Vomiting in Pediatric Patients.

Audience: This classic team-based learning activity is specifically designed for emergency medicine bound medical students and junior residents; however, general pediatrics residents and general medical students may also benefit from this activity. Senior residents and fellows felt that the cases were too basic for them but enjoyed acting as facilitators. Introduction/Background: Vomiting is a common chief complaint in pediatric patients seen in the Emergency Department. 1-3 Presentations include acute, chronic, and cyclic vomiting, with underlying etiologies such as toxin injection, emotional disturbances, and movement disequilibrium. 1 By understanding these various pathways, it is helpful for physicians to distinguish between gastrointestinal and non-gastrointestinal causes of vomiting. 1 Most cases of vomiting in the pediatric population are self-limiting and require only supportive treatment; however, physicians must be able to recognize red flags associated with vomiting that warrant further evaluation. 1,3 This task may be challenging for medical students and residents in emergency medicine and those with infrequent exposure to pediatric patients. Therefore, this team-based learning activity was developed to help junior learners in differentiating non-emergent and emergent cases of pediatric vomiting. This activity aids learners in formulating a differential based on age, history, and characteristics of vomiting. We also review specific causes of pediatric vomiting that physicians cannot miss including intussusception, pyloric stenosis, malrotation, intestinal atresia, and intracranial pathology. Educational Objectives: By the end of this TBL session, learners should be able to:Identify red flag symptoms that should prompt referral for urgent intervention by GI or surgical specialists.Recognize how chronicity of the vomiting can alter the differential diagnosisDescribe the varying pathways that can cause nausea and vomiting.Determine the necessity of imaging tests to confirm and possibly treat various causes of vomiting.Interpret imaging studies associated with specific causes of vomiting. Educational Methods: Classic Team Based Learning (cTBL). Research Methods: Learners and instructors provided verbal feedback after the session in a large group format. Learners were specifically asked if they felt the session was education, relevant, high-yield and level appropriate. One instructor provided written feedback to the cases as well. Results: Overall learners and instructors found the session to be engaging, informative and educational. Learners felt that the session was level appropriate for medical students and junior residents. As a result of feedback from the session, several of the iRAT/gRAT questions were adjusted and the group application cases were re-written and implemented. Discussion: Overall, the educational content and delivery was effective. This session was presented to a group of emergency medicine students, interns and residents. Learners were divided into smaller groups, and each group had a variety of level of learners, including pediatric emergency medicine fellows, present. The fellows, while not necessary to the delivery of the TBL, were extremely helpful in aiding the residents during the session. The final debriefing and answer review were essential to ensure that learners met all educational objectives and fully understood the materials. Topics: Pediatric vomiting, intussusception, pyloric stenosis, intestinal atresia, malrotation, gastroesophageal reflux disease, superior mesenteric artery (SMA) syndrome, hyperemesis.

The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis.

BACKGROUND: Existing difficult airway prediction tools are not practical for emergency intubation and do not incorporate physiological data. The HEAVEN criteria (Hypoxaemia, Extremes of size, Anatomic challenges, Vomit/blood/fluid, Exsanguination, Neck mobility) may be more relevant for emergency rapid sequence intubation (RSI). METHODS: A retrospective analysis included air medical RSI patients. A checklist was used to assess HEAVEN criteria prior to RSI, and Cormack-Lehane (CL) laryngoscopic view was recorded for the first intubation attempt. The incidence of a difficult (CL III/IV) laryngoscopic view as well as failure to intubate on first attempt with and without oxygen desaturation were determined for each of the HEAVEN criteria and total number of HEAVEN criteria. In addition, the association between HEAVEN criteria and both laryngoscopic view and intubation performance were quantified using multivariate logistic regression for direct laryngoscopy (DL) and video laryngoscopy (VL) configured with a Macintosh #4 non-hyperangulated blade. RESULTS: A total of 5137 RSI patients over 24 months were included. Overall intubation success was 97%. A CL III/IV laryngoscopic view was reported in 25% of DL attempts and 15% of VL attempts. Each of the HEAVEN criteria and total number of HEAVEN criteria were associated with both CL III/IV laryngoscopic view and failure to intubate on the first attempt with and without oxygen desaturation for both DL and VL. These associations persisted after adjustment for multiple co-variables including the other HEAVEN criteria. CONCLUSION: The HEAVEN criteria may be useful to predict laryngoscopic view and intubation performance for DL and VL during emergency RSI.

Tranexamic Acid in Civilian Trauma Care in the California Prehospital Antifibrinolytic Therapy Study.

INTRODUCTION: Hemorrhage is one of the leading causes of death in trauma victims. Historically, paramedics have not had access to medications that specifically target the reversal of trauma-induced coagulopathies. The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to evaluate the safety and efficacy of tranexamic acid (TXA) use in the civilian prehospital setting in cases of traumatic hemorrhagic shock. METHODS: The Cal-PAT study is a multi-centered, prospective, observational cohort study with a retrospective comparison. From March 2015 to July 2017, patients ≥ 18 years-old who sustained blunt or penetrating trauma with signs of hemorrhagic shock identified by first responders in the prehospital setting were considered for TXA treatment. A control group was formed of patients seen in the five years prior to data collection cessation (June 2012 to July 2017) at each receiving center who were not administered TXA. Control group patients were selected through propensity score matching based on gender, age, Injury Severity Scores, and mechanism of injury. The primary outcome assessed was mortality recorded at 24 hours, 48 hours, and 28 days. Additional variables assessed included total blood products transfused, the hospital and intensive care unit length of stay, systolic blood pressure taken prior to TXA administration, Glasgow Coma Score observed prior to TXA administration, and the incidence of known adverse events associated with TXA administration. RESULTS: We included 724 patients in the final analysis, with 362 patients in the TXA group and 362 in the control group. Reduced mortality was noted at 28 days in the TXA group in comparison to the control group (3.6% vs. 8.3% for TXA and control, respectively, odds ratio [OR]=0.41 with 95% confidence interval [CI] [0.21 to 0.8]). This mortality difference was greatest in severely injured patients with ISS >15 (6% vs 14.5% for TXA and control, respectively, OR=0.37 with 95% CI [0.17 to 0.8]). Furthermore, a significant reduction in total blood product transfused was observed after TXA administration in the total cohort as well as in severely injured patients. No significant increase in known adverse events following TXA administration were observed. CONCLUSION: Findings from the Cal-PAT study suggest that TXA use in the civilian prehospital setting may safely improve survival outcomes in patients who have sustained traumatic injury with signs of hemorrhagic shock.