Postconcussive Symptoms After Early Childhood Concussion.

Importance: Research on postconcussive symptoms (PCS) following early childhood concussion has been hindered by a lack of measures suitable for this age group, resulting in a limited understanding of their evolution in young children. Objective: To document PCS in the first 3 months after early childhood concussion using a developmentally appropriate measure. Design, Setting, and Participants: This cohort study used data collected at 3 Canadian and 1 US urban pediatric emergency departments (EDs) and 8 Canadian daycares from December 2018 to December 2022 as part of the Kids' Outcomes and Long-Term Abilities (KOALA) project, a prospective, multicenter, longitudinal cohort study. Participants included children aged 6 to 72 months with early childhood concussion or orthopedic injury (OI) or uninjured children from the community to serve as controls. Data were analyzed from March 2023 to January 2024. Exposure: Concussion sustained between ages 6 and 72 months. Main Outcomes and Measures: Primary outcomes were cognitive, physical, behavioral and total PCS assessed prior to injury (retrospectively), acutely (within 48 hours), and at 10 days, 1 month, and 3 months after injury or recruitment through caregiver observations using the Report of Early Childhood Traumatic Injury Observations & Symptoms inventory. Group comparisons were analyzed using ordinal regression models. Results: The study included 303 children (mean [SD] age, 35.8 [20.2] months; 152 [50.2%] male). Of these, 174 children had a concussion (mean [SD] age, 33.3 [19.9] months), 60 children had an OI (mean [SD] age, 38.4 [19.8] months) and 69 children were uninjured controls (mean [SD] age, 39.7 [20.8] months). No meaningful differences were found between the concussion and comparison groups in retrospective preinjury PCS. Significant group differences were found for total PCS at the initial ED visit (concussion vs OI: odds ratio [OR], 4.33 [95% CI, 2.44-7.69]; concussion vs control: OR, 7.28 [95% CI, 3.80-13.93]), 10 days (concussion vs OI: OR, 4.44 [95% CI, 2.17-9.06]; concussion vs control: OR, 5.94 [95% CI, 3.22-10.94]), 1 month (concussion vs OI: OR, 2.70 [95% CI, 1.56-4.68]; concussion vs control: OR, 4.32 [95% CI, 2.36-7.92]), and 3 months (concussion vs OI: OR, 2.61 [95% CI, 1.30-5.25]; concussion vs control: OR, 2.40 [95% CI, 1.36-4.24]). Significant group differences were also found for domain-level scores (cognitive, physical, behavioral) at various time points. Conclusions and Relevance: In this early childhood cohort study, concussion was associated with more PCS than OIs or typical development up to 3 months after injury. Given the limited verbal and cognitive abilities typical of early childhood, using developmentally appropriate manifestations and behaviors is a valuable way of tracking PCS and could aid in concussion diagnosis in young children.

Emergency department visits for mild traumatic brain injury in early childhood.

BACKGROUND: Brain injury during early childhood may disrupt key periods of neurodevelopment. Most research regarding mild traumatic brain injury (mTBI) has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED). METHODS: The Nationwide Emergency Department Sample was queried for children age 0-6 years with mTBI from 2016 to 2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion. RESULTS: National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was "unspecified injury of head" (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children's hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head and cervical spine were performed in 18.7% and 1.6% of patients, respectively, less often at children's hospitals (OR = 0.55, 95%CI = 0.41-0.76 for head and OR = 0.19, 95%CI = 0.11-0.34 for cervical spine). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid. CONCLUSIONS: Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide variation in diagnostic coding and computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies.

Enrollment with and without exception from informed consent in a pilot trial of tranexamic acid in children with hemorrhagic injuries.

BACKGROUND: Federal exception from informed consent (EFIC) procedures allow studies to enroll patients with time-sensitive, life-threatening conditions when written consent is not feasible. Our objective was to compare enrollment rates with and without EFIC in a trial of tranexamic acid (TXA) for children with hemorrhagic injuries. METHODS: We conducted a four-center randomized controlled pilot and feasibility trial evaluating TXA in children with severe hemorrhagic brain and/or torso injuries. We initiated the trial enrolling patients without EFIC. After 3 months of enrollment, we met our a priori futility threshold and paused the trial to incorporate EFIC procedures and obtain regulatory approval. We then restarted the trial allowing EFIC if the guardian was unable to provide timely written consent. We used descriptive statistics to compare characteristics of eligible patients approached with and without EFIC procedures. We also calculated the time delay to restart the trial using EFIC. RESULTS: We enrolled one of 15 (6.7%) eligible patients (0.17 per site per month) prior to using EFIC procedures. Of the 14 missed eligible patients, seven (50%) were not enrolled because guardians were not present or were injured and unable to provide written consent. After obtaining approval for EFIC, we enrolled 30 of 48 (62.5%) eligible patients (1.34 per site per month). Of these 30 patients, 22 (73.3%) were enrolled with EFIC. Of the 22, no guardians refused written consent after randomization. There were no significant differences in the eligibility rate and patient characteristics enrolled with and without EFIC procedures. Across all sites, the mean delay to restart the trial using EFIC procedures was 12 months. CONCLUSIONS: In a multicenter trial of severely injured children, the use of EFIC procedures greatly increased the enrollment rate and was well accepted by guardians. Initiating the trial without EFIC procedures led to a significant delay in enrollment.

Assessment of primary outcome measures for a clinical trial of pediatric hemorrhagic injuries.

OBJECTIVE: We evaluated the acceptability of the Pediatric Quality of Life Inventory (PedsQL) and other outcomes as the primary outcomes for a pediatric hemorrhagic trauma trial (TIC-TOC) among clinicians. METHODS: We conducted a mixed-methods study that included an electronic questionnaire followed by teleconference discussions. Participants confirmed or rejected the PedsQL as the primary outcome for the TIC-TOC trial and evaluated and proposed alternative primary outcomes. Responses were compiled and a list of themes and representative quotes was generated. RESULTS: 73 of 91 (80%) participants completed the questionnaire. 61 (84%) participants agreed that the PedsQL is an appropriate primary outcome for children with hemorrhagic brain injuries. 32 (44%) participants agreed that the PedsQL is an acceptable primary outcome for children with hemorrhagic torso injuries, 27 (38%) participants were neutral, and 13 (18%) participants disagreed. Several themes were identified from responses, including that the PedsQL is an important and patient-centered outcome but may be affected by other factors, and that intracranial hemorrhage progression assessed by brain imaging (among patients with brain injuries) or blood product transfusion requirements (among patients with torso injuries) may be more objective outcomes than the PedsQL. CONCLUSIONS: The PedsQL was a well-accepted proposed primary outcome for children with hemorrhagic brain injuries. Traumatic intracranial hemorrhage progression was favored by a subset of clinicians. A plurality of participants also considered the PedsQL an acceptable outcome for children with hemorrhagic torso injuries. Blood product transfusion requirement was favored by fewer participants.

Children's Mental Health Emergency Department Visits: 2007-2016.

BACKGROUND AND OBJECTIVES: Emergency department (ED) visits for children seeking mental health care have increased. Few studies have examined national patterns and characteristics of EDs that these children present to. In data from the National Pediatric Readiness Project, it is reported that less than half of EDs are prepared to treat children. Our objective is to describe the trends in pediatric mental health visits to US EDs, with a focus on low-volume, nonmetropolitan EDs, which have been shown to be less prepared to provide pediatric emergency care. METHODS: Using 2007 to 2016 Nationwide Emergency Department Sample databases, we assessed the number of ED visits made by children (5-17 years) with a mental health disorder using descriptive statistics. ED characteristics included pediatric volume, children's ED classification, and location. RESULTS: Pediatric ED visits have been stable; however, visits for deliberate self-harm increased 329%, and visits for all mental health disorders rose 60%. Visits for children with a substance use disorder rose 159%, whereas alcohol-related disorders fell 39%. These increased visits occurred among EDs of all pediatric volumes, regardless of children's ED classification. Visits to low-pediatric-volume and nonmetropolitan areas rose 53% and 41%, respectively. CONCLUSIONS: Although the total number of pediatric ED visits has remained stable, visits among children with mental health disorders have risen, particularly among youth presenting for deliberate self-harm and substance abuse. The majority of these visits occur at nonchildren's EDs in both metropolitan and nonurban settings, which have been shown to be less prepared to provide higher-level pediatric emergency care.

General Pediatricians' Performance of Accreditation Agency's Recommended Procedures: A Complementary Analysis Using Administrative Data and the Knowledge Translation Model.

INTRODUCTION: The Accreditation Council for Graduate Medical Education provided guidelines, in 2013, regarding 13 clinical procedures pediatric residents should learn. Previous studies show that, when asked, general pediatricians (GPeds) self-report performing these procedures infrequently. When examined using the knowledge translation model, this low procedural performance frequency, especially by GPeds, may indicate a problem within the primary care landscape. METHODS: This was a descriptive study using the Partners For Kids, an accountable care organization, database to obtain how frequently each of the procedures was performed for a geographically representative sample of GPeds in central Ohio. RESULTS: A total of 296 physicians participated in Partners For Kids. Nearly one-third practiced for more than 15 years (n = 83, 28%) and one-third also lived in a rural region (n = 78, 26.4%). The most commonly billed procedure was administering immunizations (n = 79,292, 92.3%); the least was peripheral intravenous catheter placement (n = 2, 0.002%). Most procedures were completed in the office-based setting. DISCUSSION: General pediatricians in central Ohio do not frequently perform the 13 recommended procedures of Accreditation Council for Graduate Medical Education. Evaluation of this problem using the knowledge translation model shows that potential barriers could be inadequate training during or after residency or more likely that these procedures are not necessary in GPeds' current scope of practice. The next step should be to see, from the practitioner's perspective, what procedures are important to their daily practice. Adapting this knowledge to the local context will help target continuing medical education/continuing professional development interventions.

Development of transfusion guidelines for injured children using a Modified Delphi Consensus Process.

BACKGROUND: There is wide variability of transfusion practices for children with hemorrhagic injuries across trauma centers. We are planning a multicenter, randomized clinical trial evaluating tranexamic acid in children with hemorrhage. Standardization of transfusion practices across sites is important to minimize confounding. Therefore, we sought to generate consensus-based transfusion guidelines for the trial. METHODS: We used a modified Delphi process utilizing a multi-site, multi-disciplinary panel of experts to develop our transfusion guidelines. A survey of 23 clinical categories on various aspects of transfusion practices was developed and distributed via SurveyMonkey®. Statements were graded on a 5-point Likert scale ("Strongly agree" to "This intervention may be harmful"). Statements were accepted if ≥ 80% of the panelists rated the statement as "Strongly agree" or "Agree". After each round, the responses were calculated and the results included on subsequent rounds. RESULTS: 35 panelists from four pediatric trauma centers participated in the study, including 11 (31%) pediatric EM physicians, 8 (23%) pediatric trauma surgeons, 5 (14%) transfusionists, 5 (14%) pediatric anesthesiologists, and 6 (17%) pediatric critical care physicians (range of 8 to 10 from each clinical site). Four survey iterations were performed. In total 176 statements were rated and 39 were accepted by criteria across all 23 categories. An rational algorithm for transfusion in trauma was then developed. CONCLUSIONS: We successfully developed transfusion guidelines for various aspects of the management of children with hemorrhagic injuries using a modified Delphi process with broad interdisciplinary participation. We anticipate implementation of these guidelines will help minimize heterogeneity of transfusion practices across clinical sites for the upcoming clinical trial evaluating tranexamic acid in children with hemorrhage.

A Comparison of National Pediatric Procedures Training Guidelines With Actual Clinical Practice in Ohio.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) and Pediatrics Review Committee (RC) recommends the clinical procedures residents should master during their training. These guidelines may be partially based on consensus opinion or tradition rather than actual need. The literature defining which procedures general pediatricians actually perform in practice is limited. OBJECTIVE: Our objective was to determine how often general pediatricians perform procedures recommended by accreditation bodies, how well prepared they feel to perform them, and how important the procedures are to their practice. METHODS: We categorized recommended procedures as emergent, urgent, or office-based, then developed and administered a survey in 2017 based on these classes. We randomly sampled and polled 439 general pediatricians from urban, suburban, or rural regions across central Ohio. Responses were compared using the Welch ANOVA, Mann Whitney U, and post-hoc tests. RESULTS: The response rate was 60% (265 of 439). Pediatricians almost never performed 11 of 13 recommended procedures, yet felt well prepared to perform them all and believed that all were important. Rural pediatricians performed significantly more emergent and office-based procedures and rated them as more important. Commonly performed non-ACGME/RC procedures were circumcision, wart removal, cerumen removal, umbilical cauterization, and suture removal. CONCLUSIONS: Findings suggest that pediatricians rarely perform most of the recommended procedures, but think they are important. There are several office-based non-ACGME recommended procedures that pediatricians commonly perform. Regional differences suggest the need for customized training based on future practice plans.

Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): study protocol for a pilot randomized controlled trial.

BACKGROUND: Trauma is the leading cause of morbidity and mortality in children in the United States. The antifibrinolytic drug tranexamic acid (TXA) improves survival in adults with traumatic hemorrhage, however, the drug has not been evaluated in a clinical trial in severely injured children. We designed the Traumatic Injury Clinical Trial Evaluating Tranexamic Acid in Children (TIC-TOC) trial to evaluate the feasibility of conducting a confirmatory clinical trial that evaluates the effects of TXA in children with severe trauma and hemorrhagic injuries. METHODS: Children with severe trauma and evidence of hemorrhagic torso or brain injuries will be randomized to one of three arms: (1) TXA dose A (15 mg/kg bolus dose over 20 min, followed by 2 mg/kg/hr infusion over 8 h), (2) TXA dose B (30 mg/kg bolus dose over 20 min, followed by 4 mg/kg/hr infusion over 8 h), or (3) placebo. We will use permuted-block randomization by injury type: hemorrhagic brain injury, hemorrhagic torso injury, and combined hemorrhagic brain and torso injury. The trial will be conducted at four pediatric Level I trauma centers. We will collect the following outcome measures: global functioning as measured by the Pediatric Quality of Life (PedsQL) and Pediatric Glasgow Outcome Scale Extended (GOS-E Peds), working memory (digit span test), total amount of blood products transfused in the initial 48 h, intracranial hemorrhage progression at 24 h, coagulation biomarkers, and adverse events (specifically thromboembolic events and seizures). DISCUSSION: This multicenter trial will provide important preliminary data and assess the feasibility of conducting a confirmatory clinical trial that evaluates the benefits of TXA in children with severe trauma and hemorrhagic injuries to the torso and/or brain. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT02840097 . Registered on 14 July 2016.

Consensus-based Criterion Standard for the Identification of Pediatric Patients Who Need Emergency Medical Services Transport to a Hospital with Higher-level Pediatric Resources.

BACKGROUND: Emergency medical services (EMS) providers must be able to identify the most appropriate destination facility when treating children with potentially severe medical illnesses. Currently, no validated tool exists to assist EMS providers in identifying children who need transport to a hospital with higher-level pediatric care. For such a tool to be developed, a criterion standard needs to be defined that identifies children who received higher-level pediatric medical care. OBJECTIVE: The objective was to develop a consensus-based criterion standard for children with a medical complaint who need a hospital with higher-level pediatric resources. METHODS: Eleven local and national experts in EMS, emergency medicine (EM), and pediatric EM were recruited. Initial discussions identified themes for potential criteria. These themes were used to develop specific criteria that were included in a modified Delphi survey, which was electronically delivered. The criteria were refined iteratively based on participant responses. To be included, a criterion required at least 80% agreement among participants. If an item had less than 50% agreement, it was removed. A criterion with 50% to 79% agreement was modified based on participant suggestions and included on the next survey, along with any new suggested criteria. Voting continued until no new criteria were suggested and all criteria received at least 80% agreement. RESULTS: All 11 recruited experts participated in all seven voting rounds. After the seventh vote, there was agreement on each item and no new criteria were suggested. The recommended criterion standard included 13 items that apply to patients 14 years old or younger. They included IV antibiotics for suspicion of sepsis or a seizure treated with two different classes of anticonvulsive medications within 2 hours, airway management, blood product administration, cardiopulmonary resuscitation, electrical therapy, administration of specific IV/IO drugs or respiratory assistance within 4 hours, interventional radiology or surgery within 6 hours, intensive care unit admission, specific comorbid conditions with two or more abnormal vital signs, and technology-assisted children seen for device malfunction. CONCLUSION: We developed a 13-item consensus-based criterion standard definition for identifying children with medical complaints who need the resources of a hospital equipped to provide higher-level pediatric services. This criterion standard will allow us to create a tool to improve pediatric patient care by assisting EMS providers in identifying the most appropriate destination facility for ill children.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time.

BACKGROUND: The emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children. OBJECTIVES: To describe the trends of emergency care for children in the United States from 2006-2014 in EDs across different pediatric volumes. METHODS: We analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006-2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics. RESULTS: From 2006-2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (-3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%). CONCLUSIONS: Overall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.

Occult head injury is common in children with concern for physical abuse.

BACKGROUND: Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients. OBJECTIVES: Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury. MATERIALS AND METHODS: This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury. RESULTS: One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-6.8), macrocephaly (OR 8.5, 95% CI 3.7-20.2), and loss of consciousness (OR 5.1, 95% CI 1.2-22.9) had higher odds of occult head injury. CONCLUSION: Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.

Individual and Neighborhood Characteristics of Children Seeking Emergency Department Care for Firearm Injuries Within the PECARN Network.

OBJECTIVE: The objective was to describe the characteristics of children seeking emergency care for firearm injuries within the PECARN network and assess the influence of both individual and neighborhood factors on firearm-related injury risk. METHODS: This was a retrospective, multicenter cross-sectional analysis of children (<19 years old) presenting to 16 pediatric EDs (2004-2008). ICD-9-CM E-codes were used to identify and categorize firearm injuries by mechanism/intent. Neighborhood variables were derived from home address data. Multivariable analysis examined the influence of individual and neighborhood factors on firearm-related injuries compared to nonfirearm ED visits. Injury recidivism was assessed. RESULTS: A total of 1,758 pediatric ED visits for firearm-related injuries were analyzed. Assault (51.4%, n = 904) and unintentional injury (33.2%, n = 584) were the most common injury mechanisms. Among children with firearm injuries, 68.3% were older adolescents (15-19 years old), 82.3% were male, 68.2% were African American, and 76.3% received public insurance/were uninsured. Extremity injuries were most common (75.9%), with 20% sustaining injuries to multiple body regions, 48.1% requiring admission and 1% ED mortality. Multivariable analysis identified firearm injury risk factors, including adolescent age (p < 0.001), male sex (p < 0.001), non-Caucasian race/ethnicity (p < 0.001), public payer/uninsured status (p < 0.001), and higher levels of neighborhood disadvantage (p < 0.001). Among children with firearm injuries, 12-month ED recidivism for any reason was 22.4%, with < 1% returning for another firearm injury. CONCLUSION: Among children receiving ED treatment within the PECARN network, there are distinct demographic and neighborhood factors associated with firearm injuries. Among younger children (<10 years old), unintentional injuries predominate, while assault-type injuries were most common among older adolescents. Overall, among this PECARN patient population, male adolescents living in neighborhoods characterized by high levels of concentrated disadvantage had an elevated risk for firearm injury. Public health efforts should focus on developing and implementing initiatives addressing risk factors at both the individual and the community level, including ED-based interventions to reduce the risk for firearm injuries among high-risk pediatric populations.

U.S. Trends of ED Visits for Pediatric Traumatic Brain Injuries: Implications for Clinical Trials.

Our goal in this paper was to use the 2006-2013 Nationwide Emergency Department Sample (NEDS) database to describe trends of annual patient number, patient demographics and hospital characteristics of pediatric traumatic brain injuries (TBI) treated in U.S. emergency departments (EDs); and to use the same database to estimate the available sample sizes for various clinical trials of pediatric TBI cases. National estimates of patient demographics and hospital characteristics were calculated for pediatric TBI. Simulation analyses assessed the potential number of pediatric TBI cases from randomly selected hospitals for inclusion in future clinical trials under different scenarios. Between 2006 and 2013, the NEDS database estimated that of the 215,204,932 children who visited the ED, 6,089,930 (2.83%) had a TBI diagnosis. During the study period in the US EDs, pediatric TBI patients increased by 34.1%. Simulation analyses suggest that hospital EDs with annual TBI ED visits >1000, Levels I and II Trauma Centers, pediatric hospitals, and teaching hospitals will likely provide ample cases for pediatric TBI studies. However, recruiting severe pediatric TBI cases for clinical trials from a limited number of hospital EDs will be challenging due to small sample sizes. Pediatric TBI-related ED visits in the U.S. increased by over 30% from 2006 to 2013. Including unspecified head injury cases with ICD-9-CM code 959.01 would significantly change the national estimates and demographic patterns of pediatric TBI cases. Future clinical trials of children with TBI should conduct a careful feasibility assessment to estimate their sample size and study power in selected study sites.

A Modified Delphi Study for Development of a Pediatric Curriculum for Emergency Medicine Residents.

OBJECTIVES: Emergency medicine (EM) trainees are expected to learn to provide acute care for patients of all ages. The American Council for Graduate Medical Education provides some guidance on topics related to caring for pediatric patients; however, education about pediatric topics varies across residency programs. The goal of this project was to develop a consensus curriculum for teaching pediatric emergency care. METHODS: We recruited 13 physicians from six academic health centers to participate in a three-round electronic modified Delphi project. Participants were selected on the basis of expertise with both EM resident education and pediatric emergency care. The first modified Delphi survey asked participants to generate the core knowledge, skills, and experiences needed to prepare EM residents to effectively treat children in an acute care setting. The qualitative data from the first round was reformulated into a second-round questionnaire. During the second round, participants used rating scales to prioritize the curriculum content proposed during the first round. In round 3, participants were asked to make a determination about each curriculum topic using a three-point scale labeled required, optional, or not needed. RESULTS: The first modified Delphi round yielded 400 knowledge topics, 206 clinical skills, and 44 specific types of experience residents need to prepare for acute pediatric patient care. These were narrowed to 153 topics, 84 skills, and 28 experiences through elimination of redundancy and two rounds of prioritization. The final lists contain topics classified by highly recommended, partially recommended, and not recommended. The partially recommended category is intended to help programs tailor their curriculum to the unique needs of their learners as well as account for variability between 3- and 4-year programs and the amount of time programs allocate to pediatric education. CONCLUSION: The modified Delphi process yielded the broad outline of a consensus core pediatric emergency care curriculum.

Pediatric Emergency Medicine Physicians' Use of Point-of-care Ultrasound and Barriers to Implementation: A Regional Pilot Study.

OBJECTIVES: Point-of-care ultrasound (POCUS) has been identified as a critical skill for pediatric emergency medicine (PEM) physicians. The purpose of this study was to profile the current status of PEM POCUS in pediatric emergency departments (EDs). METHODS: An electronic survey was distributed to PEM fellows and attending physicians at four major pediatric academic health centers. The 24-item questionnaire covered professional demographics, POCUS experience and proficiency, and barriers to the use of POCUS in pediatric EDs. We used descriptive and inferential statistics to profile respondent's PEM POCUS experience and proficiency and Rasch analysis to evaluate barriers to implementation. RESULTS: Our return rate was 92.8% (128/138). Respondents were attending physicians (68%) and fellows (28%). Most completed pediatric residencies prior to PEM fellowship (83.6%). Almost all had some form of ultrasound education (113/128, 88.3%). Approximately half (46.9%) completed a formal ultrasound curriculum. More than half (53.2%) said their ultrasound education was pediatric-specific. Most participants (67%) rated their POCUS proficiency low (Levels 1-2), while rating proficiency in other professional competencies (procedures 52%, emergency stabilization 70%) high (Levels 4-5). There were statistically significant differences in POCUS proficiency between those with formal versus informal ultrasound education (p < 0.001) and those from pediatric versus emergency medicine residencies (p < 0.05). Participants identified both personal barriers discomfort with POCUS skills (76.7%), insufficient educational time to learn POCUS (65%), and negative impact of POCUS on efficiency (58.5%)-and institutional barriers to the use of ultrasound-consultants will not use ultrasound findings from the ED (60%); insufficient mentoring (64.7%), and POCUS not being a departmental priority (57%). CONCLUSIONS: While POCUS utilization continues to grow in PEM, significant barriers to full implementation still persist. One significant barrier relates to the need for dedicated time to learn and practice POCUS to achieve sufficient levels of proficiency for use in practice.

Pediatric Concussion Management in the Emergency Department: A National Survey of Parents.

OBJECTIVE: To examine parental expectations and beliefs about diagnosis and management of pediatric concussion. STUDY DESIGN: We conducted a cross-sectional web-based survey of a nationally representative panel of US parents in March 2014. Parents of 10- to 17-year-old children responded to questions about their expectations and beliefs about diagnosis and management of pediatric concussion in the emergency department (ED). Weighted percentages for descriptive statistics were calculated, and χ2 statistics were used for bivariate analysis. RESULTS: Survey participation was 53%, and of 912 parent respondents with a child 10-17 years of age who were presented with a scenario of their child having mild symptoms of concussion, 42% would seek immediate ED care. Parents who would seek immediate ED care for this scenario were more likely than parents who would consult their child's usual provider or wait at home to "definitely expect" imaging (65% vs 21%), definitive diagnosis of concussion (77% vs 61%), a timeline for return to activity (80% vs 60%), and a signed return to play form (55% vs 41%). CONCLUSIONS: Many parents who bring children to the ED following a possible concussion are likely to expect comprehensive and definitive care, including imaging, a definitive diagnosis, a timeline for return to activity, and a signed return to play form. To manage these expectations, healthcare providers should continue to educate parents about the evaluation and management of concussion.

Challenges Enrolling Children Into Traumatic Brain Injury Trials: An Observational Study.

OBJECTIVES: In preparation for a clinical trial of therapeutic agents for children with moderate-to-severe blunt traumatic brain injuries (TBIs) in emergency departments (EDs), we conducted this feasibility study to (1) determine the number and clinical characteristics of eligible children, (2) determine the timing of patient and guardian arrival to the ED, and (3) describe the heterogeneity of TBIs on computed tomography (CT) scans. METHODS: We conducted a prospective observational study at 16 EDs of children ≤ 18 years of age presenting with blunt head trauma and Glasgow Coma Scale scores of 3-12. We documented the number of potentially eligible patients, timing of patient and guardian arrival, patient demographics and clinical characteristics, severity of injuries, and cranial CT findings. RESULTS: We enrolled 295 eligible children at the 16 sites over 6 consecutive months. Cardiac arrest and nonsurvivable injuries were the most common characteristics that would exclude patients from a future trial. Most children arrived within 2 hours of injury, but most guardians did not arrive until 2-3 hours after the injury. There was a substantial range in types of TBIs, with subdural hemorrhages being the most common. CONCLUSION: Enrolling children with moderate-to-severe TBI into time-sensitive clinical trials will require large numbers of sites and meticulous preparation and coordination and will prove challenging to obtain informed consent given the timing of patient and guardian arrival. The Federal Exception from Informed Consent for Emergency Research will be an important consideration for enrolling these children.