Buckle me up! A randomised controlled trial using a tablet-based emergency department intervention for child car safety education.

BACKGROUND AND OBJECTIVES: Correct child car restraint use significantly reduces risk of death and serious injury in motor vehicle crashes, but millions of US children ride with improper restraints. We created a tablet-based car restraint educational intervention using Computer Intervention Authoring Software (CIAS) and examined its impact on knowledge and behaviours among parents in the paediatric emergency department (PED). METHODS: This was a non-blinded, randomised controlled trial of parents of PED patients ages 0-12 years. Participants were evaluated for baseline car restraint knowledge and behaviour. The intervention group completed an interactive tablet-based module, while the control group received printed handouts on car restraint safety. After 1 week, both groups received a follow-up survey assessing changes in car restraint knowledge and behaviour. Logistic regressions determined predictors of knowledge retention and behavioural changes. Parents in the CIAS group were also surveyed on programme acceptability. RESULTS: 211 parents completed the study with follow-up data. There was no significant difference in baseline car restraint knowledge (74.3% correct in intervention, 61.8% in control, p=0.15), or increase in follow-up restraint knowledge. Significantly more intervention-group caregivers reported modifying their child's car restraint at follow-up (52.5% vs 31.8%,p=0.003), and 93.7% of them found CIAS helpful in learning to improve car safety. CONCLUSION: Parents had overall high levels of car restraint knowledge. Using CIAS led to positive behavioural changes regarding child car restraint safety, with the vast majority reporting positive attitudes towards CIAS. This novel, interactive, tablet-based tool is a useful PED intervention for behavioural change in parents. TRIAL REGISTRATION NUMBER: NCT03799393.

Is it Smoke and Mirrors? Detection of Inferior Vena Cava Thrombus by Focused Cardiac Ultrasound.

ABSTRACT: Inferior vena cava assessment is a standard component of focused cardiac ultrasound, traditionally used to qualify intravascular volume status. In this case series, we demonstrate that pediatric focused cardiac ultrasound can also diagnose inferior vena cava thrombi and masses, while distinguishing them from a potentially benign smoke-like artifact.

Point-of-Care Ultrasound for Pulse Checks in Pediatric Cardiac Arrest: Two Illustrative Cases.

ABSTRACT: Cardiac arrest is an infrequent but high-stakes scenario in pediatrics. Manual central pulse checks are unreliable. Point-of-care ultrasound is a noninvasive technique to visualize the heart and central vessels during resuscitation. We describe 2 cases in which point-of-care ultrasound helped aid management decisions in pediatric cardiac arrest.

The Feasibility of Using Point-of-Care Ultrasound During Cardiac Arrest in Children: Rapid Apical Contractility Evaluation.

INTRODUCTION: Resuscitation guidelines emphasize minimal interruption of compressions during cardiopulmonary resuscitation. Point-of-care ultrasound (POCUS) enables the clinician to visualize cardiac contractility and central artery pulsatility. The apical 4-chamber (A4), subxiphoid (SX), and femoral artery views may be used when defibrillator pads or active compressions preclude parasternal cardiac views. We hypothesized that clinicians can rapidly obtain interpretable POCUS views in healthy children from the A4, SX, and femoral positions. METHODS: A prospective study of pediatric emergency medicine providers in an urban academic hospital was performed. Stable patients of 12 years or younger were scanned. Sonologists were each allotted 10 seconds to acquire A4, SX, and femoral views. Two attempts at each view were allowed. The primary outcome was whether cardiac and femoral artery scans were interpretable for contractility and pulsatility, respectively. The secondary outcome was whether cardiac scans were interpretable for effusion or right ventricular strain. A POCUS expert reviewed scans to confirm interpretability. RESULTS: Twenty-two sonologists performed a total of 50 scans on 22 patients. A view that was interpretable for contractility was obtained on the first attempt in 86% of A4 and 94% of SX scans. A femoral view that was interpretable for pulsatility was obtained on the first attempt in 74% of scans. Expert review was concordant with sonologist interpretation. CONCLUSIONS: Pediatric emergency medicine physicians can obtain interpretable cardiac and central artery views within 10 seconds most of the time. Point-of-care ultrasound has the potential to enhance care during pediatric resuscitation. Future studies on the impact of POCUS pulse checks in actual pediatric resuscitations should be performed.

Point-of-Care Ultrasound Curriculum for Endotracheal Tube Confirmation for Pediatric Critical Care Transport Team Through Remote Learning and Teleguidance.

OBJECTIVE: Point-of-care ultrasound (POCUS) is used to manage patients in real time. This study aimed to teach pediatric critical care team members to use POCUS for endotracheal tube (ETT) placement confirmation. A secondary aim was to assess the feasibility of a remote curriculum for this purpose. METHODS: The Kern 6-step approach was used. The curriculum involved virtual didactics, asynchronous learning modules, and remote hands-on sessions using teleguidance with the Butterfly IQ+ probe, Butterfly Network, Inc, Guilford, CT. Participants learned direct and indirect methods of ETT placement confirmation and were directed to practice independently. Outcomes included attitudes and satisfaction, knowledge and skills acquisition and retention, and the use of POCUS on shift. RESULTS: Ten participants completed the curriculum. The average knobology and quiz scores improved by 29.3% and 20.8%, respectively. Improvement was sustained at re-evaluation. Seven of 10 participants performed independent scans. At the 3-month reassessment, most demonstrated mastery of thoracic scans. All required prompting for satisfactory tracheal scans. All felt positively toward POCUS and the remote curriculum. CONCLUSION: Pediatric critical care team members acquired and retained knowledge and skills for POCUS basics and ETT placement confirmation through a remote curriculum. Participants were satisfied with the course. Further studies are needed to reassess longer-term knowledge and skill retention and the effects on patient outcomes.

Point-of-Care Ultrasound to Evaluate the Acute Abdomen: A Case of Bowel Perforation After Unknown Single Magnet Ingestion.

ABSTRACT: We report the case of a 3-year-old boy who presented to the pediatric emergency department in undifferentiated shock with an acute abdomen. Point-of-care ultrasound revealed viscous perforation with a large amount of free fluid. Intraoperatively, a single magnet was discovered as the likely cause of bowel perforation and the resulting state of shock.

Agreement With Pediatric Suprapatellar Bursa Effusion Assessments by Point-of-Care Ultrasound After Remote Training.

BACKGROUND: The ease of instruction for point-of-care ultrasound (POCUS) to detect suprapatellar bursa (SPB) effusions in pediatric patients is unknown. Considering in person limitations because of the coronavirus pandemic, strategies for POCUS education by remote learning are necessary. METHODS: We crafted a 90-minute didactic training that was presented via a remote learning format. The main outcome of interest was the interobserver reliability of SPB effusion assessment by novice sonologists compared with POCUS faculty. Novice sonologists were pediatric emergency medicine (PEM) fellows. Pediatric emergency medicine fellows interpreted longitudinal SPB examinations obtained in our pediatric emergency department from July 2013 to June 2020. Assessments were performed 2 months after the remote training. Pediatric emergency medicine fellows had a limited experience performing these musculoskeletal scans and were blinded to POCUS faculty and each other's assessments. Interobserver reliability was assessed with Cohen κ coefficient. Second, we calculated test characteristics of knee radiography compared with PEM POCUS faculty determination of SPB effusion by ultrasound. We further explored how effusion size measured by POCUS impacted the diagnosis by knee radiography. A receiver operator characteristic curve of knee radiography diagnosis of SPB effusion was created using the maximal height of SPB effusion by POCUS as the predictor variable. RESULTS: A total of 116 SPB scans in 71 patients were assessed. From this group, 70 scans were of affected knees and 46 scans were of contralateral, asymptomatic knees. The mean age of patients was 10 years and 46% were girl. The prevalence of SPB effusions was 42%. The κ coefficients between the 3 novice sonologists and POCUS faculty were 0.75 (0.62-0.87), 0.77 (0.65-0.89), and 0.83 (0.72-0.93) with 88%, 89%, and 91% agreement. Knee radiography exhibited an overall sensitivity of 65% (95% confidence interval [CI], 46-79%), specificity of 84% (95% CI, 60-97%), negative predictive value of 55% (95% CI, 43-66%), and positive predictive value of 88% (95% CI, 73-96%) to diagnose SPB effusions. The area under the receiver operator characteristic curve was 0.850. With an SPB height cutoff of 4 mm as true positives, radiography had a sensitivity of 81% and a specificity of 83%. CONCLUSIONS: After a remote teleconference didactic session, PEM fellows were able to successfully diagnose SPB effusions using a longitudinal view with substantial interobserver reliability. Knee radiography exhibited limited sensitivity to rule out SPB effusions.

Ultrasound-assisted Lumbar Puncture for Obese Pediatric Oncology Patients: A Feasibility Study.

Lumbar punctures (LPs) are performed frequently on children with leukemia and lymphoma as part of the standard of care. They are typically performed by pediatric oncology providers for both diagnostic and therapeutic interventions with the aid of moderate or deep sedation. Point-of-Care Ultrasound (POCUS) has emerged as a promising strategy to aid in LP procedures and has been found to be associated with lower number of attempts, and higher success rates. We describe our experience using POCUS to assist with LPs in a subgroup of pediatric oncology patients identified to be procedurally difficult secondary to obesity. This collaboration was well received and resulted in successful LPs in most (8/9) cases. This is a promising modality to improve the delivery of care and LP success in pediatric oncology patients.

Thyrotoxicosis in a Postpartum Adolescent: A Simulation Case for Emergency Medicine Providers.

Introduction: Thyroid storm is a rare but life-threatening disease process that may be difficult to recognize and mimics other disease processes. It is critical for the emergency medicine clinician to be able to recognize thyroid storm in patients in order to effectively stabilize and treat them. Methods: In this standardized patient case, learners were faced with a 17-year-old postpartum woman presenting to the emergency department with respiratory distress and altered mental status secondary to thyroid storm. The target learners were emergency department providers, including residents, medical students, and advanced practice practitioners. Providers were expected to identify signs and symptoms of thyroid storm and to initiate appropriate diagnostic workup and management of this complex patient. Debriefing followed the simulation using a debriefing guide and PowerPoint presentation. Results: Thirty-four learners participated in this simulation. All learners agreed or strongly agreed that the simulation case was relevant to their work, and 97% agreed or strongly agreed that it was effective in teaching thyroid storm management skills. Eighty-five percent felt that following the simulation, they would be confident in their ability to recognize thyroid storm in a postpartum patient and to recognize and manage respiratory distress and altered mental status in a postpartum patient. Discussion: Learners felt that this case was effective in teaching the skills necessary for caring for postpartum patients with respiratory distress and altered mental status. Future directions include conducting the simulation in situ to include multidisciplinary teams and increasing the learner pool to include OB/GYN residents.

Point-of-Care Ultrasound for Undifferentiated Abdominal Pain in a Pediatric Patient: A Proposed Algorithm.

Abdominal pain is a common presentation in the pediatric emergency department and may pose a diagnostic challenge to the physician. Although most abdominal pain is benign, the presence of abdominal pain may represent a surgical emergency. We present an atypical presentation of perforated appendicitis in a child with 2 weeks of abdominal pain, in whom point-of-care ultrasound expedited diagnosis and patient disposition. We then recommend a diagnostic approach for using point-of-care ultrasound in a pediatric patient with undifferentiated abdominal pain.

"Full Stomach" Despite the Wait: Point-of-care Gastric Ultrasound at the Time of Procedural Sedation in the Pediatric Emergency Department.

OBJECTIVES: The objective was to use gastric point-of-care ultrasound (POCUS) to assess gastric contents and volume, summarize the prevalence of "full stomach," and explore the relationship between fasting time and gastric contents at the time of procedural sedation. METHODS: This was a prospective study of patients aged 2 to 17 years fasting prior to procedural sedation. A single sonographer scanned each patient's gastric antrum in two positions: supine with the upper body elevated and right lateral decubitus (RLD). Gastric content (empty, liquid, or solid) was noted, and the gastric volume (mL/kg) was estimated from antral cross-sectional area (CSA). "Full stomach" was defined as any solid content or >1.2 mL/kg of liquid gastric content. RESULTS: We enrolled 116 subjects, with a median fasting time of 5.8 hours. Of the 107 with evaluable images, 74 patients, 69% (95% confidence interval [CI] = 60%-77%), were categorized as having a full stomach. Each hour of fasting was associated with lower odds (odds ratio = 0.79, 95% CI = 0.65-0) of a full stomach. However, the knowledge of fasting time alone provides little ability to discriminate between risk groups (C-index = 0.66). CONCLUSIONS: Gastric POCUS classified many patients as having a full stomach at the time of expected procedural sedation, despite prolonged fasting times. These findings may inform risk-benefit considerations when planning the timing and medication choice for procedural sedation.

Carotid Space Mass Proximal to Vagus Nerve Causing Asystole and Syncope.

Manipulation of vagal nerve rootlets, whether surgical or through mass effect of a neoplasm, can result in asystole and hypotension, accompanied by ST depression and right bundle branch block. There are few case reports of a neoplasm causing these effects, and this case describes a patient with such a mass presenting with syncopal episodes. A 43-year-old man with a past medical history of HIV, bipolar disorder, and epilepsy was admitted to the neurology service for a video electroencephalogram (vEEG) to characterize syncopal episodes that were felt to be epileptic in origin. During the study, he experienced symptoms of his typical aura, which correlated with a transient symptomatic high degree AV block on telemetry, and an absence of epileptic findings on vEEG. Magnetic Resonance Imaging (MRI) of the brain showed a mass in the left posterior carotid space at the skull base. The patient underwent permanent dual chamber MRI-compatible pacemaker placement for his heart block. His syncopal episodes resolved, but presyncopal symptoms persisted. We discuss the presentation and treatment of vagal neoplasms.

Clear Cell Adenocarcinoma of the Lung Mimicking Clear Cell Renal Cell Carcinoma.

We present an unusual manifestation of a malignancy in a 61-year-old female who presented clinically and cytologically with what appeared to be clear cell renal cell carcinoma, but was found with immunohistochemistry to be clear cell adenocarcinoma of the lung. The patient presented with CT imaging demonstrating a mass in the left kidney, and cytologically, the tumor cells had high nuclear grade and clear cytoplasm. However, immunohistochemically, a positive TTF-1 nuclear stain and CK7+/CK20- profile demonstrated that these cells were of lung primary. The patient did not respond to a round of carboplatin and pemetrexed, and the patient was discharged to a hospice for pain management and palliative care.

Is a haptic simulation interface more effective than computer mouse-based interface for neonatal intubation skills training?

Objective: To compare the efficacy of a three-dimensional (3D) haptic interface to a two-dimensional (2D) mouse interface for a screen-based simulation (SBS) neonatal intubation (NI) training intervention. Primary hypothesis: a haptic interface is more effective than a mouse interface for SBS training intervention for NI. Secondary hypothesis: SBS training, regardless of interface, will result in improved NI performance on a neonatal airway simulator. Methods: 45 participants were randomised to either a haptics or a mouse interface to complete an identical SBS training intervention for NI over a five-month period. Participants completed pre- and post-training surveys to assess demographics, experience, knowledge and attitudes. The primary outcome of participants' NI skills performance was assessed on a neonatal manikin simulator. Skills were measured pre- and post- training by number of attempts and time to successfully intubate, and airway visualization. Results: The demographics, training and experience were similar between groups. There was no difference in the improvement in skills, knowledge, attitudes or satisfaction ratings pre- and post-training between the groups. There was a significant decrease in number of attempts to intubate a neonatal airway simulator (2.89 vs 1.96, p<0.05) and improvement in the percent of subjects intubating in <30 seconds (22% vs 27%, p=0.02) from pre- to post-training in the study population overall. Conclusion: Using a haptic interface did not have an advantage over a mouse interface in improving NI skills, knowledge, attitudes, or satisfaction. Overall, a SBS training intervention for NI improved skills measured on a neonatal airway simulator.