A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures.

OBJECTIVES: The aim of this study was to compare the guardian-perceived 3-month cosmetic outcome for pediatric lacerations repaired with absorbable sutures, Dermabond, or Steri-Strips. Secondarily, pain and satisfaction with the procedure from both guardian and provider perspectives were compared. METHODS: In this randomized controlled trial, we enrolled a convenience sample of children aged 0 to <18 years who presented with simple linear lacerations (≤5 cm in length, ≤0.5 cm in width, and <12 hours old) to a pediatric emergency department. Children were randomized to receive laceration repair with absorbable sutures, Dermabond, or Steri-Strips. Topical L.E.T. solution (lidocaine, epinephrine, tetracaine) was applied to wounds which were then closed by the primary team. Guardians and providers completed questionnaires regarding perceived pain and satisfaction with the procedure. Guardians were contacted 3 months after the repair and asked to email a picture of the scar with their perception of cosmesis rated on a visual analog scale from 0 to 100. RESULTS: Fifty-five patients were enrolled, of whom 30 completed 3-month follow-up (12 suture, 7 Dermabond, 11 Steri-strips). There was no statistical evidence of an association between scar appearance and closure method based on medians and interquartile ranges for cosmetic ratings of scar: suture median 70.5 (IQR 59.8-76.8), Dermabond median 85 (IQR 73-90), Steri-strips median 67 (IQR 55-78) (P = 0.254). Guardian satisfaction with length of stay, guardian and physician satisfaction with the procedure, and guardian and physician-perceived pain also showed no differences. CONCLUSIONS: No differences were observed in guardian-perceived cosmesis of simple lacerations repaired with sutures, Dermabond, or Steri-Strips when evaluated 3 months after intervention. In addition, there were no differences in guardian or physician-perceived pain or satisfaction with the closure methods. The results of this study suggest that all 3 closure methods appear to be clinically equivalent, which is largely consistent with other evidence. Further study should be expanded to a larger demographic.

Pediatric Injury Trends in Rhode Island During the COVID-19 Pandemic.

BACKGROUND: Pediatric Emergency Department (PED) visits nationally decreased while the proportion of injury-related PED visits increased during the COVID-19 pandemic. Little is known about the trends in Rhode Island (RI). METHODS: This is a planned sub-analysis of RI data from a retrospective study of pediatric injury-related visits to 40 PEDs for children <18 years old from January 2019-December 2020. We calculated frequencies and compared patient demographics, injury types, severity, and mechanisms for 3/17/2019-12/31/2019 (pre-COVID-19) versus 3/15/2020-12/31/2020 (study period). RESULTS: Despite a 31.4% decrease in total injury-related PED visits from 2019 to 2020, the proportion of injury-related PED visits increased by 8.1% (p<0.001) in 2020. The mean age of patients decreased from 8.3 (SD 5.4) to 7.7 (SD 5.4) years old (p<0.0001), with a higher proportion of female (p=0.0018), privately insured (p=0.0274), and non-Hispanic White children (p<0.001) in 2020. There was a higher proportion of trauma activations, admissions, and injuries caused by intentional self-harm (all p<0.0001). CONCLUSIONS: In RI, the total number of injury-related PED visits decreased while the proportion of injury-related PED visits increased during the COVID-19 pandemic, similar to national trends. There were significant demographic, mechanism, and intent shifts among injured patients, highlighting epidemiologic changes during the pandemic and identifying high-risk groups that would benefit from targeted education and interventions.

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic.

BACKGROUND: Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic. METHODS: This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020. RESULTS: The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019. CONCLUSIONS: The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Pivoting injury prevention efforts during a pandemic: results of an international survey.

BACKGROUND: The COVID-19 a pandemic changed the world. Public health directives to socially distance with stay-at-home orders altered injury risk factor exposure, resulting injury patterns and conducting injury prevention (IP). The objective of this study was to determine the impact the COVID-19 pandemic on injury and IP at North American trauma centers (TC). RESULTS: Sixty-two responses were received from pediatric (44%), adult (11%), and combined (31%) TC, from 22 American states, 5 Canadian provinces and Australia. The majority (91%) of programs targeted age groups from birth to 15 years old. Nearly one-third reported IP to be less of an institutional priority with funding redistributed in 15% of centers [median (IQR) - 25% (- 43, 1)], and resultant staffing changes at 38% of centers. A decrease in IP efforts was reported at 64% of TC. Overall, the majority of respondents reviewed injury data, with the top reported increased mechanisms mainly intentional: Firearm-related (75%), assaults (72%), and abuse (71%). Leading increased unintentional injuries were injuries occurring in the home such as falls (70%), followed by ATV (62%), and cycling (57%). Sites pivoted by presenting (74%) or participating (73%) in IP education virtually, social media posts (61%) and the addition of technology (29%). Top barriers were redeployment of partners (45%) and staff (31%), as well as lack of technology (40%) in the target population. Facilitators were technology at TC (74%), support of trauma program (63%), and having IP funding maintained (55%). CONCLUSIONS: Nearly two-thirds of TC decreased IP efforts during the pandemic due to staffing and funding reductions. The leading reported increased injuries were intentional, indicating that violence prevention is needed, along with support for mental health. While TC successfully pivoted by using technology, access issues in the target population was a barrier resulting in health inequities.

Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center.

OBJECTIVE: Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy. METHODS: Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020. RESULTS: The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed. CONCLUSIONS: Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.

Reliability of the Behaviorally Anchored Rating Scale (BARS) for assessing non-technical skills of medical students in simulated scenarios.

PURPOSE: Caring for critically ill patients requires non-technical skills such as teamwork, communication, and task management. The Behaviorally Anchored Rating Scale (BARS) is a brief tool used to assess non-technical skills. The investigators determined inter- and intra-rater reliability of the BARS when used to assess medical students in simulated scenarios. METHOD: The investigators created simulation scenarios for medical students during their pediatric clerkship. Content experts reviewed video recordings of the simulations and assigned BARS scores for four performance components (Situational Awareness, Decision-Making, Communication, and Teamwork) for the leader and for the team as a whole. Krippendorff's alpha with ordinal difference was calculated to measure inter- and intra-rater reliability. RESULTS: Thirty medical students had recordings available for review. Inter- and intra-rater reliability for performance components were, respectively, Individual Situational Awareness (0.488, 0.638), Individual Decision-Making (0.529, 0.691), Individual Communication (0.347, 0.473), Individual Teamwork (0.414, 0.466), Team Situational Awareness (0.450, 0.593), Team Decision Making (0.423, 0.703), Team Communication (0.256, 0.517), and Team Teamwork (0.415, 0.490). CONCLUSIONS: The BARS demonstrated limited reliability when assessing medical students during their pediatric clerkship. Given the unique needs of this population, a modified or new objective scoring system for assessing non-technical skills may be needed for medical students.

Early prediction of pediatric acute kidney injury from the emergency department: A pilot study.

BACKGROUND: Identifying acute kidney injury (AKI) early can inform medical decisions key to mitigation of injury. An AKI risk stratification tool, the renal angina index (RAI), has proven better than creatinine changes alone at predicting AKI in critically ill children. OBJECTIVE: To derive and test performance of an "acute" RAI (aRAI) in the Emergency Department (ED) for prediction of inpatient AKI and to evaluate the added yield of urinary AKI biomarkers. METHODS: Study of pediatric ED patients with sepsis admitted and followed for 72 h. The primary outcome was inpatient AKI defined by a creatinine >1.5× baseline, 24-72 h after admission. Patients were denoted renal angina positive (RA+) for an aRAI score above a population derived cut-off. Test characteristics evaluated predictive performance of the aRAI compared to changes in creatinine and incorporation of 4 urinary biomarkers in the context of renal angina were assessed. RESULTS: 118 eligible subjects were enrolled. Mean age was 7.8 ± 6.4 years, 16% required intensive care admission. In the ED, 27% had a +RAI (22% had a >50% creatinine increase). The aRAI had an AUC of 0.92 (0.86-0.98) for prediction of inpatient AKI. For AKI prediction, RA+ demonstrated a sensitivity of 94% (69-99) and a negative predictive value of 99% (92-100) (versus sensitivity 59% (33-82) and NPV 93% (89-96) for creatinine ≥2× baseline). Biomarker analysis revealed a higher AUC for aRAI alone than any individual biomarker. CONCLUSIONS: This pilot study finds the aRAI to be a sensitive ED-based tool for ruling out the development of in-hospital AKI.

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media.

OBJECTIVES: To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM). METHODS: We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect. RESULTS: Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained. CONCLUSION: Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Understanding the Process of Procedural Sedation for Orthopedic Injuries in the Pediatric Emergency Department.

OBJECTIVE: To establish a procedural sedation (PS) time line for patients in the pediatric emergency department (PED) with orthopedic injuries. METHODS: Retrospective review of patients requiring PS for orthopedic injuries. Process times were collected. Ten percent of encounters were co-reviewed. Interrater reliability and descriptive statistics were calculated. RESULTS: A total of 189 patients were included. Co-abstracted data demonstrated excellent agreement. The median time to PS and length of stay (LOS) were 214 (interquartile range [IQR]: 160-282) and 320 (IQR: 257-402) minutes, respectively. CONCLUSION: Patients with orthopedic injuries requiring PS experience prolonged PED visits. Interventions should target safely reducing the time to PS and LOS.

Preventing injuries must be a priority to prevent disease in the twenty-first century.

Injuries continue to be the leading cause of morbidity and mortality for children, adolescents, and young adults aged 1-24 years in industrialized countries in the twenty-first century. In this age group, injuries cause more fatalities than all other causes combined in the United States (U.S.). Importantly, many of these injuries are preventable. Annually in the U.S. there are >9 million emergency department visits for injuries and >16,000 deaths in children and adolescents aged 0-19 years. Among injury mechanisms, motor vehicle crashes, firearm suicide, and firearm homicide remain the leading mechanisms of injury-related death. More recently, poisoning has become a rapidly rising cause of both intentional and unintentional death in teenagers and young adults aged 15-24 years. For young children aged 1-5 years, water submersion injuries are the leading cause of death. Sports and home-related injuries are important mechanisms of nonfatal injuries. Preventing injuries, which potentially cause lifelong morbidity, as well as preventing injury deaths, must be a priority. A multi-pronged approach using legislation, advancing safety technology, improving the built environment, anticipatory guidance by clinical providers, and education of caregivers will be necessary to decrease and prevent injuries in the twenty-first century.

Trends of ED visits, admissions, and deaths for pediatric traumatic brain injury comparing sport and non-sport mechanisms.

BACKGROUND: Traumatic brain injuries (TBI) in children result in significant morbidity and mortality. There are many mechanisms, both sport and non-sport related, which cause these injuries. Studies have reported that Emergency Department (ED) visits for pediatric TBI caused by sports are increasing; however, no subsequent study has evaluated the trend in non-sport TBI. The objective of this study was to evaluate ED visits, admissions, and deaths for non-sport TBI compared to those caused by sports. METHODS: A retrospective study of children 5-19 years of age was performed at a pediatric, level 1 trauma center from 2002 to 2012. Subjects with a primary or secondary diagnosis of TBI were identified from the hospital's trauma registry, and mechanism of injury, disposition, injury severity score, and length of stay were recorded. Frequencies were used to characterize the population, Chi-square analysis was performed to determine differences between groups, and linear trend lines were calculated for sport-related and non-sport TBI by year. RESULTS: Thirteen thousand two hundred ninty one subjects were seen in the ED between 2002 and 2012 for a TBI; 9527 (72%) were from a non-sport mechanism, and 3764 (28%) were from a sport mechanism. Subjects with a non-sport TBI were more likely to be younger (p < 0.001), African American (p < 0.001), and have Medicare/Medicaid (p < 0.001). Subjects with a non-sport TBI were admitted to the hospital 15% of the time, and subjects with a sport-related TBI were admitted 10% of the time (p < 0.001). When evaluating all TBI by mechanism of injury, sport had the lowest injury severity score (mean 4.4) and the shortest length of stay (mean 1.6 days) of any mechanism. There were six deaths reported from non-sport TBI and none from sport-related TBI. ED visits for sport-related TBI increased 92%, and non-sport TBI increased 22% over 10 years. There was a peak in TBI, in both groups, seen in 2009. CONCLUSIONS: ED visits for both sport and non-sport TBI have increased over the past 10 years. TBI from a non-sport mechanism was more likely to result in hospitalization or death. Prevention efforts should be expanded to include all high-risk TBI mechanisms, not just sports.

Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department.

BACKGROUND: Apneic oxygenation (AO) has been evaluated in adult patients as a means of reducing hypoxemia during endotracheal intubation (ETI). While less studied in pediatric patients, its practice has been largely adopted. OBJECTIVE: Determine association between AO and hypoxemia in pediatric patients undergoing ETI. METHODS: Observational study at an urban, tertiary children's hospital emergency department. Pediatric patients undergoing ETI were examined during eras without (January 2011-June 2011) and with (August 2014-March 2017) apneic oxygenation. The primary outcome was hypoxemia, defined as pulse oximetry (SpO2) < 90%. The χ2 and Wilcoxon rank-sum tests examined differences between cohorts. Multivariable regression models examined adjusted associations between covariates and hypoxemia. RESULTS: 149 patients were included. Cohorts were similar except for greater incidence of altered mental status in those receiving AO (26% vs. 7%, p = 0.03). Nearly 50% of the pre-AO cohort experienced hypoxemia during ETI, versus <25% in the AO cohort. Median [IQR] lowest SpO2 during ETI was 93 (69, 99) for pre-AO and 100 [95, 100] for the AO cohort (p < 0.001). In a multivariable logistic regression model, hypoxemia during ETI was associated with AO (aOR 0.3, 95% confidence interval [CI] 0.1-0.8), increased age (for 1 year, aOR 0.8, 95% CI 0.7-1.0), lowest SpO2 before ETI (for 1% increase, aOR 0.9, 95% CI 0.8-1.0), and each additional intubation attempt (aOR 4.0, 95% CI 2.2-7.2). CONCLUSIONS: Apneic oxygenation is an easily-applied intervention associated with decreases in hypoxemia during pediatric ETI. Nearly 50% of children not receiving AO experienced hypoxemia.

Describing pediatric acute kidney injury in children admitted from the emergency department.

OBJECTIVE: To define those children who develop acute kidney injury (AKI) within 48 h of admission from the emergency department (ED) and ascertain patient-related factors in the ED associated with AKI. METHODS: Retrospective, cohort study of children, birth to 19 years, admitted to a tertiary pediatric hospital from the ED between January 2010 and December 2013 who had serum creatinine (SCr) drawn as part of clinical care. AKI was defined as a 50% increase in SCr above baseline, as measured within 48 h of hospital presentation. Multivariable logistic regression was performed to determine factors associated with AKI by comparing those with and without kidney injury on hospital presentation. RESULTS: Of all ED admissions, 13,827 subjects (27%) were included; 10% developed AKI. Of kids with AKI, 75% had a measured SCr consistent with AKI while in the ED, 36% were admitted to the intensive care unit, and 2% died (all significantly more than children without AKI). Young age, history of AKI or solid organ transplant, receipt of intravenous fluids or central venous access in the ED, and admission to intensive care were factors independently associated with AKI (AUC = 0.793, 95% CI 0.78-0.81). CONCLUSIONS: One in 10 children who had SCr measured and were admitted to a tertiary pediatric hospital had AKI on or within 48 h of presentation. Inherent characteristics, identifiable in the ED, are associated with an increased risk of AKI. Future research should focus on improving AKI recognition in the ED by the development of a risk stratification tool.

History of Tick Bite: A Gift or a Red Herring?

Fever of unknown origin can be challenging to the emergency medicine physician and the array of both benign and potentially life-threatening diagnoses on the differential can lead to a costly, time-consuming work-up. In this article, we present a case of potentially fatal tick-borne illness with a focus on history, physical exam, and laboratory findings that would differentiate this diagnosis from other causes of fever of unknown origin and aid in early and efficient initiation of treatment for patients.

ED utilization trends in sports-related traumatic brain injury.

BACKGROUND: Emergency department (ED) visits for sports-related traumatic brain injuries (TBIs) have risen. This study evaluated how the number and severity of admissions have changed as ED visits for sports-related TBIs have increased. METHODS: A retrospective study of children aged 0 to 19 years at a level 1 trauma center was performed. Patients from 2002 to 2011 with a primary or secondary diagnosis of TBI were identified from the hospital's inpatient and outpatient trauma registries. Frequencies were used to characterize the population, χ(2) analysis was performed to determine differences between groups, and regression analysis looked at relationship between year and injury severity score or length of stay. RESULTS: Sport was responsible for injury in 3878 (15.4%) cases during the study period; 3506 (90.4%) were discharged from the hospital, and 372 (9.6%) were admitted. Seventy-three percent were male patients and 78% Caucasian; mean age was 13 ± 3.5 years. ED visits for sports-related TBIs increased 92% over the study period, yet there was no significant change (χ(2) = 9.8, df = 9, P = .37) in the percentage of children admitted. Mean injury severity score for those admitted decreased from 7.8 to 4.8 (ß = -0.46; P = .006); length of stay trended downward (ß = -0.05; P = .05). CONCLUSIONS: The percentage of children being admitted from the ED with sports-related TBI has not changed over the past 10 years. The severity of admitted sports-related TBI is decreasing. Additional research is needed to correlate these trends with other TBI mechanisms.

Stable cytotoxic T cell escape mutation in hepatitis C virus is linked to maintenance of viral fitness.

Mechanisms by which hepatitis C virus (HCV) evades cellular immunity to establish persistence in chronically infected individuals are not clear. Mutations in human leukocyte antigen (HLA) class I-restricted epitopes targeted by CD8(+) T cells are associated with persistence, but the extent to which these mutations affect viral fitness is not fully understood. Previous work showed that the HCV quasispecies in a persistently infected chimpanzee accumulated multiple mutations in numerous class I epitopes over a period of 7 years. During the acute phase of infection, one representative epitope in the C-terminal region of the NS3/4A helicase, NS3(1629-1637), displayed multiple serial amino acid substitutions in major histocompatibility complex (MHC) anchor and T cell receptor (TCR) contact residues. Only one of these amino acid substitutions at position 9 (P9) of the epitope was stable in the quasispecies. We therefore assessed the effect of each mutation observed during in vivo infection on viral fitness and T cell responses using an HCV subgenomic replicon system and a recently developed in vitro infectious virus cell culture model. Mutation of a position 7 (P7) TCR-contact residue, I1635T, expectedly ablated the T cell response without affecting viral RNA replication or virion production. In contrast, two mutations at the P9 MHC-anchor residue abrogated antigen-specific T cell responses, but additionally decreased viral RNA replication and virion production. The first escape mutation, L1637P, detected in vivo only transiently at 3 mo after infection, decreased viral production, and reverted to the parental sequence in vitro. The second P9 variant, L1637S, which was stable in vivo through 7 years of follow-up, evaded the antigen-specific T cell response and did not revert in vitro despite being less optimal in virion production compared to the parental virus. These studies suggest that HCV escape mutants emerging early in infection are not necessarily stable, but are eventually replaced with variants that achieve a balance between immune evasion and fitness for replication.