradycardia after closed head trauma should invariably prompt concern for significant intracranial injury, yet other less common causes for the clinical picture do exist. This case reports one such scenario in which fracture to the patient's inferior orbital wall resulted in the rare though potentially life-threatening oculocardiac reflex, a vagally mediated phenomenon with possible respiratory, cardiovascular, and gastric motility effects.