Pediatrics in Disasters: Evolution of a Hybrid Global Health Training Program During the COVID-19 Pandemic.

This report describes the Pediatrics in Disasters (PEDS) course during a novel hybrid in-person and virtual format due to the coronavirus disease 2019 pandemic. International and local faculty collaborated on 2021 precourse revisions and course facilitation for multinational in-person and virtual students. Student and facilitator 2021 surveys and 2019 to 2021 student feedback reported overall satisfaction with the course while suggesting needed improvements to maximize international and virtual student participation. The hybrid PEDS course structure successfully achieved course goals and incorporated international faculty. Lessons learned will guide future course revisions and fellow global health educators.

Foreign Body Esophageal Perforation Leading to Multifocal Brain Abscesses: A Case Report.

BACKGROUND: Among those aged 5 years or younger, foreign bodies are the fourth most common pediatric exposure reported to the American Association of Poison Control Centers. Although the majority of ingested foreign bodies pass through the gastrointestinal tract without complication, those that do not spontaneously pass can lead to a number of serious complications, such as gastrointestinal obstruction or perforation, which can be complicated by bleeding from aortoesophageal fistula, secondary mediastinitis, peritonitis, esophageal or gastrointestinal fistula formation, and abscesses. CASE REPORT: We present the case of a 10-month-old child who presented with new-onset focal seizure in the setting of multiple brain abscesses, ultimately found to be due to esophageal perforation from a retained, metallic esophageal foreign body. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Foreign bodies that are retained for longer than 24 h after ingestion have been associated with a higher risk of complications because they are less likely to pass spontaneously through the gastrointestinal tract. Early identification and removal of foreign bodies is necessary to prevent subsequent complications. In patients who have a subacute history of cough, gagging, vomiting, and decreased oral intake with an otherwise unknown cause, foreign-body ingestion or aspiration should be considered. In addition, central nervous system abscess and infection should be considered in patients with concerns about previous foreign body ingestion or aspiration and who are newly presenting with fever, focal neurologic changes, and irritability.

Ketamine Sedation and Hypoxia: A Quality Improvement Project to Reduce Respiratory Events Receiving Intervention.

BACKGROUND: Ketamine is a well-studied and safe medication used for procedural sedation in the pediatric emergency department (ED). However, in our ED and urgent care (UC), we had higher rates of respiratory events receiving intervention (REs) than has been reported nationally. OBJECTIVE: A quality improvement (QI) project was initiated to address this problem with the following aim: during a 24-month period, we aimed to decrease REs during i.v. ketamine sedation from > 10% to < 6% in our network of EDs and UCs. METHODS: Inclusion criteria included patients in our EDs and UCs who received i.v. ketamine for procedural sedation. We organized a multidisciplinary team to identify key drivers for the primary outcome (i.e., REs) and establish interventions. We based process measures on key interventions and utilized 2 Plan-Do-Study-Act (PDSA) cycles, which we evaluated with Shewhart P (provost) charts. Balancing measures included length of sedation, success of sedation, and length of stay. RESULTS: REs decreased from 11.4% to 4.9%; this rate was maintained for 12 months, starting 1 month after PDSA cycle 2 implementation. There was no difference in REs for length of stay, length of sedation, or success of sedation. CONCLUSIONS: Using QI methodology, we reduced and maintained rates of RE to < 6%. Due to the nature of the project, it is difficult to link one intervention to the reduction in REs; however, a significant shift occurred just after PDSA cycle 2 interventions. This project can give a guideline for interventions to improve the safety of pediatric ketamine sedations.

Intranasal Fentanyl and Quality of Pediatric Acute Care.

BACKGROUND: Changes in the manner in which medications can be delivered can have significant effects on the quality of care in the acute care setting. OBJECTIVE: The objective of this study was to evaluate the change in three Institute of Medicine quality indicators (timeliness, safety, and effectiveness) in the pediatric emergency department (ED) after the introduction of the Mucosal Atomizer Device Nasal™ (MADn) for opioid analgesia. METHODS: This was a retrospective review of patients receiving opioid analgesia for certain conditions over a 5-year period. We compared patients receiving intravenous opioid (IVO) to those receiving intranasal fentanyl (INF). Timeliness outcomes include time from medication order to administration, time from dose to discharge, overall time to analgesia, and ED length of stay. Effectiveness outcomes include change in pain score and frequency of repeat dosing. Safety outcomes were the frequency of reversal agent administration or a documented oxygen desaturation of < 90%. Sensitivity analyses were performed to evaluate the effect of moderate sedation on all three outcomes. RESULTS: During the study period, 1702 patients received opioid analgesia, 744 before and 958 after MADn introduction, of whom, 233 (24%) received INF. After MADn introduction, patients receiving INF had a shorter time to discharge from dose (109 vs. 203 min; p < 0.05) and shorter ED length of stay (168 vs. 267 min; p < 0.05). There was no difference in pain score reduction; however, repeat dosing was less frequent for patients receiving INF (16% vs. 27%). There was no use of reversal medication and no difference in the frequency of oxygen desaturations. When patients undergoing moderate sedation were removed from the analysis, there was no difference in the direction of findings for all three outcomes. CONCLUSIONS: INF is associated with improved timeliness and equivalent effectiveness and safety when compared to IVO in the setting of the pediatric ED.

Evaluating Clinical Effectiveness and Pharmacokinetic Profile of Atomized Intranasal Midazolam in Children Undergoing Laceration Repair.

BACKGROUND: Atomized intranasal midazolam is a common adjunct in pediatrics for procedural anxiolysis. There are no previous studies of validated anxiety scores with pharmacokinetic data to support optimal procedure timing. OBJECTIVES: We describe the clinical and pharmacokinetic profile of atomized intranasal midazolam in children presenting for laceration repair. METHODS: Children 11 months to 7 years of age and weighing <26 kg received 0.4 mg/kg of atomized intranasal midazolam for simple laceration repair. Blood samples were obtained at 3 time points in each patient, and the data were fit with a 1-compartment model. Patient anxiety was rated with the Observational Scale of Behavioral Distress. Secondary outcomes included use of adjunctive medications, successful completion of procedure, and adverse events. RESULTS: Sixty-two subjects were enrolled, with a mean age of 3.3 years. The median time to peak midazolam concentration was 10.1 min (interquartile range 9.7-10.8 min), and the median time to the procedure was 26 min (interquartile range 21-34 min). There was a trend in higher Observational Scale of Behavioral Distress scores during the procedure. We observed a total of 2 adverse events, 1 episode of vomiting (1.6%) and 1 paradoxical reaction (1.6%). Procedural completion was successful in 97% of patients. CONCLUSIONS: Atomized intranasal midazolam is a safe and effective anxiolytic to facilitate laceration repair. The plasma concentration was >90% of the maximum from 5 to 17 min, suggesting this as an ideal procedural timeframe after intranasal midazolam administration.

Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department.

BACKGROUND: The co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. OBJECTIVE: Our objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED). METHODS: This was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21 years of age. The attending physician administered either ketamine 1 mg/kg i.v. or ketamine 0.5 mg/kg and propofol 0.5 mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5 mg/kg/dose) or ketamine/propofol (0.25 mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores. RESULTS: Ninety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores by providers, including nurses, were higher for KM, although parents were equally satisfied with both sedation regimens. CONCLUSIONS: We found no significant differences in adverse events between the KM and CoKP groups. While CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

Pediatrics in disasters: evaluation of a global training program.

The findings of this evaluation document partial success for the PEDS training program to achieve its 3 aims. It will take several years for the dissemination of this program to reach a critical mass of pediatricians and other physicians in many LMICs. Obtaining stronger support from MOHs and other governmental agencies is necessary to achieve this goal. Another additional approach would be to integrate the training into medical school and residency programs.

Fascia iliaca compartment nerve block versus systemic pain control for acute femur fractures in the pediatric emergency department.

OBJECTIVE: To compare management of acute femur fractures in children who received a fascia iliaca compartment nerve block (FICNB) to those who received systemic intravenously administered analgesics in the pediatric emergency department. The comparison evaluated frequency of use, effectiveness, and associated adverse event profiles. METHODS: Study population was derived from a retrospective chart review of pediatric patients sustaining acute femur fractures between 2005 and 2009. Cases (received FICNB) were compared with controls (only systemic analgesia) in terms of effectiveness and adverse event. Outcomes included total doses of systemic medications received and comparison of preintervention and postintervention pain scores. RESULTS: Two hundred fifty-nine charts were reviewed: 158 who received FICNB versus 101 who did not. The median dose of systemic medications was 1 dose lower in the FICNB group compared with the systemic medications group. This remained significant after controlling for age and preintervention pain scores (P = 0.02). Median postintervention pain scores in the FICNB group were 1.5 points lower than those in the systemic medications group. This remained significant while controlling for preintervention pain scores and age (P < 0.01). There was no difference in the total adverse events between the FICNB and the control group in either the unadjusted or adjusted analyses (P = 0.08). The FICNB group had 2 seizure episodes, one of which had associated subarachnoid hemorrhage. No patient in either group experienced bradycardia, arrhythmia, visual disturbance, abnormal hearing, mouth numbness, motor tremors, pain or bleeding at injection site, or prolonged nerve block. CONCLUSIONS: We report on the largest number of FICNBs administered in a pediatric emergency department for acute femur fractures. Effectiveness, as measured by pain scores and total doses of systemic analgesia, was improved in the FICNB group versus the control. There was no difference in adverse events between the groups.

Etomidate for short pediatric procedures in the emergency department.

OBJECTIVE: This study aimed to prospectively determine the etomidate dose associated with adequate sedation and few significant respiratory events for procedures of short duration in children. METHODS: This is a prospective cohort study in an urban pediatric emergency department of patients 4 to 18 years requiring sedation and analgesia for painful procedures of short duration. Patients received fentanyl 1 µg/kg followed by intravenously administered etomidate 0.1 to 0.2 mg/kg as a loading dose. An additional dose of etomidate 0.1 mg/kg was intravenously administered if needed. The level of sedation was determined by The Children's Hospital of Wisconsin Sedation Score. The primary outcome was to determine the etomidate dose associated with an adequate level of sedation and procedural completion. RESULTS: Sixty patients were enrolled. The most frequent procedure was fracture reduction (50/60, 83.3%). Procedures were successfully completed for 59 (98.3%) of 60 patients. The initial dose of etomidate associated with adequate sedation was 0.2 mg/kg intravenously administered for 33 (66.7%) of 50 patients requiring fracture reduction and for 6 (60.0%) of 10 patients receiving a procedure other than fracture reduction. Respiratory depression was noted in 9 (16.4%) of 55 patients, and oxygen desaturation was noted in 23 (39.0%) of 59 patients. Of 58 patients, 21 (36.2%) experienced a respiratory adverse event requiring brief intervention including oxygen supplementation, stimulation, and/or airway repositioning. No patient experienced a significant adverse respiratory event, defined as positive pressure ventilation. Median time to discharge-ready was 21 minutes. CONCLUSIONS: For short-duration painful emergency department procedures, etomidate 0.2 mg/kg intravenously administered after fentanyl was associated with effective sedation, successful procedural completion, and readily managed respiratory adverse events in children.

Mass transfer of pediatric tertiary care hospital inpatients to a new location in under 12 hours: lessons learned and implications for disaster preparedness.

OBJECTIVE: To report an experience with large-scale rapid transportation of hospitalized children, highlighting elements applicable to a disaster event. STUDY DESIGN: This was a retrospective study of the relocation of an entire pediatric inpatient population. Mitigation steps included postponement of elective procedures, implementation of planned discharges, and transfer of selected patients to satellite hospitals. Drills and simulations were used to estimate travel times and develop contingency plans. A transfer queue was modified as necessary to account for changing acuity. The Hospital Incident Command System was used. RESULTS: Thirteen critical care teams, 5 general crews, 2 vans, and 4 other vehicles transferred a total of 111 patients 8.5 miles in 11.6 hours. Patients were transferred along parallel (vs series) circuits, allowing simultaneous movement of patients from different areas. Sixty-four patients (including 32 infants) were considered critically ill; 24 of these patients required ventilator support, 3 required inhaled nitric oxide, 30 required continuous infusions, and 4 had an external ventricular drain. There were no adverse outcomes. CONCLUSIONS: Mass inpatient pediatric transfers can be managed rapidly and safely with parallel transfers. Preexisting agreements with regional pediatric teams are imperative. Disaster preparedness concepts, including preplanning, evacuation priorities, recovery analysis, and prevention/mitigation, can be applied to this event.