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Pediatr Crit Care Med ; 20(7): e293-e300, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-31149966


OBJECTIVES: To identify the clinical findings available at the time of hospitalization from the emergency department that are associated with deterioration within 24 hours. DESIGN: A retrospective case-control study. SETTING: A pediatric hospital in Ottawa, ON, Canada. PATIENTS: Children less than 18 years old who were hospitalized via the emergency department between January 1, 2008, and December 31, 2012. Cases (n = 98) had an unplanned admission to the PICU or unexpected death on the hospital ward within 24 hours of hospitalization and controls (n = 196) did not. INTERVENTIONS: None. MAIN RESULTS: Ninety-eight children (53% boys; mean age 63.2 mo) required early unplanned admission to the PICU. Multivariable conditional logistic regression resulted in a model with five predictors reaching statistical significance: higher triage acuity score (odds ratio, 4.1; 95% CI, 1.7-10.2), tachypnea in the emergency department (odds ratio, 4.6; 95% CI, 1.8-11.8), tachycardia in the emergency department (odds ratio, 2.6; 95% CI, 1.1-6.5), PICU consultation in the emergency department (odds ratio, 8.0; 95% CI, 1.1-57.7), and admission to a ward not typical for age and/or diagnosis (odds ratio, 4.5; 95% CI, 1.7-11.6). CONCLUSIONS: We have identified risk factors that should be included as potential predictor variables in future large, prospective studies to derive and validate a weighted scoring system to identify hospitalized children at high risk of early clinical deterioration.

JAMA ; 315(10): 1014-25, 2016 Mar 08.
Artículo en Inglés | MEDLINE | ID: mdl-26954410


IMPORTANCE: Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist. OBJECTIVE: To derive and validate a clinical risk score for PPCS among children presenting to the emergency department. DESIGN, SETTING, AND PARTICIPANTS: Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury. EXPOSURES: All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria. MAIN OUTCOMES AND MEASURES: The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury. RESULTS: In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort. CONCLUSIONS AND RELEVANCE: A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.

Síndrome Posconmocional/diagnóstico , Accidentes de Tránsito/estadística & datos numéricos , Adolescente , Factores de Edad , Área Bajo la Curva , Traumatismos en Atletas/complicaciones , Conmoción Encefálica/diagnóstico , Conmoción Encefálica/etiología , Niño , Preescolar , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Humanos , Masculino , Anamnesis , Análisis Multivariante , Variaciones Dependientes del Observador , Síndrome Posconmocional/etiología , Estudios Prospectivos , Medición de Riesgo , Sensibilidad y Especificidad , Factores Sexuales , Factores de Tiempo
CJEM ; 18(6): 443-452, 2016 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-26906352


OBJECTIVES: Bronchiolitis is the leading cause of hospital admission for infants, but few studies have examined management of this condition in community hospital settings. We reviewed the management of children with bronchiolitis presenting to community hospitals in Ontario. METHODS: We retrospectively reviewed a consecutive cohort of infants less than 12 months old with bronchiolitis who presented to 28 Ontario community hospitals over a two-year period. Bronchiolitis was defined as first episode of wheezing associated with signs of an upper respiratory tract infection during respiratory syncytial virus season. RESULTS: Of 543 eligible children, 161 (29.7%, 95% Confidence Interval (CI) 22.3 to 37.0%) were admitted to hospital. Hospital admission rates varied widely (Interquartile Range 0%-40.3%). Bronchodilator use was widespread in the emergency department (ED) (79.7% of patients, 95% CI 75.0 to 84.5%) and on the inpatient wards (94.4% of patients, 95% CI 90.2 to 98.6%). Salbutamol was the most commonly used bronchodilator. At ED discharge 44.7% (95% CI 37.5 to 51.9%) of patients were prescribed a bronchodilator medication. Approximately one-third of ED patients (30.8%, 95% CI 22.7 to 38.8%), 50.3% (95% CI 37.7 to 63.0%) of inpatients, and 23.5% (95% CI 14.4 to 32.7) of patients discharged from the ED were treated with corticosteroids. The most common investigation obtained was a chest x-ray (60.2% of all children; 95% CI 51.9 to 68.5%). CONCLUSIONS: Infants with bronchiolitis receive medications and investigations for which there is little evidence of benefit. This suggests a need for knowledge translation strategies directed to community hospitals.

Albuterol/uso terapéutico , Bronquiolitis/tratamiento farmacológico , Broncodilatadores/uso terapéutico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Bronquiolitis/diagnóstico , Bronquiolitis/epidemiología , Broncodilatadores/farmacología , Análisis por Conglomerados , Estudios de Cohortes , Femenino , Hospitales Comunitarios , Humanos , Incidencia , Lactante , Tiempo de Internación , Masculino , Variaciones Dependientes del Observador , Ontario , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento
JAMA Pediatr ; 167(3): 259-65, 2013 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-23303474


OBJECTIVE To identify predictors of persistent concussion symptoms (PCS) in children following concussion. DATA SOURCES We searched MEDLINE, Embase, and the Cochrane Library to April 2012. STUDY SELECTION A systematic review of the literature to identify prognosticators of PCS following pediatric concussion was conducted. Studies evaluating patients aged 2 years to 18 years with PCS were eligible. MAIN OUTCOME MEASURES The association of clinically available factors with PCS development. RESULTS A literature search yielded 824 records; 561 remained after removal of duplicates. Fifteen studies were included in descriptive analysis; heterogeneity precluded a meta-analysis. Larger prospective studies concluded that the risk for PCS was increased in older children with loss of consciousness, headache, and/or nausea/vomiting. Smaller studies noted that initial dizziness may predict PCS. Patients with premorbid conditions (eg, previous head injury, learning difficulties, or behavioral problems) may also have increased risk. CONCLUSIONS Minimal, and at times contradictory, evidence exists to associate clinically available factors with eventual development of PCS in children. Future trials must be adequately powered to determine which variables best predict the time to full symptom resolution. Expert consensus should delineate which postconcussion assessment measures are preferred to reduce heterogeneity going forward. Research to improve care for the epidemic of pediatric concussion depends on early identification of those most in need of intervention.

Síndrome Posconmocional , Adolescente , Conmoción Encefálica/complicaciones , Niño , Preescolar , Femenino , Humanos , Masculino , Pronóstico , Factores de Riesgo
Child Abuse Negl ; 35(11): 905-14, 2011 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-22104188


OBJECTIVES: Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International Classification of Diseases (ICD) codes documenting abuse suspicion. Additional objectives were to determine the proportion of these fractures with admission ICD abuse coding, and physician text diagnoses recording abuse suspicion in the ED and/or admission notes. Factors possibly associated with abuse-related ED ICD codes were also examined. METHODS: Children less than three years of age that presented primarily with a fracture to two large academic children's hospitals from 1997 to 2007 and were evaluated for suspicion of abuse by child protective services were included in this retrospective review. The main outcome measure was the proportion of the fracture cases that had abuse suspicion reflected in ED discharge ICD codes. RESULTS: Of the 216 eligible patients, only 23 (11.5%) patients had ED ICD codes that included the possibility of abuse. Forty-nine (22.7%) had the possibility for abuse documented by physicians as an ED discharge diagnosis. In addition, 53/149 (35.6%) of all admitted patients and 34/55 (61.8%) of confirmed abuse cases included abuse-related admission ICD coding. Female gender was found to be a factor associated with ED ICD abuse codes. CONCLUSION: Current standards of ICD coding result in a significant underestimate of the prevalence of children assessed in the ED and hospital wards for possible and confirmed abusive fracture(s).

Maltrato a los Niños/diagnóstico , Codificación Clínica/estadística & datos numéricos , Servicio de Urgencia en Hospital , Fracturas Óseas/diagnóstico , Clasificación Internacional de Enfermedades , Canadá/epidemiología , Preescolar , Femenino , Fracturas Óseas/epidemiología , Hospitales Pediátricos , Humanos , Lactante , Masculino , Registros Médicos , Estudios Retrospectivos